中国儿童细菌耐药监测组2018年儿童细菌感染及耐药监测

目的 了解目前中国大陆儿童细菌感染和耐药现状。方法 菌株资料来源于2018年1月1日至12月31日中国大陆11所三级甲等儿童医院。细菌抗生素敏感性试验采用自动化仪器法及KB纸片法,肺炎链球菌青霉素药物敏感试验采用E-test法,结果判断采用美国临床实验室标准化委员会(CLSI)2017年判断标准。结果 共对62 212临床分离株进行监测,革兰阳性菌和阴性菌的比例分别为42.2%和57.8%。前5位分离株分别是:肺炎链球菌(12.9%)、大肠埃希菌(12.4%)、流感嗜血杆菌(11.8%)、金黄色葡萄球菌(10.3%)和卡他莫拉菌(7.2%)。金黄色葡萄球菌是新生儿最主要的致病菌(17.0%)。57.0%的标本来源于呼吸道,其中下呼吸道主要致病菌为肺炎链球菌,上呼吸道主要致病菌为化脓性链球菌。肠杆菌科细菌中耐碳青霉烯类药物(CRE)的比例为8.7%,其中新生儿组CRE检出率远高于非新生儿组(16.8% vs 7.2%)。CRE总体耐药率较高,对Ⅰ~Ⅳ类头孢类和酶抑制剂复合制剂耐药率均>85%。鲍曼不动杆菌中,碳青霉烯类耐药的鲍曼不动杆菌(CR-ab)比例为63.2%,非新生儿组中检出率(69.7%)高于新生儿组(35.2%)。碳青霉烯类耐药的铜绿假单胞菌的比例为27.2%,在新生儿组和非新生儿组检出率分别为25.0%和27.3%,两组差异无统计学意义。耐甲氧西林金黄色葡萄球菌和凝固酶阴性葡萄球菌的比例分别为34.9%和77.3%。化脓性链球菌对青霉素不敏感率0.1%,非脑脊液来源的肺炎链球菌中青霉素不敏感菌株(PNSP)比例为21.3%。流感嗜血杆菌β-内酰胺酶阳性检出率为61.1%。结论 呼吸道感染占儿童细菌性感染的首位。碳青霉烯类耐药菌对多种抗生素呈现高水平耐药,新生儿组CRE比例高于非新生儿组,CR-ab比例低于非新生儿组。     

中国儿童细菌耐药监测组2018年儿童细菌感染及耐药监测

目的 了解目前中国大陆儿童细菌感染和耐药现状。方法 菌株资料来源于2018年1月1日至12月31日中国大陆11所三级甲等儿童医院。细菌抗生素敏感性试验采用自动化仪器法及KB纸片法,肺炎链球菌青霉素药物敏感试验采用E-test法,结果判断采用美国临床实验室标准化委员会(CLSI)2017年判断标准。结果 共对62 212临床分离株进行监测,革兰阳性菌和阴性菌的比例分别为42.2%和57.8%。前5位分离株分别是:肺炎链球菌(12.9%)、大肠埃希菌(12.4%)、流感嗜血杆菌(11.8%)、金黄色葡萄球菌(10.3%)和卡他莫拉菌(7.2%)。金黄色葡萄球菌是新生儿最主要的致病菌(17.0%)。57.0%的标本来源于呼吸道,其中下呼吸道主要致病菌为肺炎链球菌,上呼吸道主要致病菌为化脓性链球菌。肠杆菌科细菌中耐碳青霉烯类药物(CRE)的比例为8.7%,其中新生儿组CRE检出率远高于非新生儿组(16.8% vs 7.2%)。CRE总体耐药率较高,对Ⅰ~Ⅳ类头孢类和酶抑制剂复合制剂耐药率均>85%。鲍曼不动杆菌中,碳青霉烯类耐药的鲍曼不动杆菌(CR-ab)比例为63.2%,非新生儿组中检出率(69.7%)高于新生儿组(35.2%)。碳青霉烯类耐药的铜绿假单胞菌的比例为27.2%,在新生儿组和非新生儿组检出率分别为25.0%和27.3%,两组差异无统计学意义。耐甲氧西林金黄色葡萄球菌和凝固酶阴性葡萄球菌的比例分别为34.9%和77.3%。化脓性链球菌对青霉素不敏感率0.1%,非脑脊液来源的肺炎链球菌中青霉素不敏感菌株(PNSP)比例为21.3%。流感嗜血杆菌β-内酰胺酶阳性检出率为61.1%。结论 呼吸道感染占儿童细菌性感染的首位。碳青霉烯类耐药菌对多种抗生素呈现高水平耐药,新生儿组CRE比例高于非新生儿组,CR-ab比例低于非新生儿组。     

