Antimicrobial treatment of ENT infections

Ear, nose and throat (ENT) or upper respiratory tract infections (URTI) are the most common infections in children and the leading causes of antibiotic prescriptions. In most cases, these infections are due to (or are triggered by) viruses and even when bacterial species are implicated, recovery is usually spontaneous. The first imperative is to refrain from prescribing antibiotics in a large number of URTIs: common cold, most cases of sore throat, laryngitis, congestive otitis, and otitis media with effusion. On the contrary, a decision to treat sore throats with antibiotics is based primarily on the positivity of the Group A Streptococcus (GAS) rapid antigen diagnostic tests. For ear infections, only (a) purulent acute otitis media in children under 2 years of age and (b) complicated or symptomatic forms of purulent acute otitis media (PAOM) in older children should be treated with antibiotics. Amoxicillin is the first-line treatment in the most cases of ambulatory ENT justifying antibiotics. Severe ENT infections (mastoiditis, epiglottitis, retro- and parapharyngeal abscesses, ethmoiditis) are therapeutic emergencies necessitating hospitalization and initial intravenous antibiotic therapy.

From the original SARS-CoV-2 strain to the Omicron variant: predictors of COVID-19 in ambulatory symptomatic children

OBJECTIVES

To determine the predictors of a positive SARS-CoV-2 test in a pediatric ambulatory setting.

PATIENTS AND METHODS

We performed a cross-sectional prospective study (November 2020-February 2022) of 93 ambulatory settings in France. We included symptomatic children < 15 years old tested for SARS-CoV-2. For each period corresponding to the spread of the original strain and its variants (period 1: original strain; period 2: Alpha, period 3: Delta; period 4: Omicron), we used a multivariate analysis to estimate adjusted odds ratios (aORs) associated with COVID-19 among age, signs, symptoms or contact, and 95 % confidence intervals (95CIs).

RESULTS

Of 5,336 children, 13.9 % (95CI 13.0-14.8) had a positive test. During the first three periods, the positivity rate ranged from 5.6 % (95CI 4.6-6.7) to 12.6 % (95CI 10.8-14.6). The main factors associated with a positive test were contact with an infected adult at home or outside the home (aOR 11.5 [95CI 4.9-26.9] to 38.9 [95CI 19.3-78.7]) or an infected household child (aOR 15.0 [95CI 4.8-47.1] to 28.4 [95CI 8.7-92.6]). By contrast, during period 4, aORs for these predictors were substantially lower (2.3 [95CI 1.1-4.5] to 5.5 [95CI 3.2-7.7]), but the positivity rate was 45.7 % (95CI 42.3-49.2).

CONCLUSIONS

In pediatric ambulatory settings, before the Omicron period, the main predictor of a positive test was contact with an infected person. During the Omicron period, the odds of these predictors were substantially lower while the positivity rate was higher. An accurate diagnostic strategy should only rely on testing and not on age, signs, symptoms or contact.

Antibiotic treatment of skin and soft tissue infections

Bacterial skin and soft tissues infections are common in children and frequently do not require systemic antibiotics, especially if lesions are superficial. Careful washing is always indicated in superficial lesions and is often sufficient. Careful evaluation of symptoms (which may be difficult despite the accessibility of the lesions) should be performed before prescription. Therefore, the need for drainage (spontaneous or surgical) should be assessed considering that antibiotics are mostly useless if purulent lesions are drained. Presence of toxinic symptoms (i.e., generalized cutaneous rash, diarrhea, hypotension) are strongly associated with enhanced severity. The bacterial targets for antibiotics are mainly Staphylococcus aureus (SA) and Streptococcus pyogenes. Considering the low incidence of methicillin-resistant SA in France, the French Pediatric Infectious Disease Group recommends the use of amoxicillin + clavulanate as the first-line antibiotic in most children suffering from severe skin infections requiring antibiotic treatment. In patients presenting toxinic symptoms and signs, the adjunction of an antibiotic with antitoxin properties such as clindamycin should be considered.

