Invasive Group A streptococcal infections: are we facing a new outbreak? A case series with the experience of a single tertiary center

BACKGROUND

In pediatric age, Group A Streptococcus (GAS) is responsible for a wide spectrum of clinical manifestations, from mild localized infections to life-threatening invasive diseases. In December 2022, the World Health Organization reported an increased incidence of scarlet fever and invasive GAS infections (iGAS) cases in Europe and the United States. In line with these observations, surveillance has been strengthened in our Region, allowing the identification of certified or highly suspected forms of iGAS.

CASE PRESENTATION

We report here 4 emblematic cases of iGAS admitted to our Intensive Care Unit (ICU) in the short time span from mid-February to mid-March 2023. Particularly, we describe a case of pleuropneumonia (4 year old boy) and a case of respiratory failure (2 year old boy), who necessitated Non-Invasive Ventilation support, a case of Streptococcal Toxic Shock Syndrome (6 year old girl), presenting with multi-organ failure, who needed Invasive Ventilation, and a case of meningitis (5 year old girl). All these patients needed intensive care support.

CONCLUSIONS

Accurate differential diagnosis and early treatment both could help to reduce the transmission of GAS and consequently the risk of severe iGAS. These cases confirmed the need for close monitoring and appropriate notification, in order to verify their actual increased incidence.

Epidemiological and Clinical Profile of Pediatric Burns in the COVID-19 Era: The Experience of a Reference Center

Pediatric burns represent a significant public health problem. We analyzed the characteristics of pediatric burns in a reference center, in order to identify better strategies for prevention and care. Burn patients admitted to the pediatric departments of our hospital from January 2020 to June 2022 were retrospectively evaluated. Age, gender, the etiology of injuries, the total burn surface area (TBSA), the degree of burns, the length of hospital stay (LOS), concomitant SARS-CoV-2 infection, and burn surface microbial colonization were analyzed. Forty-seven patients were included in the analysis (M:F = 1:0.67). Most of the cases involved patients between 0 and 4 years of age (83%). Hot liquid burns accounted for 79% of cases, flame burns for 9%, thermal burns for 6%, scald burns for 4% and chemical burns for 2%. Mean TBSA was 14 ± 11%. A second-degree lesion was detected in 79% of patients and third-degree in 21%. Mean LOS was 17 days. No additional infection risks or major sequelae were reported in patients with SARS-CoV-2 infection. Fifteen different species of bacteria plus C. parapsilosis were isolated, while no anaerobic microorganisms were detected. In the light of our experience, we recommend a carefully planned and proactive management strategy, always multidisciplinary, to ensure the best care for the burned child.

Multi-centre study found no increased risk of clinically important brain injuries when children presented more than 24 hours after a minor head trauma

AIM

Validated clinical decision rules on neuroimaging are not available for children who are evaluated more than 24 hours after a minor head trauma. We compared clinically important traumatic brain injuries in children who presented with a minor head trauma within, or after, 24 hours.

METHODS

This was a retrospective analysis of patients aged 0-17 years, who were evaluated for minor head traumas by 5 paediatric emergency departments in Northern Italy between January 2019 and June 2020. Children with clinically important traumatic brain injuries were divided into those who had presented within, and after, 24 hours.

RESULTS

The study comprised 5,981 children (59.9% boys), with a median age of 2 years, including 243 (4.1%) who had presented more than 24 hours after their minor head trauma. Neuroimaging was performed on 448 (7.5%) patients and the time of presentation had no impact on the rates of clinically important traumatic brain injuries. Multiple logistic regression did not show any association between clinically important traumatic brain injuries and late presentation.

CONCLUSION

Delayed presentation to a paediatric emergency department after a minor head trauma did not alter the risk of clinically important traumatic brain injuries and the same neuroimaging rules could apply.