Aetiology and outcome of pneumonia in human immunodeficiency virus-infected children hospitalized in South Africa

To determine the aetiology and outcome of pneumonia in human immunodeficiency virus (HIV)infected children, we prospectively investigated 250 children hospitalized with pneumonia who were known or clinically suspected to be HIV-positive, or who required intensive care support in Cape Town, South Africa. Blood culture, induced sputum or bronchoalveolar lavage, nasopharyngeal aspirate and gastric lavage were performed. Of the total, 151 children (60.4%) were HIV-infected. Pneumocystis carinii pneumonia (PCP), occurring in 19 (7.6%) children (15 HIVpositive), was the AIDS-defining infection in 20.3%. The incidence and type of bacteraemia (14.3%) were similar in HIV-positive and HIV-negative patients; S. pneumoniae (5%) and S. aureus (2%) were the predominant isolates. Sputum or BAL cultures yielded bacteria in 145 of 243 (60%) specimens; viruses were cultured in 37 (15.2%). Bacterial prevalence (including M. tuberculosis in 8%) and anti-microbial resistance did not differ by HIV status except for S. aureus which was more common in HIV-infected children. Thirty-one (20%) HIV-positive and 8 (8%) HIV-negative children died [RR 1.16 (95% CI 1.05-1.28), p = 0.008]; using multiple logistic regression, PCP was the only risk factor for mortality (p = 0.03). Conclusion: In South Africa, PCP is an important AIDS-defining infection in children; bacterial pathogens occur commonly and with a similar prevalence in HIV-positive and HIV-negative children hospitalized for pneumonia. HIV-infected children with pneumonia have a worse outcome than HIV-negative patients.     

Low-dose warfarin for the prevention of central line-associated thromboses in children with malignancies--a randomized, controlled study

Background: Central venous lines (CVLs) are essential in the care of children with malignancies, but are associated with venous thromboembolism (VTE) and infections. Effective and safe prophylactic approaches are deficient. Aim: To perform a study of adjusted low-dose warfarin for the prevention of CVL-related VTE in children with malignancies. Methods: Children with newly diagnosed cancer, a CVL in a jugular vein and an expected treatment period of over 6 mo were eligible for the study. Participants were randomized to low-dose warfarin, with intended international normalized ratio (INR) 1.3-1.9, or to a control group. Primary outcome was VTE in a jugular vein diagnosed by ultrasonography at 1, 3 and 6 mo after inclusion. Secondary outcome was CVL-related infections, mainly measured as days on antibiotics or positive blood cultures. Results: The study enrolled 73 children, and 62 completed it fully. Asymptomatic CVL-related VTE was frequent (42%), but often transient. Regardless of severity, timing and duration, CVL-related VTE was equally frequent among children on warfarin as compared to controls (p=0.44). Low-dose warfarin (p=0.59) or jugular CVL-related VTE (p=0.91) did not have any impact on days on antibiotics, but we observed a tendency towards an association between CVL-related VTE and positive blood cultures (p=0.15).

