Top PDF CLINICAL PROFILE OF ACUTE LOWER RESPIRATORY TRACT INFECTIONS IN CHILDREN BETWEEN 2MONTHS TO 5 YEARS

ABSTRACT: BACKGROUND: Acute respiratory infections are a leading cause of morbidity and mortality in under-five children in developing countries. Hence, the present study was undertaken to study the various risk factors, clinical profile and outcome of acute lower respiratory tract infections (ALRI) in children aged 2 month to 5 years. OBJECTIVE: clinical features, laboratory assessment and morbidity and mortality pattern associated with acute lower respiratory tract infections in children aged 2 months to 5 years. METHODS: 100 ALRI cases fulfilling WHO criteria for pneumonia, in the age group of 2 month to 5 years were evaluated for clinical profile as per a predesigned proforma in a rural medical college. RESULTS: Of cases 61% were infants and remaining 39%12-60 months age group, males outnumbered females with sex ratio of 1.3;1. Elevated total leukocyte counts for age were observed in only 22% of cases, of these 3% were having pneumonia, 9% severe pneumonia and 10% very severe pneumonia. Significant association was found between leukocytosis and ALRI severity (p=0.0001) Positive blood culture was obtained in 8% of cases and was significantly associated with ALRI severity (p=.0.027). Among the ALRI cases, 84% required oxygen supplementation at any time during the hospital stay and 8% required mechanical ventilation. The mortality rate was 1%; with 99% of cases recovering and getting discharged uneventfully. CONCLUSION: Among the clinical variables, the signs and symptoms of ALRI as per the WHO ARI Control Programme were found in almost all cases. Regarding the laboratory profile, leukocytosis and blood culture positivity were observed in a small percentage, but significant association with ALRI severity was observed for both. Thus, clinical signs, and not invasive blood tests are a better diagnostic tools, though the latter may provide additional therapeutic and prognostic information in severe disease.

Viruses are the major cause of lower respiratory tract infections in childhood and the main viruses involved are Human Respiratory Syncytial Virus (HRSV), Human Metapneumovirus (HMPV), Influenzavirus A and B (FLUA and FLUB), Human Parainfluenza Virus 1, 2 and 3 (HPIV1, 2 and 3) and Human Rhinovirus (HRV). The purposes of this study were to detect respiratory viruses in hospitalized children younger than six years and identify the influence of temperature and relative air humidity on the detected viruses. Samples of nasopharyngeal washes were collected from hospitalized children between May/2004 and September/2005. Methods of viral detection were RT-PCR, PCR and HRV amplicons were confirmed by hybridization. Results showed 54% (148/272) of viral positivity. HRSV was detected in 29% (79/272) of the samples; HRV in 23.1% (63/272); HPIV3 in 5.1% (14/272); HMPV in 3.3% (9/272); HPIV1 in 2.9% (8/272); FLUB in 1.4% (4/272), FLUA in 1.1% (3/272), and HPIV2 in 0.3% (1/272). The highest detection rates occurred mainly in the spring 2004 and in the autumn 2005. It was observed that viral respiratory infections tend to increase as the relative air humidity decreases, showing significant association with monthly averages of minimal temperature and minimal relative air humidity. In conclusion, viral respiratory infections vary according to temperature and relative air humidity and viral respiratory infections present major incidences it coldest and driest periods.

Acute respiratory infections (ARI) are important causes of morbidity and mortality worldwide, affecting mainly children under five years old. These infections can be caused by different organisms, but viruses are the most frequent. This study aimed to describe clinical and epidemiological aspects of viral ARI in children 0-12 years of age treated in the emergency department of a tertiary hospital in the city of Fortaleza, from January 2007 to December 2008. Therefore, we collected 1318 samples of nasopharyngeal secretions of children. The samples were subjected to indirect immunofluorescence for detection of the following respiratory viruses: respiratory syncytial virus (RSV), human metapneumovirus (hMPV), adenovirus, influenza A and B and parainfluenza 1, 2 and 3. The results of this study showed that at least one respiratory virus was detected in 383 (29.1%) samples. The most prevalent virus was RSV (44.4%), and presented the same seasonal pattern of a defined association with the rainy season. Co-infection occurred in 12 (3.1%) samples and RSV was the most frequently associated. The average age of patients was 23 months and there was no association between gender of these patients and positivity of the tests, although most children were male. Among the clinical diagnoses of viral etiology, there was predominance of upper respiratory infection diseases (URID) (51.2%), and in relation to the specific diagnosis of the lower respiratory infections diseases (LRID), stood out pneumonia. Therefore, the results of this study highlight the importance of viruses as causes of ARI in children in Fortaleza, with the highest rates occurring between the months March to June, differing from the southern region, where the highest rates are found in the months from July to October.

The proportion of mild to severe disease varies between high and low income countries 12 . The severity of lower respiratory tract infections in children younger than five years is worse in developing countries, resulting in a higher case-fatality rate 12 . The costs of ARTI are enormous, as they lead children and their family to health care facilities with a remarkable number of doctor´s visits, hospital admissions and health care costs 6,13,14. In the United States of America (USA), URTI are the most common illness, responsible for absence from work or school 15 . In developed countries, ARTI are the leading cause of morbidity, accounting for 20% of medical consultations, 30% of labor absenteeism and 75% of all drug prescriptions 16,10 . Many of these prescriptions are unnecessary because drug therapy has little or none effect on viral URTI 10 .