Caregivers' Intention to Vaccinate Their Children Under 12 Years of Age Against COVID-19: A Cross-Sectional Multi-Center Study in Milan, Italy

The impact of Coronavirus disease 2019 (COVID-19) on the pediatric population is increasingly recognized. A widespread vaccination in childhood would provide benefits for children and might help ending the pandemic by enhancing community protection. Following recent approval by the European Medicines Agency (EMA) of Comirnaty (Pfizer-BioNTech) for children aged 5-11 years, we aimed to investigate caregivers' intention to vaccinate their children <12 years of age against COVID-19. A structured questionnaire was administered to caregivers of children aged <12 years visiting the Emergency Department or the outpatient clinics in three major hospitals of Milan, Italy, from 20 September to 17 October 2021. A total of 612 caregivers were invited to participate and 604 accepted (response rate >98%). Three questionnaires were excluded due to compiling errors and 601 were included in the analysis. A total of 311 (51.7%) caregivers stated they would have their child vaccinated, 138 (23%) would refuse to vaccinate their child and 152 (25.3%) were unsure. The intention to vaccinate the child was higher in caregivers vaccinated against COVID-19, in those with a bachelor's degree or higher level of education, and in those with friends/acquaintances who became ill or died due to COVID-19. This study shows that increasing efforts are necessary to provide evidence-based tailored information to caregivers and to promote vaccination in this pediatric age group.

Bloody Diarrhea and Shiga Toxin-Producing Escherichia coli Hemolytic Uremic Syndrome in Children: Data from the ItalKid-HUS Network

OBJECTIVE

To analyze the results of an enhanced laboratory-surveillance protocol for bloody diarrhea aimed at identifying children with Shiga toxin-producing Escherichia coli (STEC) infection early in the course of the disease toward the early identification and management of patients with hemolytic uremic syndrome (HUS).

STUDY DESIGN

The study (2010-2019) involved a referral population of 2.3 million children. Stool samples of patients with bloody diarrhea were screened for Shiga toxin (Stx) genes. Positive patients were rehydrated and monitored for hemoglobinuria until diarrhea resolved or STEC-HUS was diagnosed.

RESULTS

A total of 4767 children were screened; 214 (4.5%) were positive for either Stx1 (29.0%) or Stx2 (45.3%) or both Stx1+2 (25.7%); 34 patients (15.9%) developed STEC-HUS (0.71% of bloody diarrheas). Hemoglobinuria was present in all patients with HUS. Patients with Stx2 alone showed a greater risk of STEC-HUS (23.7% vs 12.7%) and none of the patients with Stx1 alone developed HUS. During the same period of time, 95 other patients were diagnosed STEC-HUS but were not captured by the screening program (26 had nonbloody diarrhea, 11 came from areas not covered by the screening program, and 58 had not been referred to the screening program, although they did meet the inclusion criteria). At HUS presentation, serum creatinine of patients identified by screening was significantly lower compared with that of the remaining patients (median 0.9 vs 1.51 mg/dL).

CONCLUSIONS

Nearly 1% of children with bloody diarrhea developed STEC-HUS, and its diagnosis was anticipated by the screening program for Stx. The screening of bloody diarrhea for Stx is recommended, and monitoring patients carrying Stx2 with urine dipstick for hemoglobinuria is suggested to identify the renal complication as early as possible.

Supporting the Regional Network for Children with Burn Injuries in a Pediatric Referral Hospital for COVID-19

Considerable reorganization of the regional network for pediatric burn treatment during the pandemic was required to cope with severe burn injuries in small children. In support of the emergency network for burns during the COVID-19 pandemic, we referred to regional indications for centralization in our hospital for all children aged less than 5 years who presented with severe burns, >15% of total body surface area (TBSA), or who necessitated admittance to the pediatric intensive care unit (PICU). A new service with a dedicated management protocol was set up to treat pediatric burns in our SARS-CoV-2 pediatric hospital during the lockdown period. A multidisciplinary burn treatment team was set up to offer compassionate and comprehensive burn care. Patient's clinical data, burn features, treatment and follow up were recorded. A higher number of admissions was recorded from February to December 2020 compared with the same period in 2019 (52 vs. 32 admissions). Eighteen patients were admitted to the COVID-19 Service (10 M/8 F; 3.10 ± 2.6 yrs); ten children (55.5%) were hospitalized in the ward and eight in the ICU (44.5%). Fifty percent of the cases presented with lesions extending over >15% TBSA; in one case, TBSA was 35%. All patients suffered 2nd-degree burns; while five patients also had 3rd degree lesions covering more than 15% TBSA. All of the injuries occurred at home. No major secondary infections were recorded. Successful treatment was achieved in 94.4% of cases. The average length of stay was 15.2 ± 12.6 days. A proactive, carefully planned service, involving a multidisciplinary team, was created to ensure appropriate care in a pediatric hospital during the COVID-19 period, despite the effective pandemic associated challenges. Better health promotion in pediatric burn cases should also include dedicated TBSA assessment and a database of children's burn characteristics.