Conclusion: Our randomized study of low-dose oral anticoagulation for the prevention of CVL-related asymptomatic VTE in children with cancer did not show any benefit of warfarin adjusted to maintain INR between 1.3 and 1.9.     

Preoperative bacterial colonization of the upper airways does not predict postoperative airway infection in children

The aim of this prospective non-interventional investigation was to study whether preoperative colonization of nasopharynx with potentially pathogenic airway bacteria carried an increased risk for the development of early postoperative bacterial airway infections after heart surgery in preschool children. Of the 91 patients studied, 62 (68%) were colonized preoperatively in the nasopharynx with Moraxella catarrhalis, Streptococcus pneumoniae, Haemophilus influenzae and/or Staphylococcus aureus. Nine children developed postoperative airway infections (four pneumonia, three bacterial bronchitis and two acute otitis media). Preoperative colonization was not significantly associated with increased risk for postoperative airway infection: 6/62 (10%) in colonized vs 3/29 (10%) in non-colonized children. Preoperative nasopharynx cultures in asymptomatic children should be avoided since it is unpleasant for the child, is not cost-effective, and may lead to unnecessary antibiotic treatment.     

Central line-associated venous late effects in children without prior history of thrombosis

Background: The frequency of asymptomatic central line-associated thromboses is high and well recognized among children with cancer, while the long-term consequences are mainly unknown. Aim: In a cross-sectional study, we evaluated clinical and radiological venous outcome in children with previous long-standing intravascular catheters. Methods: The study enrolled 71 children previously treated for malignant or haematological diseases, 4-180 (median 37) mo after removal of their central lines. Inclusion criteria were a prior central line in a jugular vein for a minimum of 6 mo and no previous history of thrombosis. The children had clinical examination for post-thrombotic syndrome (PTS) and Doppler ultrasonography of the central neck veins. Twelve children had additional venous magnetic resonance imaging (MRI). But no kind of venography was performed in the remaining. Results: We observed mild PTS with increased superficial collaterals in four children (6%), but no cases of more severe PTS. None complained of symptoms related to venous late effects. By ultrasonography, post-thrombotic venous alterations were detected in 17 children (24%), and five of these had complete occlusion of the veins. The sensitivity for pathologically increased collaterals to identify occlusive thrombosis was 0.6, while the specificity was 0.98. Occlusive venous thromboembolism was associated with the total number of central venous lines (CVLs; p=0.002), previous severe CVL-associated infections (p=0.001) and duration of central line in place (p=0.042).

Conclusion: In spite of no prior history of thrombosis, children with previous long-term jugular lines frequently had local thrombotic sequelae, while clinical symptoms of PTS were rare.     

Early post-convulsive prolongation of QT time in children

Aim: An important differential diagnosis of seizures in childhood is the long QT syndrome. Childhood epilepsy occurs about 400 times more often than long QT syndrome. We had observed children with slight post-convulsive prolongation of QT time more often than the reported incidence of long QT syndrome. We therefore conducted a prospective study to define the characteristics of post-convulsive prolongation of QT time in children. Methods: We investigated 30 consecutive infants and children (3 mo to 14 y) within 2 h after seizures. A follow-up ECG was obtained 1-9 d later. We also obtained ECGs from 30 healthy age- and gender-matched controls. We calculated the QT interval corrected for heart rate (QTc) by Bazett's formula in leads II, V5, V6, QT dispersion and the number of notched T waves. Results: We found a QTc interval of more than 440 ms in one or more leads in the first ECG in seven of 30 infants and children compared to 1 of 30 in the follow-up ECG (p=0.0003) and two of 30 in the healthy controls (p=0.14). Average QTc was higher for all leads in the first ECG. This was statistically significant in leads II (414 vs 402 ms, p=0.008), V5 (416 vs 404 ms, p=0.002) and V6 (415 vs 399 ms, p=0.001). Compared to healthy controls, QT dispersion was slightly larger in the early post-convulsive ECG (36 vs 31 ms, p=0.03). Notched T waves occurred more frequently in the early compared to the late post-convulsive ECGs (p=0.009).

