To inform next steps in pediatric diarrhea burden reduction by understanding the shifting enteropathogen landscape after rotavirus vaccine implementation.
We conducted a case-control study of 1788 ...medically attended children younger than 5 years, with and without gastroenteritis, after universal rotavirus vaccine implementation in Peru. We tested case and control stools for 5 viruses, 19 bacteria, and parasites; calculated coinfection-adjusted attributable fractions (AFs) to determine pathogen-specific burdens; and evaluated pathogen-specific gastroenteritis severity using Clark and Vesikari scales.
Six pathogens were independently positively associated with gastroenteritis: norovirus genogroup II (GII) (AF 29.1, 95% confidence interval CI: 28.0-32.3), rotavirus (AF 8.9, 95% CI: 6.8-9.7), sapovirus (AF 6.3, 95% CI: 4.3-7.4), astrovirus (AF 2.8, 95% CI: 0.0-4.0); enterotoxigenic Escherichia coli heat stable and/or heat labile and heat stable (AF 2.4, 95% CI: 0.6-3.1), and Shigella spp. (AF 2.0, 95% CI: 0.4-2.2). Among typeable rotavirus cases, we most frequently identified partially heterotypic strain G12P8 (54 of 81, 67%). Mean severity was significantly higher for norovirus GII-positive cases relative to norovirus GII-negative cases (Vesikari 12.7 vs 11.8; P < .001 and Clark 11.7 vs 11.4; P = .016), and cases in the 6- to 12-month age range relative to cases in other age groups (Vesikari 12.7 vs 12.0; P = .0002 and Clark 12.0 vs 11.4; P = .0016).
Norovirus is well recognized as the leading cause of pediatric gastroenteritis in settings with universal rotavirus vaccination. However, sapovirus is often overlooked. Both norovirus and sapovirus contribute significantly to the severe pediatric disease burden in this setting. Decision-makers should consider multivalent vaccine acquisition strategies to target multiple caliciviruses in similar countries after successful rotavirus vaccine implementation.
Abstract Background Pneumonia is a leading cause of morbidity and mortality in children worldwide; however, its diagnosis can be challenging, especially in settings where skilled clinicians or ...standard imaging are unavailable. We sought to determine the diagnostic accuracy of lung ultrasound when compared to radiographically-confirmed clinical pediatric pneumonia. Methods Between January 2012 and September 2013, we consecutively enrolled children aged 2–59 months with primary respiratory complaints at the outpatient clinics, emergency department, and inpatient wards of the Instituto Nacional de Salud del Niño in Lima, Peru. All participants underwent clinical evaluation by a pediatrician and lung ultrasonography by one of three general practitioners. We also consecutively enrolled children without respiratory symptoms. Children with respiratory symptoms had a chest radiograph. We obtained ancillary laboratory testing in a subset. Results Final clinical diagnoses included 453 children with pneumonia, 133 with asthma, 103 with bronchiolitis, and 143 with upper respiratory infections. In total, CXR confirmed the diagnosis in 191 (42%) of 453 children with clinical pneumonia. A consolidation on lung ultrasound, which is our primary endpoint for pneumonia, had a sensitivity of 88.5%, specificity of 100%, and an area under-the-curve of 0.94 (95% CI 0.92–0.97) when compared to radiographically-confirmed clinical pneumonia. When any abnormality on lung ultrasound was compared to radiographically-confirmed clinical pneumonia the sensitivity increased to 92.2% and the specificity decreased to 95.2%, with an area under-the-curve of 0.94 (95% CI 0.91–0.96). Conclusions Lung ultrasound had high diagnostic accuracy for the diagnosis of radiographically-confirmed pneumonia. Added benefits of lung ultrasound include rapid testing and high inter-rater agreement. Lung ultrasound may serve as an alternative tool for the diagnosis of pediatric pneumonia.
Community-acquired pneumonia remains the leading cause of death in children worldwide, and current diagnostic guidelines in resource-poor settings are neither sensitive nor specific. We sought to ...determine the ability to correctly diagnose radiographically confirmed clinical pneumonia when diagnostics tools were added to clinical signs and symptoms in a cohort of children with acute respiratory illnesses in Peru.
Children < 5 years of age with an acute respiratory illness presenting to a tertiary hospital in Lima, Peru, were enrolled. The ability to predict radiographically confirmed clinical pneumonia was assessed using logistic regression under four additive scenarios: clinical signs and symptoms only, addition of lung auscultation, addition of oxyhemoglobin saturation (Spo
), and addition of lung ultrasound.
Of 832 children (mean age, 21.3 months; 59% boys), 453 (54.6%) had clinical pneumonia and 221 (26.6%) were radiographically confirmed. Children with radiographically confirmed clinical pneumonia had lower average Spo
than those without (95.9% vs 96.6%, respectively; P < .01). The ability to correctly identify radiographically confirmed clinical pneumonia using clinical signs and symptoms was limited (area under the curve AUC = 0.62; 95% CI, 0.58-0.67) with a sensitivity of 66% (95% CI, 59%-73%) and specificity of 53% (95% CI, 49%-57%). The addition of lung auscultation improved classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 75% (95% CI, 69%-81%) and specificity of 53% (95% CI, 49%-57%) for the presence of crackles. In contrast, the addition of Spo
did not improve classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 40% (95% CI, 33%-47%) and specificity of 72% (95% CI, 68%-75%) for an Spo
≤ 92%. Adding consolidation on lung ultrasound was associated with the largest improvement in classification (AUC = 0.85; 95% CI, 0.82-0.89) with a sensitivity of 55% (95% CI, 48%-63%) and specificity of 95% (95% CI, 93%-97%).
