Análisis de orina y detección de infecciones graves en niños

 Fuente: Pediatria Basada en la evidencia.

Junio 2013 - Volumen 9 - Número 2

  PDF     English

AVC | Artículos Valorados Críticamente
De S, Williams GJ, Hayen A, Macaskill P, McCaskill M, Isaacs D, et al. Accuracy of the "traffic light" clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study. BMJ. 2013;346:f866¹. D.O.I.: 10.1136/bmj.f866.

Revisores: Ortega Páez E¹, Perdikidis Olivieri L<sup>2

1</sup>CS Maracena. Distrito metropolitano. Granada (España).
²EAP Juncal. Torrejón de Ardoz. Madrid (España).
Correspondencia: Eduardo Ortega Páez. Correo electrónico: edortegap@gmail.com


Fecha de aceptación: 10/05/2013   Fecha de publicación: 29/05/2013   

Resumen Estructurado

Objetivo: determinar la precisión de una regla de predicción clínica para la detección de tres tipos de infecciones graves (infección del tracto urinario [ITU], neumonía, y bacteriemia) junto con otras infecciones graves menos frecuentes (artritis, osteomielitis, meningitis, etc.). Además se valoró si la realización de un análisis de orina mejoraba el rendimiento de este sistema (sistema de semáforo para la detección de las tres infecciones graves  más frecuentes indicadas previamente).
Diseño: análisis retrospectivo de los datos procedentes de un estudio de cohortes realizado previamente (estudio FEVER) de julio 2004 a junio 2006, mediante la aplicación de la guía Standard for Reporting of Diagnostic Accuracy (STARD). Cada niño fue evaluado en el estudio original mediante la escala de triaje Australasiatica (5 niveles de gravedad clínica, siendo  el número 1 el más urgente). La información clínica se registró en un formato electrónico estandarizado. Las pruebas complementarias se solicitaron según criterio del clínico.
Emplazamiento: una unidad de Urgencias Pediátricas.
Población de estudio: 15 871 casos de niños menores de cinco años que acudían con un proceso febril al servicio de Urgencias Pediátricas. Se excluyeron los niños trasladados de otros hospitales, aquellos con procesos malignos, y los transplantados.
Intervención: los autores calcularon para los cuatro tipos de infecciones la sensibilidad y especificidad para dos umbrales de una prueba positiva (presencia de uno o más ítems en  la zona roja de la escala frente a la presencia de una o más ítems de la zona roja o ámbar) representando los resultados mediante curvas ROC.
Para el subgrupo de niños a los que se había realizado un análisis de orina se reevaluó el sistema comparando con y sin análisis de orina. Teniendo en cuenta cuatro umbrales para positividad en el análisis. Se construyeron los cocientes de probabilidad de la prueba positiva (CPP) con intervalos de confianza del 95%, análisis de la concordancia entre los ítems de la escala NICE y los campos del estudio FEVER.
Medición del resultado: se clasificaron los episodios febriles como de bajo, medio y alto riesgo de infección grave (zona verde, ámbar o rojo del sistema de semáforo NICE). Se utilizaron las pruebas microbiológicas y radiológicas como estándar de oro. La unidad de análisis fue el niño que consultaba por primera vez por fiebre (temperatura axilar mayor o igual a 38 ºC) en las primeras 24 horas. Los casos particulares se definieron adecuadamente. El seguimiento fue adecuado.
Resultados principales: combinando las categorías de riesgo intermedio y alto de infección bacteriana grave (IBG) los resultados de sensibilidad (S) fueron 85,8% (IC 95%: 83,6 a 87,7) y especificidad (E) de 28,5% ( IC 95%: 27,8% a 29,3%) para la detección de cualquier infección grave. Si se añadía la esterasa leucocitaria urinaria a la evaluación (68,8% de las infecciones graves no detectadas por la escala eran ITUs), los resultados fueron S: 92,1% (IC 95%: 89,3% a 94,1%) y E: 22,3% (IC 95%: 20,9 a 23,8%). Se realizó análisis de orina (mediante tira) en el 23,1% de todos los casos de niños con fiebre (métodos de recogida fueron variables). Para la detección de ITU la asociación de análisis de orina a la escala dio un CPP: 1,17 (IC 95%: 1,12 a 1,23). Para la detección de cualquier infección grave para la prueba combinada el CCP fue de 1,10 (IC 95%: 1,06 a 1,14).
Conclusión: el sistema NICE para predicción de infecciones graves no consiguió identificar una proporción considerable de infecciones graves sobre todo ITU. La asociación con el análisis de orina mejoró considerablemente su rendimiento.
Conflicto de intereses: los autores declaran no tener ninguno.

