The aim of our study was to determine the prevalence of genotypic resistance to nucleoside analog... more The aim of our study was to determine the prevalence of genotypic resistance to nucleoside analogues and protease inhibitors before and after 1997, the year of introduction of Highly Active Antiretroviral Therapy (HAART) in Campania (Italy). Forty-eight plasma HIV-RNA positive patients who had not been previously treated for HIV infection (naïve) were enrolled in two Divisions of Infectious Diseases. The main demographic characteristics were collected for each subject and the primary mutant genotypes were sought only in HIV-RNA positive patients with viral loads higher than 10,000 copies/ml. The diagnosis of HIV infection dated back to before 1996 for 21 out of 48 patients and to after 2000 for the other 27. INNO-Line Probe Assay (LiPA) HIV-RT and INNO-LiPA HIV protease (Innogenetics, Italy) were used to detect mutations conferring resistance to zidovudine, didanosine, zalcitabine, lamivudine, stavudine, saquinavir, indinavir, rotonavir, nelfinavir and amprenavir. No mutations associated with primary resistance to nucleoside analogues and protease inhibitors were detected in the 21 patients who had acquired HIV infection before 1996, whereas one or more mutations were seen in three of the 27 (11.1%) patients with HIV infection diagnosed after 2000. This study confirms that LiPA is a suitable tool for epidemiological surveys of HIV genotypic primary resistance. Drug-resistant HIV-1 genotypes, resistant both to nucleoside analogues and protease inhibitors, were detected only in subjects who had acquired HIV infection after 2000, most of whom had zidovudine-resistant mutants. These data suggest that the introduction of HAART has brought about the circulation of drug-resistant HIV genotypes.
Hyperosmolar therapies aim at controlling increased intracranial pressure (ICP) in patients with ... more Hyperosmolar therapies aim at controlling increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI). The aim of this study was to evaluate the effect of 7.5% hypertonic saline (HTS) on ICP and cerebral perfusion pressure (CPP) in children with severe TBI.
European Journal of Clinical Microbiology & Infectious Diseases, 2016
Staphylococcus aureus is an infrequent cause of community-associated (CA-SA) pneumonia in childre... more Staphylococcus aureus is an infrequent cause of community-associated (CA-SA) pneumonia in children. The aim of this study was to evaluate the clinical, epidemiological, microbiological, and molecular characteristics of CA-SA pneumonia among children hospitalized in two large tertiary care referral centers during an 8-year period. Cases of CA-SA pneumonia admitted between 2007 and 2014 were retrospectively examined through medical record review. Molecular investigation was performed for available strains; mecA, Panton-Valentine leukocidin (PVL) (lukS-lukF-PV), and fibronectin binding protein A (fnbA) genes were detected by polymerase chain reaction (PCR). Clones were assigned by agr groups, pulsed-field gel electrophoresis (PFGE), SCCmec, and multilocus sequencing typing (MLST). In total, 41 cases were recorded (boys, 61 %), with a median age of 4.3 months (range, 1-175). Methicillin-resistant S. aureus (MRSA) accounted for 31 cases (75.6 %). Complications included empyema (25/41, 61 %), pneumatoceles (7/41, 17 %), and lung abscess (1/41, 2.5 %). Intensive care unit (ICU) admission was required in 58.5 %. Two deaths occurred (4.9 %). Definitive therapy was based on vancomycin with or without other antibiotics (55.9 %), followed by clindamycin and linezolid (26.5 % each). All isolates were susceptible to vancomycin (MIC 90 2 mg/L, range 1-2), teicoplanin, and linezolid, whereas 26.8 % were resistant to clindamycin. Among the 25 studied strains, 20 were mecApositive (MRSA), carrying also the fnbA gene. Of these, 90 % belonged to the ST80-IV/agr3/PVL-positive clone. Methicillin-susceptible S. aureus (MSSA) strains showed polyclonality, 3/5 were PVL-positive, and 3/5 were fnbA-positive. MRSA and particularly the ST80-IV clone predominated among staphylococcal pneumonia cases in children. Treatment provided was effective in all but two patients, despite the relatively high minimum inhibitory concentration (MIC) of vancomycin and a high resistance to clindamycin.