The addition of lung ultrasound and auscultation to clinical signs and symptoms improved the ability to correctly classify radiographically confirmed clinical pneumonia. Implementation of auscultation- and ultrasound-based diagnostic tools can be considered to improve diagnostic yield of pneumonia in resource-poor settings.
Community-acquired pneumonia remains the leading cause of death in children worldwide, and current diagnostic guidelines in resource-poor settings are neither sensitive nor specific. We sought to ...determine the ability to correctly diagnose radiographically confirmed clinical pneumonia when diagnostics tools were added to clinical signs and symptoms in a cohort of children with acute respiratory illnesses in Peru.
Children < 5 years of age with an acute respiratory illness presenting to a tertiary hospital in Lima, Peru, were enrolled. The ability to predict radiographically confirmed clinical pneumonia was assessed using logistic regression under four additive scenarios: clinical signs and symptoms only, addition of lung auscultation, addition of oxyhemoglobin saturation (Spo2), and addition of lung ultrasound.
Of 832 children (mean age, 21.3 months; 59% boys), 453 (54.6%) had clinical pneumonia and 221 (26.6%) were radiographically confirmed. Children with radiographically confirmed clinical pneumonia had lower average Spo2 than those without (95.9% vs 96.6%, respectively; P < .01). The ability to correctly identify radiographically confirmed clinical pneumonia using clinical signs and symptoms was limited (area under the curve AUC = 0.62; 95% CI, 0.58-0.67) with a sensitivity of 66% (95% CI, 59%-73%) and specificity of 53% (95% CI, 49%-57%). The addition of lung auscultation improved classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 75% (95% CI, 69%-81%) and specificity of 53% (95% CI, 49%-57%) for the presence of crackles. In contrast, the addition of Spo2 did not improve classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 40% (95% CI, 33%-47%) and specificity of 72% (95% CI, 68%-75%) for an Spo2 ≤ 92%. Adding consolidation on lung ultrasound was associated with the largest improvement in classification (AUC = 0.85; 95% CI, 0.82-0.89) with a sensitivity of 55% (95% CI, 48%-63%) and specificity of 95% (95% CI, 93%-97%).
The addition of lung ultrasound and auscultation to clinical signs and symptoms improved the ability to correctly classify radiographically confirmed clinical pneumonia. Implementation of auscultation- and ultrasound-based diagnostic tools can be considered to improve diagnostic yield of pneumonia in resource-poor settings.
ABSTRACT
Background:
Acute diarrhea is an important cause of morbidity and mortality in children. Oral rehydration salts (ORS) have lowered mortality without having an effect on the duration or ...severity of diarrhea. Some studies have reported that heat‐killed Lactobacillus bacteria have a beneficial effect in the treatment of acute diarrhea. In this placebo‐controlled study the duration of diarrhea was compared for 2 types of treatment: Lactobacillus LB (Lacteol) in association with oral rehydration and oral rehydration alone.
Patients and Methods:
A total of 80 nondehydrated children between the ages of 3 months and 4 years with acute watery diarrhea were randomly assigned to be treated with Lactobacillus LB or placebo plus ORS. The primary endpoint was the duration of diarrhea; intake of ORS and change in body weight between the time of randomization and the last assessment were also measured.
Results:
In 71 of the 80 patients, diarrhea was resolved: 36 in the Lactobacillus LB group and 35 in the placebo group. Several clinical characteristics of the 2 treatment groups were comparable at baseline. Median duration of diarrhea was 16.6 hours in the placebo group compared with 10.0 hours in the Lactobacillus LB group (P = 0.275). In the subgroup with a duration of diarrhea of more than 24 hours at inclusion, duration of diarrhea measured from that point was shorter for the Lactobacillus LB group (30.4 h vs 8.2 h; P = 0.044). ORS intake was similar for both groups. Lactobacillus LB was well tolerated, with only one patient experiencing an adverse effect.
Conclusions:
Lactobacillus LB is an effective and safe treatment for children with well‐established diarrhea (>24 h).
Bismuth subsalicylate has been in common use in the United States for more than 75 years as an over-the-counter treatment for diarrhea,
1
but only recently have its efficacy and safety been assessed ...through controlled clinical trials. Controlled studies indicate that this treatment is effective and prevents traveler's diarrhea
2
. DuPont et al.
3
showed that bismuth subsalicylate reduced the frequency of unformed stools, increased stool consistency, and decreased the frequency of nausea and abdominal cramps in American students residing in Mexico. Steinhoff et al.
4
found bismuth to have a beneficial effect when given for viral gastroenteritis due to Norwalk agent. Bismuth . . .
Bismuth in Infants with Watery Diarrhea Abramson, J S; Givner, L B; Woods, Jr, C R
The New England journal of medicine,
12/1993, Letnik:
329, Številka:
23
Journal Article
Recenzirano
To the Editor:
Figueroa-Quintanilla et al. (June 10 issue)
1
state that bismuth subsalicylate could be a useful, safe, and cost-effective adjunct to oral rehydration and nutritional therapy in ...children with acute watery diarrhea. We are surprised that they did not consider the risk of Reye's syndrome, since the use of aspirin, a salicylate-containing drug, has been associated with an increased risk of this syndrome. Whether or not there is an increased risk of Reye's syndrome with the use of bismuth subsalicylate remains to be determined. The syndrome, however, has been reported in patients whose only exposure to salicylates was to . . .
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