Comentario Crítico

Justificación: la fiebre es una de las causas más frecuentes de consulta tanto en Atención Primaria como en los Servicios de Urgencias Pediátricos. Los datos de estimación de prevalencia de IBG son muy dispares según las series publicadas y oscilan entre el 12,8 al 29% en niños menores de 36 meses (media ponderada de 18%)². Aunque la causa más frecuente de la fiebre son las infecciones virales, es importante en estos pacientes realizar reglas de decisión que clasifique el riesgo potencial de IBG. La Guía de práctica clínica del NICE³ clasifica según una serie de criterios clínicos el riesgo de presentar IBG como bajo, medio o grave. El trabajo que comentamos intenta validar esta regla de decisión.
Valor o rigor científico: la población del estudio está claramente definida con mención de los criterios de inclusión y exclusión, así como las variables predictivas. El tamaño muestral es adecuado. El patrón de referencia de las pruebas microbiológicas y radiológicas está bien definido. Se asegura el seguimiento de los pacientes posteriores a la intervención. Los resultados se dan de forma adecuada con valoración de medidas de impacto con sus intervalos de confianza. Pero existen una serie de debilidades, como son el hecho de que el trabajo sea retrospectivo, que su diseño no fue hecho para probar la regla de decisión si no para valorar las causas de infecciones bacterianas ocultas en general, la aplicación de uno de los patrones de referencia (la detección de ITU mediante tira reactiva de orina), solo a un grupo de sujetos (23,1%) según el criterio individual del médico que le atendiera y la falta de cegamiento en los evaluadores. La vacunación previa (neumococo, meningococo) podría hacer que existiera una subrepresentación de IBG. Todo ello podría sesgar los resultados hacia la disminución de la efectividad de la variable de resultado que se está analizando.
Importancia clínica: aplicando la regla NICE y añadiendo la esterasa leucocitaria y la realización de nitritos en orina (NICE II) para la detección IBG combinando los riesgos moderado y alto, los autores obtienen un CPP de 1,17 (IC 95%: 1,12 a 1,23), un cociente de probabilidad negativo (CPN) de 0,35%; y para la detección de infección bacteriana en general un CPP de 1,10 (IC 95%: 1,06 a 1,14). Estos resultados indican que la ganancia diagnóstica es muy pobre, ya que sus valores son muy cercanos a la unidad, probablemente por que la prueba se ha aplicado a un número escaso de sujetos. Esto supondría una pérdida de 0,2% en el diagnóstico (probabilidad IBG según NICE: 20,85% y probabilidad según NICE II: 20,65%)* y una ganancia en descartar la enfermedad de 2,65% (probabilidad de descartar la enfermedad según NICE: 9,86% y según NICE II: 7,2%)*. Otras escalas de decisión clínica como la de YALE⁴ presentan ganancia algo mejores para la prueba positiva (25,7%) pero peores par la prueba negativa (17,71). Mas recientemente se han publicado reglas de decisión con la adición de pruebas diagnósticas como la procalcitonina (PCT) y la proteína C reactiva (PCR)⁵ o la saturación O₂⁶, aumentando la capacidad predictiva de forma notable.
Aplicabilidad clínica: la aplicación de la regla NICE II no sería válida para diagnostico de IBG, pero si para descartarla. La adición de esterasa leucocitaria y nitritos en la orina es una prueba fácil, accesible y poco costosa, lo que le hace especialmente útil en Atención Primaria frente a otras reglas de decisión mas costosas y de difícil acceso como añadir PCR y/o PCT. No obstante, serían necesarios más estudios de diseño adecuado aplicando la esterasa leucocitaria y los nitritos a todos los pacientes, para intentar conocer el alcance real de esta nueva regla.
Conflicto de intereses de los autores del comentario: no existe.
* Datos calculados por los revisores a partir del articulo original.