Conclusion: Slight to moderate post-convulsive prolongation of the QT interval is not rare but transient in paediatric patients.     

Transient and chronic neutropenias detected in children with different viral and bacterial infections

Aim: The aim of the study was to identify the relationship of acquired neutropenias with infections in childhood and to assess their course, complications, short and long-term outcome. Method: During a two-year period, all children admitted to the pediatric ward with neutropenia were investigated for underlying infections with indices of infection, cultures of body fluids and serological tests. Results: Sixty-seven previously healthy children, aged (median, 25-75%) 0.7 years (0.2-1.5), were identified with neutropenia (frequency: 2.0%). An infectious agent was identified in 34/67 cases (50.7%) (viral infection: n=24, bacterial: n=10). In 50/67 (74.6%) children, neutropenia recovered within 2 months (transient neutropenia, TN), while in 17/67 (25.4%) of them it persisted for more than two months. Two years after diagnosis 50/67 children (74.6%) accepted to be reassessed. Of these children, 8/50 (16%) remained neutropenic (neutropenic children, NC), while 42/50 had recovered completely. Conclusion: Neutropenia during childhood is usually transient, often following viral and common bacterial infections, does not present serious complications and in the majority, it resolves spontaneously. However, in a significant percentage of patients, neutropenia is discovered during the course of an infection, on a ground of a preceding chronic neutropenic status.     

Behavioural effects of phenylalanine-free amino acid tablet supplementation in intellectually disabled adults with untreated phenylketonuria

Aim: To evaluate the effects of phenylalanine (Phe)-free essential amino acid (AA) tablets enriched in tyrosine and tryptophan on the performance of intellectually disabled adult patients with untreated phenylketonuria (PKU). Methods: Phe-free AA tablets and placebo tablets were administered to 19 untreated PKU subjects on a normal diet for 6 mo in a prospective double-blinded crossover study. The adaptive behaviour of the patients was tested prior to the study and at 6 and 12 mo after the start, using a simplified version of the Vineland Adaptive Behaviour Scale. For each sub-domain, the patients were rated either “0” (for poor performance) or “1” (for good performance). Neurological signs and symptoms and specific behavioural characteristics were recorded monthly by caretakers. Every 6 mo, neurological examination of the patients was performed, and the caretakers were interviewed. The statistical significance of the results was tested by means of the Fisher's exact and Wilcoxon tests. Results: The most significant changes were an improved concentration and the development of a meaningful smile, which were observed in 44% and 43% of the patients on AA tablet treatment, respectively, but not patients on placebo. Other important but less significant changes included increased awareness of external stimuli (63%) and less self-injury (43%), and 40% were smiling and laughing occasionally. The mean overall rating increased from an initial value of 6.3 to 10.1 in patients when on AA tablet treatment (p=0.002), and to 7.0 in patients when on placebo (p=0.068). The difference between active AA treatment and placebo was statistically significant (p=0.027).

Conclusions: This pilot study suggests that Phe-free AA tablets enriched in tyrosine and tryptophan may improve the quality of life in some intellectually disabled adults with untreated PKU.     

Methicillin-resistant Staphylococcus aureus bacteraemia in neonatal intensive care units: an analysis of 90 episodes

Aim: To delineate the clinical features of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in infants hospitalized at the neonatal intensive care unit. Methods: Episodes of MRSA bacteraemia in Chang Gung Children's Hospital neonatal intensive care unit from 1997 to 1999 were reviewed for incidence, predisposing factors, clinical presentations, treatment and outcome. Results: Ninety episodes of MRSA bacteraemia were identified. The overall rate of MRSA bacteraemia was 1.05 per 1000 patient days during the 3-y period. Most of the patients were premature infants (76%), with prior operation or invasive procedures (39%), had an indwelling intravascular catheter (79%) and exposure to antibiotic therapy (96%). A localized cutaneous infection was found in 53.3% of the episodes. The most common clinical diagnoses were catheter-related infections (54.4%), skin and soft tissue infections (21.1%), bacteraemia without a focus (20%) and pneumonia (16.7%). Metastatic infection occurred in 18% of these infants. Among the patients treated with vancomycin for ≤14 d, 88.7% did not develop any complications, and 11.3% developed a recurrence.