Principles of curative antibiotic treatment

Infectious diseases are constantly evolving for many reasons. New infectious agents are regularly discovered, mainly because of the development of identification methods, including the molecular tools and mass spectrometry. Changes in the epidemiology of infectious diseases are not always understood, but several factors undoubtedly play an important role, notably the impact of vaccination implementations, the ecological consequences of antibiotic treatments and their excessive use, and the secular epidemiological trends of pathogenic agents. Antibiotic resistance has been recognized as one of the major challenges for humanity and few new antibiotics with potent activity against resistant Gram-negative rods have been developed in recent years. The rationalization of antibiotic treatments is a key for reducing or limiting antimicrobial resistance. This guide takes into account the latest recommendations, the consensus conferences, and the guidelines of the Pediatric Infectious Diseases Group of the French Society of Pediatric, the French Infectious Diseases Society, and French official agencies. For each clinical situation, the main bacterial target of the antibiotic treatment, the first-choice antibiotic and the alternative treatment, as well as the most important findings for the diagnosis and treatment of the infection are detailed.

[Antibiotic prophylaxis for ENT and ophtalmologic pediatric surgery]

ENT and dental surgical procedures are the most common causes of surgery in children: the majority of them (adenoidectomy, tonsillectomy, trans-tympanic tubes, etc.) does not warrant antibiotic prophylaxis (ABP). When ABP is justified, it follows the general rules of surgical antibiotic prophylaxis: a molecule spectrum including the main bacterial targets (and possibly not used in curative treatment), short-term administration, a single injection 30 to 60 minutes before surgical incision. For cataracts, prophylaxis by intracameral cefuroxime must supplant the antibiotic therapy.

[Plea for advancement of the age of vaccination against human papillomavirus in France: Position of the Pediatric Infections Pathology Group (GPIP) and the French Association of Ambulatory Pediatrics (AFPA)]

Vaccination against human papillomavirus (HPV) is recommended in France at 14 years. The Groupe de Pathologie Infectieuse Pédiatrique de la Société Française de Pédiatrie takes a clear position for advancement of age of vaccination at 11-12 years based on the following arguments: (i) data on the long-term persistence of protective antibodies are reassuring; (ii) these vaccines can be co-administered with vaccines recommended in the current immunization schedule at this age; (iii) actually, nearly 20% of adolescents have had sexual intercourse when the vaccination schedule is finished; (iv) vaccination beyond 14 years increases the risk of occurrence of coincidental autoimmune diseases; (v) the immunogenicity of vaccines against HPV is better when they are administered before age 15; (vi) finally, especially by reducing the number of injections from 3 to 2, the immunization at 11-12 years could improve immunization coverage which is insufficient nowadays.

[Impact of CRP rapid test in management of febrile children in paediatric emergency units of Ile-de-France]

OBJECTIVE

Fever is a common cause of children visits to emergency units. Clinical evaluation does not always eliminate a bacterial infection. Among blood markers, several publications showed the interest of CRP. This study was undertaken to evaluate correlation between two techniques of CRP, one by usual technique at the laboratory and the other by a rapid test, and to evaluate the impact of this rapid test for febrile children at the emergency room, when a hospitalization was not immediately decided.

MATERIAL AND METHODS

The study was undertaken in 2004-2005 in eight emergency paediatric units in Ile-de-France concerning febrile children during two periods. In period A, children had at the same time a CRP dosage through two methods, whereas in period B, only a rapid CRP test was first managed. The test used was NycoCard CRP Single test (Progen Biotechnique).

RESULTS

Between September 2004 and June 2005, 572 children were included, 268 in period A and 304 in period B. Comparison of CRP results by the two methods showed for 247 children (93%) a fairly good linear correlation (r: 0.929). Blood cell count was the most often prescribed test (99.4 vs 10.5%). Conversely to chest radiography, blood culture, fibrinogen and urinary test were significantly most frequent in period A. The average cost of the additional examinations was 2.6 times more important during the first period. Duration of children management in the units was approximately two times shorter when rapid CRP test was used (199.7+/-92.8 vs 103.5+/-98.6 min).

CONCLUSION

This study shows the interest of rapid CRP test for febrile children in the emergency units, and has to be confirmed in ambulatory paediatric practice.

Prospective X-ray densitometry and ultrasonography study of the hand bones of patients with rheumatoid arthritis of recent onset

OBJECTIVE

Bone demineralization observed in early rheumatoid arthritis is not easily measured. To measure bone loss and to discriminate between rheumatoid arthritis and other rheumatic diseases, we used two methods: dual-energy X-ray absorptiometry and ultrasonography.