Cómo citar este artículo

Ortega Páez E. Perdikidis L. El análisis de orina podría mejorar el rendimiento de la escala NICE para la detección de infecciones graves en niños. Evid Pediatr. 2013;7:30.

Bibliografía

1. Williams GJ, Hayden A, McCaskill P, McCaskill M, Isaacs D, et al. Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study. BMJ. 2013;346:f866.
2. Marin Reina P, Ruiz Alcántara I, Vidal Micó S, López-Prats Lucea JL, Modesto i Alapont, V. Exactitud del test de procacitonina en el diagnóstico de bacteriemia oculta en pediatría: revisión sistemática y metanálisis. An Pediatr (Barc). 2010;72:403-12.
3. National Collaborating Centre for Women’s and Children’s Health. Feverish illness in children: assessment and initial management in children younger than five years. RCOG Press, 2007.
4. Teach SJ, Fleisher GR. Efficacy of an observation scale in detecting bacteremia in febrile children three to thirty-six months of age, treated as outpatients. Occult Bacteremia Study Group. J Pediatr. 1995;126:877-81.
5. Gomez B, Bressan S, Mintegi S, Da Dalt L, Blazquez D, Olaciregui I, et al. Diagnostic value of procalcitonin in well-appearing young febrile infants. Pediatrics. 2012;130:815-22.
6. Nijman RG, Vergouwe Y, Thompson M, vanVeen N, vanMeurs AHJ, Vander Lei J, et al. Clinical prediction model to aid emergency doctors managing febrile children at risk of serious bacterial infections. Diagnostic study. BMJ. 2013;346:f170.

incipiente Otitis media acuta - Hyperämie (Photo credit: Wikipedia)

Cochrane Database Syst Rev. 2012 Sep 12;9:CD009163. doi: 10.1002/14651858.CD009163.pub2.

Antibiotics for otitis media with effusion in children. 

van Zon A, van der Heijden GJ, van Dongen TM, Burton MJ, Schilder AG.

Source

Department of Otorhinolaryngology & Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht,Utrecht, Netherlands. alicevanzon@gmail.com.

Abstract

BACKGROUND:

Otitis media with effusion (OME) is characterised by an accumulation of fluid in the middle ear behind an intact tympanic membrane, without the symptoms or signs of acute infection. In approximately one in three children with OME, however, a bacterial pathogen is identified in the middle ear fluid. In most cases, OME causes mild hearing impairment of short duration. When experienced in early life and when episodes of (bilateral) OME persist or recur, the associated hearing loss may be significant and have a negative impact on speech development and behaviour. Since most cases of OME will resolve spontaneously, only children with persistent middle ear effusion and associated hearing loss potentially require treatment. Previous Cochrane reviews have focused on the effectiveness of ventilation tube insertion, adenoidectomy, autoinflation, antihistamines, decongestants, and oral and topical intranasal steroids in OME. This review focuses on the effectiveness of antibiotics in children with OME.

OBJECTIVES:

To assess the effects of antibiotics in children up to 18 years with OME.

SEARCH METHODS:

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 22 February 2012.

SELECTION CRITERIA:

Randomised controlled trials comparing oral antibiotics with placebo, no treatment or therapy of unproven effectiveness. Our primary outcome was complete resolution of OME at two to three months. Secondary outcomes included resolution of OME at other time points, hearing, language and speech, ventilation tube insertion and adverse effects.

DATA COLLECTION AND ANALYSIS:

Two authors independently extracted data using standardised data extraction forms and assessed the quality of the included studies using the Cochrane 'Risk of bias' tool. We presented dichotomous results as risk differences as well as risk ratios, with their 95% confidence intervals. If heterogeneity was greater than 75% we did not pool data.