Background: VLBWI mortality rates vary across NICUs, however few comparisons are available betwee... more Background: VLBWI mortality rates vary across NICUs, however few comparisons are available between different national networks. Aim: To compare and analyze differences in neonatal mortality rates of two VLBWI cohorts from Neonatal Networks in Spain and Japan. Methods: Risk/protective factors, complications, and morbi-mortality outcomes were compared among inborn VLBWI admitted to NICU´s from SEN-1500 (7,006 infants, 63 NICU's) and NRNJ (8,695 infants, 69 NICU's) from 2005 to 2007. Nonparametric independent comparison analysis and logistic regression models were performed to predict mortality adjusting for perinatal risks factors. Results: Significant differences were found in gestation [mean(SD); 29.3(2.9) vs. 28.6(3.3) wks] and birthweigh [1117(271) vs. 1031(304)g. Both, 28-days neonatal and pre-discharge mortality rates were significantly higher in SEN-1500 (12.5% and 14.7%) than in NRNJ (6.4 and 9.2%). Differences in mortality remained even when adjusting for GA, birthweight, prenatal steroid use, 1 and 5-min Apgar scores and presence of major congenital anomalies. There were many differences in clinical management among networks. In SEN-1500, use of surfactant and high frequency ventilation and DBP and PDA ligation rates were lower, but had higher rates of NEC, grades 3-4 IVH, and specially of sepsis (32.7% vs. 7.3%; p< 0.001). Conclusion: Differences in neonatal and predischarge mortality rates of VLBWI form SEN-1500 and NRNJ could not completely be explained by initial risk and protective factors. Sepsis-related mortality accounted for 61.3% of the excess mortality in SEN-1500. The implementation of systematic preventive strategies for sepsis seems mandatory.
Background: Healthcare-associated infections (HCAIs) are associated with increased morbidity and ... more Background: Healthcare-associated infections (HCAIs) are associated with increased morbidity and mortality and with excess costs. Central line-associated bloodstream infections (CLABSIs) are the most common HCAIs in neonates and children. Aim: To establish national benchmark data for rates of CLABSI in neonatal and paediatric intensive care units (NICUs and PICUs) and paediatric oncology units (ONCs). Methods: Active surveillance for CLABSI was conducted from June 2016 to February 2017. A collaborative of 14 NICUs, four PICUs, and six ONCs participated in the programme. Surveillance definitions of central line (CL), central line utilization (CLU) ratio, CLABSI event, and CLABSI rate were based on the Centers for Disease Control and Prevention's 2014 National Healthcare Safety Network criteria. Medical records were assessed daily for calculating CL-days, patient-days, and susceptibility of isolated organisms. Findings: A total of 111 CLABSI episodes were recorded. The overall mean CLABSI rate was 4.41 infections per 1000 CL-days, and the CLU ratio was 0.31. CLABSI rates were 6.02 in NICUs, 6.09 in PICUs, and 2.78 per 1000 CL-days in ONCs. A total of 123 pathogens were isolated. The most common pathogens were Enterobacteriaceae (36%), followed by Grampositive cocci (29%), non-fermenting Gram-negative bacteria (16%), and fungi (16%). Overall, 37% of Gram-negative pathogens were resistant to third-generation cephalosporins and 37% to carbapenems.
Κατάθλιψη και προβλήματα συναισθήματος και συμπεριφοράς παιδιών και εφήβων στην Ελλάδα: Αποτελέσματα επιδημιολογικής μελέτης σε εθνικό δείγμα
Σκοπός της μελέτης: Η εκτίμηση του επιπολασμού των καταθλιπτικών συμπτωμάτων των παιδιών και των ... more Σκοπός της μελέτης: Η εκτίμηση του επιπολασμού των καταθλιπτικών συμπτωμάτων των παιδιών και των προβλημάτων συναισθήματος και συμπεριφοράς των εφήβων στην Ελλάδα και η μελέτη των χαρακτηριστικών των παιδιών και εφήβων σε κίνδυνο. Υλικό και μέθοδος: Εθνικό αντιπροσωπευτικό δείγμα 548 παιδιών (46.53% αγόρια, μέση ηλικία: 10.20 έτη, σταθερή απόκλιση: 1.17) και 1194 εφήβων (40.07% αγόρια, μέση ηλικία: 13.60 έτη, σταθερή απόκλιση: 1.70) συμπλήρωσαν αντίστοιχα τα ερωτηματολόγια Children’s Depression Inventory (CDI) και Strengths and Difficulties Questionnaire (SDQ) παράλληλα με άλλα ερωτηματολόγια. Αποτελέσματα: Μεταξύ των παιδιών, 6.35% των αγοριών και 12.94% των κοριτσιών εμφάνισαν σοβαρό κίνδυνο για κατάθλιψη (βαθμολογία CDI ≥ 15). Η επίδραση του φύλου στην εμφάνιση των καταθλιπτικών συμπτωμάτων ήταν σημαντική (p < 0.05). Αντίθετα, η επίδραση της ηλικίας και της αλληλεπίδρασης φύλο x ηλικία δεν εμφάνισε στατιστικά σημαντική διαφορά. Οι κοινωνικο-οικονομικές διαφορές στα καταθλιπτικ...