Comparison of 5 milligrams of netilmicin per kilogram of body weight once daily versus 2 milligrams per kilogram thrice daily for treatment of gram-negative pyelonephritis in children

The efficacy and safety of netilmicin, 5 mg/kg of body weight once daily or 2 mg/kg thrice daily for 10 days, for the treatment of gram-negative pyelonephritis in children were compared in a prospective, randomized trial. Explicit criteria were used to define the site of infection, treatment outcome, and adverse effects. Netilmicin was given to 74 children once daily and to 70 children three times daily. At 1 week posttreatment, 73 (99%) of 74 children treated with netilmicin once daily and 70 (100%) of 70 children treated with netilmicin three times daily were cured. At 4 weeks posttreatment, no relapse was detected and the rate of reinfection was essentially identical in the two treatment groups. Peak serum netilmicin concentrations were higher in patients given the once-daily regimen, whereas a higher trough level was detected in patients given the three-times-daily regimen. Nephrotoxicity, which was defined as an increase in the serum creatinine level of greater than or equal to 0.3 mg/dl over the baseline, was rare (3%) and reversible and occurred regardless of the treatment regimen. Ototoxicity, which was assessed by pure-tone audiometry (250 to 8,000 Hz) and brain stem-evoked response (6,000 Hz), occurred in 2 of 32 children who were evaluated. In these two children, who were given the once-daily regimen, wave V was not evokable monolaterally below 25 and 40 dB normal hearing level, respectively. Thus, it may be possible to treat childhood pyelonephritis with netilmicin once daily. However, this new approach needs to be confirmed in other studies.

Electrophysiological observations on the palmomental reflex in normal neonates

The authors report normative data on the electrical response (EMG response) recorded from the mentoneal muscles by repetitive mechanical stimulation of the thenar eminence surface of the hand in 18 neonates, 1 to 6 days old: the so-called palmomental reflex (PMR) or palm-chin reflex. PMR potentials showed in most cases great variability in amplitude and duration but not in latency, and they were present in all but one of the cases. The PMR was monolateral in one case only. Evoked potentials from the scalp were also recorded after electrical stimulation of the thenar eminence. The afferent branch of the PMR is constituted of impulses originating mainly from median nerve, skin and muscle receptors. Such impulses may reach facial motor nuclei following corticofugal pathways throughout a long-loop circuit.

[Criteria for selecting antibacterial drugs for use in newborn infants]

During the last years many advancements have been made in the field of clinical pharmacology. Nowadays we have a better understanding of the factors influencing absorption, distribution and elimination of antibacterial drugs in the newborn. However many problems have not been faced yet; of primary importance are earliness and aiming of therapy. Much has been written about the use of hematologic screening tests for an early diagnosis of sepsis and the use of tests for a rapid etiologic diagnosis. This is probably the result not only of the commonly encountered difficulty in making a clinical diagnosis of sepsis (based on clinical findings that are often insidious and aspecific) but also of the implications concerning either a "non-diagnosis" or a large use of antibacterial drugs. The choice of an appropriate antibacterial therapy in the newborn with sepsis implies a careful interpretation of the data concerning: 1) bacterial epidemiology and 2) sensitivity towards drugs of the bacterial most commonly identified in sepsis. For that purpose, it is important to distinguish between early and late sepsis and between the etiological agents more frequently responsible for the first and those for the later. Moreover it is important to consider the role of rapid tests in the etiological diagnosis, as a guide to the modification of the initial empirical therapy.

[Therapy of lower urinary tract infections in children]

Infection of the urinary tract has been described for nearly two centuries, yet the diagnosis, localization of infection, outcome, and management of UTI continue to generate significant problems. The two basic aims of treatment of UTI are the relief of symptoms and the prevention, or at least limitation, of damage to the renal parenchyma. The initial choice of an antimicrobial in the patient with a suspected UTI is based on knowledge of the expected organisms and their antimicrobial susceptibilities. The spectrum of urinary pathogens and their antibiotic susceptibility patterns in our geographical area are presented. Moreover therapeutic regimens in the treatment of upper and lower UTI are discussed.