Conclusions: MRSA is an established pathogen in our NICU. MRSA bacteraemia in the neonates predominantly presented as catheter-related infections, and metastatic infections were not infrequently seen. In uncomplicated MRSA bacteraemia, treatment with vancomycin for ≤14 d seems to be adequate.     

儿童急性淋巴细胞白血病中性粒细胞缺乏伴发热单中心血流感染病原菌分析

目的 分析儿童急性淋巴细胞白血病(ALL)化疗后中性粒细胞缺乏伴发热(FN)血流感染的临床特点、危险因素和病原菌分布。方法 回顾性分析2007年1月1日至2016年12月31日上海交通大学附属儿童医院血液肿瘤科收治的ALL化疗后发生FN住院患儿的临床资料和血培养结果,分析菌株的分布及药敏特点。结果 纳入ALL患儿312例,FN1 548例次,共送检1 700例次血培养,血培养阳性率7.5%(127/1 700),血流感染发生率8.2%(127/1 548),病死率9.4%(12/127)。血流感染革兰阳性菌51.1%(65/127),革兰阴性菌47.2%(60/127),真菌1.5%(2/127)。革兰阴性菌血流感染与革兰阳性菌血流感染比较,ANC<0.1×10⁹·L^-1的患儿占比(P=0.041)和感染性休克发生率更高(P=0.002)。2012~2016年铜绿假单胞菌构成比较2007~2011年增加(χ²=4.712,P=0.030)。ALL的危险程度分层IR/HR(OR=2.560,P=0.045)和ANC<0.1×10⁹·L^-1(OR=0.754,P=0.025)是血流感染发生的独立危险因素。结论 ALL患儿发生FN时血流感染病原菌阳性率较高(8.2%),以革兰阳性菌感染为主。在严重粒细胞缺乏时以革兰阴性菌血流感染为主,铜绿假单胞菌感染有增加趋势,合并感染性休克是FN死亡的独立危险因素。     

儿童急性淋巴细胞白血病中性粒细胞缺乏伴发热单中心血流感染病原菌分析

目的 分析儿童急性淋巴细胞白血病(ALL)化疗后中性粒细胞缺乏伴发热(FN)血流感染的临床特点、危险因素和病原菌分布。方法 回顾性分析2007年1月1日至2016年12月31日上海交通大学附属儿童医院血液肿瘤科收治的ALL化疗后发生FN住院患儿的临床资料和血培养结果,分析菌株的分布及药敏特点。结果 纳入ALL患儿312例,FN1 548例次,共送检1 700例次血培养,血培养阳性率7.5%(127/1 700),血流感染发生率8.2%(127/1 548),病死率9.4%(12/127)。血流感染革兰阳性菌51.1%(65/127),革兰阴性菌47.2%(60/127),真菌1.5%(2/127)。革兰阴性菌血流感染与革兰阳性菌血流感染比较,ANC<0.1×10⁹·L^-1的患儿占比(P=0.041)和感染性休克发生率更高(P=0.002)。2012~2016年铜绿假单胞菌构成比较2007~2011年增加(χ²=4.712,P=0.030)。ALL的危险程度分层IR/HR(OR=2.560,P=0.045)和ANC<0.1×10⁹·L^-1(OR=0.754,P=0.025)是血流感染发生的独立危险因素。结论 ALL患儿发生FN时血流感染病原菌阳性率较高(8.2%),以革兰阳性菌感染为主。在严重粒细胞缺乏时以革兰阴性菌血流感染为主,铜绿假单胞菌感染有增加趋势,合并感染性休克是FN死亡的独立危险因素。     