Blood cultures are sometimes obtained from intravascular catheters for convenience. However, ther... more Blood cultures are sometimes obtained from intravascular catheters for convenience. However, there is controversy regarding this practice. The authors compared the diagnostic test characteristics of blood cultures obtained from intravascular catheters and peripheral veins. Relevant studies for inclusion in this review were identified through PubMed (January 1970-October 2005) and the Cochrane Central Register of Controlled Trials. Studies that reported clear definitions of true bacteraemia were included in the analysis. Two reviewers independently extracted the data. Six studies were included in the analysis, providing data for 2677 pairs of blood cultures obtained from an intravascular catheter and a peripheral venipuncture. A culture obtained from an intravascular catheter was found to be a diagnostic test for bacteraemia with better sensitivity (OR 1.85, 95 % CI 1.14-2.99, fixed effects model) and better negative predictive value (almost with statistical significance) (OR 1.55, 95 % CI 0.999"2.39, fixed effects model) but with less specificity (OR 0.33, 95 % CI 0.18-0.59, random effects model) and lower positive predictive value (OR 0.41, 95 % CI 0.23-0.76, random effects model) compared to a culture taken by peripheral venipuncture. In a group of 1000 patients, eight additional patients with true bacteraemia would be identified and 59 falsely diagnosed as having bacteraemia by a blood culture obtained from an intravascular catheter compared to results of the peripheral blood culture. Given the consequences of undertreating patients with bacteraemia, the authors believe that, based on the available evidence, at least one blood culture should be obtained from the intravascular catheter.
Background: Recommendations on withholding antibiotics in children with acute otitis media (AOM) ... more Background: Recommendations on withholding antibiotics in children with acute otitis media (AOM) have been inadequately implemented in clinical practice. Objectives: We evaluated the role of prescribing antibiotics for AOM. We performed a meta-analysis of randomized controlled trials (RCTs) that were retrieved from searches performed in the PubMed and Cochrane databases, and compared antibiotic treatment with placebo or watchful waiting (delayed antibiotic treatment if clinically indicated) for patients with AOM. Results: We identified seven trials comparing antibiotic treatment with placebo (all double-blinded) and four trials comparing antibiotic treatment with watchful waiting (two investigator-blinded and two open-label) trials, all of which involved children (6 months to 12 years). Clinical success was more likely with antibiotics than comparator treatment in: placebo-controlled trials [seven RCTs, 1405 patients, risk ratio (RR)51.11, 95% confidence interval (CI)51.05 -1.18]; watchful waiting trials (four RCTs, 915 patients, RR 51.18, 95% CI51.07-1.32); and all trials combined (11 RCTs, 2320 patients, RR 51.13, 95% CI51.08-1.19). Similarly, persistence of symptoms 2-4 days after treatment initiation was less likely with antibiotics in: placebo-controlled trials (four RCTs, 1014 patients, RR50.75, 95% CI 50.64-0.88) and all trials combined (five RCTs, 1299 patients, RR 50.68, 95% CI50.54-0.85). Diarrhoea was more likely with antibiotics (seven RCTs, 1807 patients, RR 51.50, 95% CI 51.16-1.95). No differences between the compared treatments were found regarding other effectiveness and safety outcomes. Conclusions: Antibiotic treatment is associated with a more favourable clinical course in children with AOM, compared with placebo, and also compared with watchful waiting. However, safety issues and the rather small treatment effect difference render the consideration of additional factors necessary in relevant clinical decision making.