MAIN RESULTS:

We included 23 studies (3027 children) covering a range of antibiotics, participants, outcome measures and time points of evaluation. Overall, we assessed the studies as generally being at low risk of bias.Our primary outcome was complete resolution of OME at two to three months. The differences (improvement) in the proportion of children having such resolution (risk difference (RD)) in the five individual included studies ranged from 1% (RD 0.01, 95% CI -0.11 to 0.12; not significant) to 45% (RD 0.45, 95% CI 0.25 to 0.65). Results from these studies could not be pooled due to clinical and statistical heterogeneity.Pooled analysis of data for complete resolution at more than six months was possible, with an increase in resolution of 13% (RD 0.13, 95% CI 0.06 to 0.19).Pooled analysis was also possible for complete resolution at the end of treatment, with the following increases in resolution rates: 17% (RD 0.17, 95% CI 0.09 to 0.24) for treatment for 10 days to two weeks, 34% (RD 0.34, 95% CI 0.19 to 0.50) for treatment for four weeks, 32% (RD 0.32, 95% CI 0.17 to 0.47) for treatment for three months, and 14% (RD 0.14, 95% CI 0.03 to 0.24) for treatment continuously for at least six months.We were unable to find evidence of a substantial improvement in hearing as a result of the use ofantibiotics for otitis media with effusion; nor did we find an effect on the rate of ventilation tube insertion. We did not identify any trials that looked at speech, language and cognitive development or quality of life. Data on the adverse effects of antibiotic treatment reported in six studies could not be pooled due to high heterogeneity. Increases in the occurrence of adverse events varied from 3% (RD 0.03, 95% CI -0.01 to 0.07; not significant) to 33% (RD 0.33, 95% CI 0.22 to 0.44) in the individual studies.

AUTHORS' CONCLUSIONS:

The results of our review do not support the routine use of antibiotics for children up to 18 years with otitis media witheffusion. The largest effects of antibiotics were seen in children treated continuously for four weeks and three months. Even when clear and relevant benefits of antibiotics have been demonstrated, these must be balanced against the potential adverse effects when making treatment decisions. Immediate adverse effects of antibiotics are common and the emergence of bacterial resistance has been causally linked to the widespread use ofantibiotics for common conditions such as otitis media.

PMID:

 

22972136

 

[PubMed - indexed for MEDLINE]

Full Text: 

otitismediaefusion cochrane2012.pdf (860 KB)

https://mega.co.nz/#!4tc3zKgL!bxwes0RBKMXdbQnzqBSjZ2MDu2AM4a5X3Q9oD9pcIH4

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Pediatric deaths due to varicella are becoming a thing of the past

                       Image via Wikipedia Source: MD Consult

ST LOUIS (MD Consult) - With implementation of the varicella vaccination program in the United States, deaths due to the disease among children and adolescents have virtually ceased, finds a study reported in the August 2011 issue of Pediatrics.

Using data from the Mortality Multiple Cause-of-Death records of the US National Center for Health Statistics, investigators analyzed temporal patterns of deaths among individuals of all ages for which varicella was listed as an underlying or contributing cause between 1990 and 2007. The vaccination program was introduced in 1995.

Over the first 12 years of the program, the annual average mortality rate for varicella listed as the underlying cause fell by 88%, from 0.41 per million population in 1990-1994 to 0.05 per million population in 2005-2007.

The same pattern was evident across all age-groups. The reduction was 97%, 90%, and 67% among children and adolescents younger than 20 years, among adults aged 20 to 49 years, and among adults aged 50 years or older, respectively.

In the last 6 years analyzed (2002-2007), there were 3 deaths each among children aged 1 to 4 years and aged 5 to 9 years; in sharp contrast, there were an average of 13 and 16 deaths annually, respectively, before the vaccine was introduced.

All of the deaths among children and adolescents younger than 20 years in 2002-2007 occurred in those who did not have high-risk conditions as strictly defined by the study, although 3 occurred in children or adolescents having conditions that could increase risk.

"The impressive decline in varicella deaths can be directly attributed to successful implementation of the 1-dose vaccination program," the investigators conclude. "With the current 2-dose program, there is potential that these most severe outcomes of a vaccine-preventable disease could be eliminated."

Pediatrics. 2011;128:214-220. 

 

• Did the varicella zoster vaccine prove to be effective long term?
• A prospective cohort study evaluated the long-term effectiveness of the vaccine, its impact on varicella and herpes zoster epidemiology, and the impact of a second dose of the vaccine.
• Long-term follow-up demonstrated that varicella vaccination was effective at preventing chicken pox and seemed to lower risk of herpes zoster over a 14-year period.