Specific real-time polymerase chain reaction places Kingella kingae as the most common cause of osteoarticular infections in young children

BACKGROUND: The use of universal 16S rDNA polymerase chain reaction (PCR) has recently shown that the place of Kingella kingae in osteoarticular infections (OAI) in young children has been underestimated, but this technique is not the most sensitive or the most rapid method for molecular diagnosis. We developed a specific real-time PCR method to detect K. kingae DNA and applied it to the etiologic diagnosis of OAI. PATIENTS AND METHODS: All children admitted to a pediatric unit for OAI between January 2004 and December 2005 were enrolled in this prospective study. Culture-negative osteoarticular specimens were tested by 16S rDNA PCR and by K. kingae-specific real-time PCR when sufficient sample remained. RESULTS: By culture alone, a pathogen was identified in 45% of the 131 specimens tested (Staphylococcus aureus, n = 25; K. kingae, n = 17; others, n = 18). 16S rDNA PCR and K. kingae-specific PCR were both applied to 61 of the culture-negative samples. The combination of culture and 16S rDNA PCR identified a pathogen in 61% of cases (K. kingae DNA, n = 16; DNA of other microorganisms, n = 5). Specific real-time PCR identified a further 6 cases caused by K. kingae and confirmed all 16 universal PCR-positive cases, bringing the overall documentation rate to 66%. K. kingae was the leading cause of OAI in this pediatric series (n = 39, 45%), followed by S. aureus (n = 25, 29%) CONCLUSION: The K. kingae-specific real-time PCR places K. kingae as the leading cause of OAI in children at our hospital.     

Upper endoscopic findings in children with active juvenile chronic arthritis

Aim: To investigate the association between gastroduodenal mucosal damage and symptoms of the digestive tract in children with juvenile chronic arthritis (JCA) Methods: This was a prospective, open, non-randomized study. Gastroscopy was performed on 45 children with active JCA in 1996-2000. Gastrointestinal symptoms before and during the treatment were noted, as was the length of antirheumatic medication, for which the data were retrospectively assessed. Plasma haemoglobin (Hb) and mean corpuscular volume (MCV) levels and erythrocyte sedimentation rate (ESR) were analysed. Mucosal biopsies were obtained for histology and Helicobacter pylori culture. All patients were taking non-steroidal anti-inflammatory drugs (NSAIDs) and 11 (24.4%) were on peroral steroids; 16 (35.6%) were receiving hydorxychloroquine, 9 salazopyrine, 5 myocrisine and 14 methotrexate. Results: Seven children (15.6%) were found to have active inflammation in their gastric and/or duodenal mucosa, two having ulcers and two being infected with H. pylori. Abnormal endoscopic findings were more common in symptomatic children (n = 24) than in children without symptoms (n = 21) (75% vs 38%, p = 0.017). There was no clear association between the Hb or MCV level and the degree of gastroduodenal inflammation (p = 0.98 and 0.7, respectively). Significantly more children (66.6% vs 33.3%) experienced abdominal pain after beginning medical therapy than before therapy (p = 0.02).

Conclusion: Endoscopic evaluation of patients with JCA and receiving NSAIDs should be considered at least in symptomatic cases.     

Morbidity in children born to women infected with human immunodeficiency virus in South Africa: does mode of feeding matter?