R2293 Prevalence of genotypic resistance to nucleoside analogues, non-nucleoside analogues and protease inhibitors in HIV-infected persons in Athens, Greece
International Journal of Antimicrobial Agents, 2007
Prevalence of genotypic resistance to nucleoside analogues and protease inhibitors in Spain
AIDS, 2000
ABSTRACT To examine the prevalence of resistance mutations to nucleoside reverse transcriptase in... more ABSTRACT To examine the prevalence of resistance mutations to nucleoside reverse transcriptase inhibitors (NRTI) and protease inhibitors (PI) in a representative HIV-1 population in Spain. A cross-sectional study was conducted including 601 HIV-infected patients who attended 20 Spanish hospitals in June 1998. Drug resistant mutations were examined using hybridization line probe assays (LiPA). The 6 bp insert at position 69 and the codon 75 mutant were examined by sequencing analysis in specimens lacking reactivity to 69/70 and 74 bands on LiPA, respectively. Primary resistance to NRTI was recognized in nine out of 52 (17%) naive individuals, whereas primary resistance to PI was found in seven out of 126 (6%) PI-naïve patients. The codons most frequently involved in NRTI resistance were at positions 70 (66%), 184 (44%), 215 (33%), and 41 (11%), whereas the most common PI resistance mutation was at codon 82 (6/7 subjects). In pre-treated patients, the overall prevalence of resistant genotypes was 72.9% for NRTI and 27.2% for PI. The most frequent NRTI mutations occurred at codons 184 (38.5%), 215 (30.1%), and 41 (22.5%), whereas the most frequent PI mutations in pre-treated subjects were found at positions 82 (15.8%) and 84 (11.4%). Overall, patients who began triple combinations as initial therapy showed a lower number of key resistance mutations than those who began highly active antiretroviral therapy (HAART) after being exposed to NRTI for a period of time (mean number of mutations, 0.1 versus 1.8, P&lt; 0.05). Codon 75 mutant was found in three out of 387 patients (0.7%), whereas no insertions at codon 69 were recognized. The prevalence of primary genotypic resistance to NRTI and PI in Spain was 17% and 6%, respectively. Zidovudine, lamivudine, indinavir and ritonavir were the drugs most frequently affected. These data support the use of resistance testing prior to the introduction of first-line antiretroviral therapies in Spain. Among pre-treated subjects, drug resistance genotypes were less prevalent in those who began HAART as initial therapy.
The objective of this study is to determine the level of depressive symptoms among a sample of Gr... more The objective of this study is to determine the level of depressive symptoms among a sample of Greek children aged 8-12 years, as measured by the Greek Children's Depression Inventory (CDI), as well as to examine CDI's psychometric properties. A nationwide school-based sample of 650 children was initially recruited and depressive symptoms were assessed with the CDI among 538 children who provided all relevant information. Statistical evaluation included assessment of CDI internal reliability, test-retest reliability, determination of age, gender and socioeconomic status (SES) effects. Based on the distributions of CDI scores observed in this normative sample, a recommended cutoff score, identifying a high probability of serious levels of depressive symptoms that need to be further evaluated, was defined. Internal reliability and test-retest reliability were satisfactory and the expected associations with age and gender were observed. High SES was correlated with significantly less depression symptoms. The prevalence of depressive risk, when the cutoff point of 19 or 13 was taken as threshold, was much lower than those obtained from studies in other countries. The cutoff point of 15, corresponding to 90th percentile of the present sample, may be used as a screening threshold for further assessment. The present results are encouraging providing evidence about the psychometric properties of the CDI and implications for child mental health promotion planning in Greece. Further validation of the CDI against other measures and psychiatric diagnoses is needed.
Unintentional Acute Cyanide Poisoning of an Infant
Background: Cyanide ingestion is particularly dangerous because of the early onset of severe symp... more Background: Cyanide ingestion is particularly dangerous because of the early onset of severe symptoms, lack of suspicion and delay in diagnosis. Cyanide poisoning of infants is rare. Case Report: An 11-month old girl presented in the emergency department in coma, hypothermic, bradycardic and gasping for air, after the ingestion of an unknown substance, later identified as a cyanide containing jewel cleaning solution. Her laboratory tests revealed profound lactic acidosis. She was treated with the cyanide antidote kit with a rapid improvement of her clinical and laboratory state. Excessive methemoglobinemia was noted with no further adverse events. Her final outcome was excellent. Discussion: Although unintentional ingestion of household substances is often in young children, cyanide poisoning is rare since the sale of consumer products containing soluble cyanide salts is prohibited. Patients rapidly progress to a stuporous state and tissue hypoxia in the absence of cyanosis may be a...
Admissions due to vaccine preventable diseases in a large paediatric intensive care unit in Greece over a 10-year period
AIM Childhood immunisation is an important preventive measure. However, care givers may delay rou... more AIM Childhood immunisation is an important preventive measure. However, care givers may delay routine immunisations or seek exemptions from state vaccine mandates. Vaccine refusal creates barriers on vaccine coverage and leads to morbidity and mortality. METHODS Our study reviews morbidity and mortality from vaccine preventable diseases (VPDs) in a large paediatric intensive care unit in Greece over a 10-year period. RESULTS During the study period, 73 cases of VPDs were recorded, corresponding to 3.5% of total paediatric intensive care unit admissions. Influenza was the most prevalent VPD, followed by pneumococcal disease, measles, pertussis and meningococcal disease. Most patients (83.3%) were unvaccinated for the admission's VPD. Outcome was unfavourable for 31.9% of the patients (17 children died, 6 developed chronic impairment). CONCLUSION Absent or incomplete vaccination may result in serious morbidity and mortality from preventable diseases. Strengthening vaccination stra...