METHODS

From a population-based recruitment, 32 patients with early peripheral polyarthritis (median disease duration: 4 months) were studied. Clinical, laboratory, functional, hand-bone assessments were made at the entry an at months 6 and 12. Bone X-ray densitometry measurements were made on 16 areas of the hand. Speed of sound was measured across the proximal phalanges of the four fingers. X-rays of both hands were scored according to the modified Sharp's score. At 12 months, patients were classified as rheumatoid arthritis (N = 15; 9 F) or as other rheumatic diseases.

RESULTS

We found: 1) significantly decreased bone mineral density (BMD) of the whole hand, in the rheumatoid arthritis group versus the other rheumatic diseases group, at 6 and 12 months (P < 0.05); 2) no significant decrease of bone mineral density (BMD) in other areas in the rheumatoid arthritis group; 3) no significant change of ultrasounds in either group; and 4) no significant correlation between the decrease of BMD in the rheumatoid arthritis group and clinical, biological or radiologic parameters, except for IFNgamma, whose production in whole blood cell culture was lower at entry in the rheumatoid arthritis group.

CONCLUSION

DEXA bone assessment in rheumatoid arthritis was able t detect bone loss in the whole hand at 6 months.

Negative feedback between prostaglandin and alpha- and beta-chemokine synthesis in human microglial cells and astrocytes

The understanding of immune surveillance and inflammation regulation in cerebral tissue is essential in the therapy of neuroimmunological disorders. We demonstrate here that primary human glial cells were able to produce alpha- and beta-chemokines (IL-8 > growth related protein alpha (GROalpha) >> RANTES > microphage inflammatory protein (MIP)-1alpha and MIP-1beta) in parallel to PGs (PGE2 and PGF2alpha) after proinflammatory cytokine stimulation: TNF-alpha + IL-1beta induced all except RANTES, which was induced by TNF-alpha + IFN-gamma. Purified cultures of astrocytes and microglia were also induced by the same combination of cytokines, to produce all these mediators except MIP-1alpha and MIP-1beta, which were produced predominantly by astrocytes. The inhibition of PG production by indomethacin led to a 37-60% increase in RANTES, MIP-1alpha, and MIP-1beta but not in GROalpha and IL-8 secretion. In contrast, inhibition of IL-8 and GRO activities using neutralizing Abs resulted in a specific 6-fold increase in PGE2 but not in PGF2alpha production by stimulated microglial cells and astrocytes, whereas Abs to beta-chemokines had no effect. Thus, the production of PGs in human glial cells down-regulates their beta-chemokine secretion, whereas alpha-chemokine production in these cells controls PG secretion level. These data suggest that under inflammatory conditions, the intraparenchymal production of PGs could control chemotactic gradient of beta-chemokines for an appropriate effector cell recruitment or activation. Conversely, the elevated intracerebral alpha-chemokine levels could reduce PG secretion, preventing the exacerbation of inflammation and neurotoxicity.

The effect of process and formulation variables on the properties of spray-dried beta-galactosidase

The objective of this study was to evaluate the joint effects of various processing and formulation variables on the properties of spray-dried beta-galactosidase using statistically designed experiments. The key response variables evaluated were product yield, residual enzymatic activity, moisture content and particle size and appearance. The residual enzymatic activity and product yield were significantly affected by the processing variables. The highest product yields were obtained when the drier outlet temperature was relatively high, resulting in extensive protein denaturation. Subsequent experiments, therefore, compared the relative effectiveness of four stabilizers (mannitol, sucrose, arginine hydrochloride and trehalose) in terms of their ability to preserve enzymatic activity during the spray-drying process and during long-term storage. Trehalose was the most suitable stabilizer. The effect of a number of other formulation variables (total solids level, ratio of stabilizer to protein, presence of surfactant and presence of buffer) was also investigated. A final formulation consisting of 6% beta-galactosidase and 10% trehalose in deionized water was selected. Spray-drying at inlet and outlet temperatures of 140 and 95 degrees C, respectively, results in greater than 70% yields of a fully active product with a moisture content of 2-5% and a mean particle size of 2-4 microns.