Aim: To examine infant morbidity risks associated with refraining from breastfeeding where it is used in an attempt to prevent mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV). Methods: The population consisted of infants born to HIV-infected women in South Africa who were participating in a vitamin A intervention trial to prevent MTCT of HIV. Women chose to breastfeed or formula feed their infants according to UNAIDS guidelines. Actual feeding practices and morbidity were recorded at clinic follow-up visits at 1 wk, 6 wk, 3 mo and every 3 mo thereafter until 15 mo of age or cessation of breastfeeding. The infant's HIV status was assessed according to a predetermined algorithm. Results: HIV-infected infants who were never breastfed had a poorer outcome than those who were breastfed; 9 (60%) of those who were never breastfed had 3 or more morbidity episodes compared with 15 (32%) of breastfed children [odds ratio (OR) 4.05, 95% confidence interval (95% CI) 0.91-20.63, p = 0.05]. During the first 2 mo of life, never-breastfed infants (regardless of HIV status) were nearly twice as likely to have had an illness episode than breastfed infants (OR 1.91, 95% CI 1.17-3.13, p = 0.006).

Conclusion: The significant extra morbidity experienced in the first few months by all never-breastfed infants and at all times by HIV-infected infants who are not breastfed needs to be considered in all decisions by mothers, health workers and policy makers so as not to offset any gains achieved by decreasing HIV transmission through avoiding breastfeeding.     

Effectiveness of home-based peer counselling to promote breastfeeding in the northeast of Brazil: a randomized clinical trial

Aims: To evaluate the effectiveness of home-based peer counselling to increase breastfeeding rates for unfavourably low birthweight babies. Methods: Randomized clinical trial carried out in maternity hospitals and households in Fortaleza, one of the regions in Brazil with very low income; 1003 mothers and their newborns were selected in eight maternity hospitals. Newborns needed were healthy and weighed less than 3000 g. Intervention: Breastfeeding counselling, conducted by lay counsellors from the community, during home visits carried out on days 5, 15, 30, 60, 90 and 120 after birth. Main outcome measure: Feeding methods in the fourth month of life. Results: The intervention increased exclusive breastfeeding (24.7% vs 19.4%; p=0.044), delayed the introduction of formula and increased the time infants substituted breastfeeding to bottle milk (bottle milk 33.4% in the control group and 20.1% in the intervention group; p=0.00002). When comparing the frequency of artificial breastfeeding versus all other forms of breastfeeding (exclusive+predominant+partial), the intervention increased breastfeeding rates in 39% (RR=0.61; CI 95%: 0.50-0.75); 15% of children were free from artificial feeding (absolute risk reduction). The number of families to be visited to avoid one child receiving artificial feeding (NNT) was 7 (CI 95%: 5-13).

Conclusions: Breastfeeding counselling, promoted by lay counsellors, can impact favourably on exclusive breastfeeding rates and contribute to delaying the utilization of milk formula and weaning. The intervention has great application potential because most cities in the northeast of Brazil count on community health workers that could do the counselling.     

Contribution of a broad range polymerase chain reaction to the diagnosis of osteoarticular infections caused by Kingella kingae: description of twenty-four recent pediatric diagnoses

BACKGROUND: Microbiologic diagnosis of septic arthritis and osteomyelitis in children is hindered by the less than optimal yield of blood and osteoarticular fluid cultures. PATIENTS AND METHODS: All patients admitted to a pediatric unit for osteoarticular infections (OAI) between January 2001 and February 2004 were enrolled in this prospective study. Osteoarticular fluid and biopsy samples that were negative by conventional culture were tested by polymerase chain reaction (PCR) with universal 16S ribosomal DNA primers. RESULTS: We enrolled 171 children. Culture was positive in 64 cases (37.4%), yielding Kingella kingae in 9 cases. The 107 culture-negative specimens were tested by 16S ribosomal DNA PCR. Fifteen samples (14%) were positive, all for Kingella DNA sequences. K. kingae was the second cause of OAI in this population (30.4%), after Staphylococcus aureus (38%). Patients with Kingella infection diagnosed by culture (9 cases) did not differ from those diagnosed by PCR (15 cases) in terms of their clinical characteristics (including prior antibiotic therapy). The characteristics of the 24 children with arthritis (n = 17) or osteomyelitis (n = 7) were similar to those reported elsewhere. Fever (>38 degrees C) and symptom onset shortly before hospitalization (median, 4.5 days) were significantly associated with arthritis. CONCLUSION: Use of molecular diagnostic methods increases the identification of K. kingae in osteoarticular infections.     