Rescue Decompressive Craniectomy in Children with Severe Traumatic Brain Injury
Journal of Pediatric Intensive Care
Decompressive craniectomy (DC) is considered a rescue therapy in patients with traumatic brain in... more Decompressive craniectomy (DC) is considered a rescue therapy in patients with traumatic brain injury (TBI) with increased intracranial pressure (ICP). In this retrospective study, we examined the impact of craniectomy on ICP in children with severe TBI and their neurological outcome. A total of 14 patients were enrolled. Peak ICP was significantly lower (31 ± 2.9 to 19 ± 4.6, p < 0.001) and minimum cerebral perfusion pressure (CPP) higher (41 ± 10.5 to 58 ± 11.4, p < 0.001) postcraniectomy. The survival rate was 71%. However, 57% of our cohort had a poor neurological outcome at 6 months postinjury. In conclusion, although rescue DC was effective in controlling ICP and CPP, the long-term neurological outcome remained poor.
Characteristics ofBordetella pertussisinfection among infantsand children admitted to paediatric intensive care units in Greece: A multicentre, 11-year study
Hyperosmolar therapies aim at controlling increased intracranial pressure (ICP) in patients with ... more Hyperosmolar therapies aim at controlling increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI). The aim of this study was to evaluate the effect of 7.5% hypertonic saline (HTS) on ICP and cerebral perfusion pressure (CPP) in children with severe TBI. Medical records of patients 14 years or younger with severe TBI, admitted in the pediatric intensive care unit of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Aghia Sophia&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital, Athens, Greece, during 2009 to 2015, and received HTS apart from mannitol were retrospectively reviewed. The ICP and CPP pre-HTS and 30, 60, and 120 minutes post-HTS infusion were evaluated. Furthermore, the presence of adverse effects, the long-term neurological outcome, and survival were recorded. Twenty-nine patients requiring in total 136 HTS infusions were analyzed. The ICP was significantly reduced and CPP elevated at 30, 60, and 120 minutes postinfusion; and furthermore, postadministration ICP and CPP were predominantly within acceptable limits. No significant adverse effects were recorded and most of the patients survived, however, one third had severe neurological impairment at 6 months postinjury. In our study, 7.5% HTS infusion as a second-tier osmotic therapy was associated with significant reduction of ICP and increase of CPP in children with severe TBI.
Early switch to oral versus intravenous antimicrobial treatment for hospitalized patients with acute pyelonephritis: a systematic review of randomized controlled trials
Current Medical Research and Opinion, Nov 7, 2008
Acute pyelonephritis is a common infection with significant morbidity and mortality, particularly... more Acute pyelonephritis is a common infection with significant morbidity and mortality, particularly in pediatric populations. Early-switch strategies (from intravenous to oral treatment) may be an acceptable or even preferred option in the treatment of patients with acute pyelonephritis in terms of effectiveness and safety and can also reduce the economical burden associated with pyelonephritis. We sought to evaluate the effectiveness and safety of early-switch strategies in hospitalized patients with acute uncomplicated pyelonephritis. We searched in PubMed, Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials (RCTs) that compared intravenous antibiotic regimens to regimens including an early switch to oral (after initial intravenous) treatment. Eight RCTs (6 in children) were eligible for inclusion. In 5 RCTs the intravenous antibiotic treatment arms were not switched to oral treatment until the end of the study while in the remaining 3 RCTs the intravenous arms were switched late to oral treatment (after 5-10 days). Data regarding the incidence of renal scars, microbiological eradication, clinical cure, reinfection, persistence of acute pyelonephritis, and adverse events were provided in 4 (all pediatric trials), 6 (4 pediatric), 4 (2 pediatric), 5 (3 pediatric), 3 (1 pediatric), and 5 RCTs (3 pediatric), respectively. There were no differences regarding the above outcomes between the two compared treatment regimens in either pediatric or adult populations. Early switch to oral antibiotic strategies seem to be as effective and safe as intravenous regimens for the treatment of hospitalized patients with acute pyelonephritis. These findings suggest that there is probably a potential to decrease the duration of intravenous treatment by 4-11 days in hospitalized patients with acute pyelonephritis without compromising their outcomes.
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