---

SUMMARY

Practice Update Editorial Team

Vaccination of children for varicella zoster virus (VZV) has substantially decreased incidence of disease. Before the vaccine was licensed and recommended in the United States, VZV infection was highly prevalent, with more than 90% of people experiencing an infection by the age of 20 years. The efficacy of one dose of this medication was shown to be high in clinical trials, with a recent implementation of a second dose showing increased effectiveness in multiple studies. The overall effect of this vaccination on herpes zoster (HZ) incidence is not well understood.
In this prospective cohort study, Baxter et al aimed to assess the long-term effectiveness of the vaccine, its impact on varicella and HZ epidemiology, and the impact of the second dose, which was introduced in 2006. The study was conducted at multiple Kaiser Permanente Northern California sites and included children 12 to 23 months of age who received varicella vaccination in 1995. Consenting parents were interviewed via telephone every 6 months for 14 years, until 2009. Outcomes included breakthrough cases of varicella, number of lesions, and rates of HZ. Person-time was calculated based on the interview cycle.
The analytic cohort included 7386 patients and a total of 103,098 person-years (PY) were collected. In the 14 years after varicella vaccination, there were 1505 cases of breakthrough varicella. All cases followed the first vaccine dose. No cases of breakthrough were reported after the second dose was received. The average incidence was 15.9 cases per 1000 PY (95% CI, 15.1–16.7). This finding represented a 9 to 10 times lower rate of incidence as compared with same-aged children in the era preceding vaccination. Effectiveness was 89% to 90%, depending on the reference study. Of the 113 reported cases of HZ, 46 cases were confirmed. This finding represented an incidence rate of 0.45 per 1000 PY (95% CI, 0.33–0.60). Compared to similar children who experienced naturally acquired varicella, this finding suggested a 40% decreased incidence in those who were vaccinated.
This prospective cohort study showed, over 14 years of follow-up, varicella vaccination was effective in preventing VZV, with no evidence of waning effectiveness. Further, findings suggested a decreased incidence rate of HZ among vaccinated children as compared with unvaccinated children of the same age.

 

Long-term Effectiveness of Varicella Vaccine: A 14-Year, Prospective Cohort Study

1. Roger Baxter, MD^a,
2. Paula Ray, MPH^a,
3. Trung N. Tran, MD, PhD^b,
4. Steve Black, MD^c,
5. Henry R. Shinefield, MD^d,
6. Paul M. Coplan, ScD, MBA^e,
7. Edwin Lewis, MPH^a,
8. Bruce Fireman, MA^a, and
9. Patricia Saddier, MD, PhD^b

+ Author Affiliations

1. ^aKaiser Permanente Vaccine Study Center, Oakland, California;
2. ^bEpidemiology Department, Merck Sharp & Dohme Corp, Whitehouse Station, New Jersey;
3. ^cCenter for Global Health, Cincinnati Children’s Hospital, Cincinnati, Ohio;
4. ^dUniversity of California San Francisco Medical Center, University of California, San Francisco, San Francisco, California; and
5. ^ePurdue Pharma, Stamford, Connecticut

Abstract from Pediatrics

BACKGROUND: Varicella vaccine was licensed in the United States in 1995 for individuals ≥12 months of age. A second dose was recommended in the United States in June 2006. Varicella incidence and vaccine effectiveness were assessed in a 14-year prospective study conducted at Kaiser Permanente Northern California.

METHODS: A total of 7585 children vaccinated with varicella vaccine in their second year of life in 1995 were followed up prospectively for breakthrough varicella and herpes zoster (HZ) through 2009. A total of 2826 of these children received a second dose in 2006–2009. Incidences of varicella and HZ were estimated and compared with prevaccine era rates.

RESULTS: In this cohort of vaccinated children, the average incidence of varicella was 15.9 per 1000 person-years, nine- to tenfold lower than in the prevaccine era. Vaccine effectiveness at the end of the study period was 90%, with no indication of waning over time. Most cases of varicella were mild and occurred early after vaccination. No child developed varicella after a second dose. HZ cases were mild, and rates were lower in the cohort of vaccinated children than in unvaccinated children during the prevaccine era (relative risk: 0.61 [95% confidence interval: 0.43–0.89]).

CONCLUSIONS: This study confirmed that varicella vaccine is effective at preventing chicken pox, with no waning noted over a 14-year period. One dose provided excellent protection against moderate to severe disease, and most cases occurred shortly after the cohort was vaccinated. The study data also suggest that varicella vaccination may reduce the risks of HZ in vaccinated children.