Percutaneous endoscopic gastrostomy in children with cancer

We reviewed the clinical course of 32 children with cancer who received nutrition through a feeding tube placed percutaneously during gastroscopy (PEG). Their median age was 5.1 y (75%, range: 1.8-13.7 y, min: 3.5 mo) when the PEG was done 0.7-23 mo after diagnosis (median: 1.8 mo, 75%; range: 0.9-8 mo). Five of the children underwent bone marrow transplantation with the gastrostomy in place. There was a significant (p     

Hand, foot and mouth disease in Singapore: a comparison of fatal and non-fatal cases

Aim: An epidemic of hand, foot and mouth disease (HFMD) occurred in Singapore between September and November 2000. During the epidemic, there were four HFMD-related deaths and after the epidemic, another three HFMD-related deaths. This study sought to determine the risk factors predictive of death from HFMD disease. Methods: The risk factors for fatal HFMD were determined by comparing clinical and laboratory findings between fatal cases (n = 7) and non-fatal controls (n = 131) admitted between September 2000 and April 2001. Enterovirus 71 positive fatal cases (n = 4) and non-fatal controls (n = 63) were also compared. Results: In total, 138 HFMD cases with a mean age of 32 mo were studied. The majority of fatal cases died from interstitial pneumonitis, of whom three also had brainstem encephalitis. Of the 131 non-fatal cases, 3 had concomitant infections (respiratory syncytial virus bronchiolitis, right-sided pneumonia, Haemophilus influenzae type b meningitis), 2 had aseptic meningitis, and 1 each had transient drowsiness, intravenous immunoglobulin-related complications and transverse myelitis. By multivariate logistic regression analysis, atypical physical findings (p = 0.0006), raised total white cell count (p = 0.0128), vomiting (p = 0.0116) and absence of mouth ulcers (p = 0.043) were predictive of a fatal course. Although previous epidemics have described neurogenic pulmonary oedema as the main cause of death, the fatal cases in this study died mainly from interstitial pneumonitis alone or with myocarditis or encephalitis.

Conclusion: Although HFMD is generally a benign disease, risk factors such as vomiting, absence of mouth ulcers, atypical presentation and raised total white cell count should alert the physician of a fatal course of illness.     

Cerebral excitatory amino acids and Na+, K+-ATPase activity during resuscitation of severely hypoxic newborn piglets

We tested the hypothesis that early brain recovery in hypoxic newborn piglets is improved by resuscitating with an O₂ supply close to the minimum level required by the newborn piglet brain. Severely hypoxic 2-5-d-old anaesthetized piglets were randomly divided into three resuscitation groups: hypoxaemic (n = 8), 21% O₂ (n = 8), and 100% O₂ groups (n = 8). The hypoxaemic group was mechanically ventilated with 12-18% O₂ adjusted to achieve a cerebral venous O₂ saturation of 17-23% (baseline; 45±1%, mean±SEM). During the 2h resuscitation period, extracellular aspartate and glutamate concentrations in the cerebral striatum were higher during hypoxaemic resuscitation (p = 0.044 and p = 0.055, respectively) than during resuscitation with 21% O₂ or 100% O₂, suggesting an unfavourable accumulation of potent excitotoxins during hypoxaemic resuscitation. The cell membrane Na⁺,K⁺-ATPase activity of cerebral cortical tissue after 2 h resuscitation was similar in the three groups (p = 0.30). In conclusion, hypoxaemic resuscitation did not normalize early cerebral metabolic recovery as efficiently as resuscitation with 21% O2 or 100% O₂. Resuscitation with 21% O₂ was as efficient as resuscitation with 100% O₂ in this newborn piglet hypoxia model.