In United States, It was believed that Mycoplasmas to be responsible for 15-20% of all cases of Community- Acquired Pneumonia (CAP) between 1962 and 1975 in Seattle, Washington (Foy, 1993). An serological studies conducted in Denmark, showed a pattern of M. pneumoniae infections over a 50-year period from 1946 through 1995 with endemic disease transmission punctuated with cyclic epidemics every 3-5 years (Lind et al., 1997). A number of well-described outbreaks of M. pneumonia respiratory infections in the community and in closed or semi-closed settings such as military bases, hospitals, religious communities, schools and institutions for the mentally or developmentally disabled have been reported. Even though long-term morbidity is uncommon, the acute illnesses are often disruptive and can consume significant resources (Waites and Talkington, 2004). A Finnish study (Korppi et al., 2004), reported that M. pneumoniae was detected in 30% of pediatric CAP and in over 50% among children aged 5 years or older, making it the single most common pathogen detected. A study performed in the United States during the 1990s detected M. pneumoniae in 23% of CAP in children 3-4 years of age (Block et al., 1995) and in French study (Layani-Milon et al., 1999), documented the occurrence of M. pneumonia in children less than 4 years of age without significant differences in infection rates for other children or adults. These findings may reflect the greater number of young children who attend day care centers on a regular basis than in previous years and the ease with which young children share respiratory secretions

Respiratory syncytial virus (RSV) is the main cause of acute lower respiratory tract infections (ALRTI) in the first year of life, resulting in hospitalization of nearly 120,000 children every year in the United States [1]. In developing countries, it is estimated that 0.5% to 2% of all children with RSV disease are hospitalized; of these, 7% to 21% develop respiratory insufficiency, leading to death in 0.5 to 1.5% of hospitalized cases [2-5]. The incidence of RSV infection ranges from 15.8 to 32.2% in studies conducted in Brazilian university hospitals [6,7]. Infections due to RSV generally occur as annual outbreaks. In South America, they take place during autumn and winter. In a study conducted at a university hospital in the city of São Paulo (1995 to 1999) involving 248 children with ALRTI, 90.4% of the RSV-infection cases occurred between April and July [7].

Each child received a median four doses of palivizumab (variation of 1–5; Q1-Q3: 3–4 doses), totaling 754 doses, using 749.1mL of the immunobiological. Among the 198 children followed, 45 (22.7%) received ive doses of palivi- zumab, 75 (37.9%) four doses, 75 (37.9%) three doses, 1 (0.5%) received two doses and 2 (1.0%) received one dose. The interval between the doses was less than 35 days in 96.9% of cases from the irst to the second dose, in 93.3% of cases from the second to the third dose, in 78.3% of cases from third to fourth dose, and in 60.0% of cases from fourth to ifth dose. In relation to clinical events, 117 (59.1%) children had at least one episode of respiratory infection, totaling 175 episodes with a median of 1.0 (range of 0–4; Q1-Q3: 1–2 episodes/patients) and mean of 1.5 episodes/patient. Among respiratory infections, 104 (59.4%) were of the upper respiratory tract and 71 (40.6%), of the lower re- spiratory tract (Figure 1).

Children were treated according to WHO therapeutic guide- lines for complicated SAM [4,5] adapted by MSF. Dietary treatment included 8 daily meals of F-75 milk for stabilization in intensive care or transition unit, followed by F-100 milk for nutritional rehabilitation in cases exiting intensive care prior to discharge. Amoxicillin was given systematically, or parenteral ceftriaxone in cases of suspected severe or complicated infectious syndrome, i.e. lower respiratory tract infection, meningitis, sepsis or prostration. Treatment was modified based on indications such as non-improvement of clinical condition and/or results of bacterial culture and antibiotic sensitivity testing. Depending on the type of infection suspected, cloxacillin (skin infection, severe pneumonia, S. aureus bacteremia) or ciprofloxacin (urinary tract infection, severe, explosive or persistent diarrhea .72 hours, bloody diarrhea, bacteremia with suspected gram negative bacteria) was added in case of treatment failure, based on lack of improvement or worsening of symptoms within 72 hours following treatment. Children with uncomplicated malaria diag- nosed either by rapid test and/or smear microscopy were given oral artesunate and amodiaquine for 3 days. Children with severe or complicated malaria received arthemether IM and then artesunate-amodiaquine if their condition improved, for 7 days total.

The respiratory viruses are recognized as the most frequent lower respiratory tract pathogens for infants and young children in developed countries but less is known for developing populations. The authors conducted a prospective study to evaluate the occurrence, clinical patterns, and seasonal trends of viral infections among hospitalized children with lower respiratory tract disease (Group A). The presence of respiratory viruses in children’s nasopharyngeal was assessed at admission in a pediatric ward. Cell cultures and immunofluorescence assays were used for viral identification. Complementary tests included blood and pleural cultures conducted for bacterial investigation. Clinical data and radiological exams were recorded at admission and throughout the hospitalization period. To better evaluate the results, a non- respiratory group of patients (Group B) was also constituted for comparison. Starting in February 1995, during a period of 18 months, 414 children were included- 239 in Group A and 175 in Group B. In Group A, 111 children (46.4%) had 114 viruses detected while only 5 children (2.9%) presented viruses in Group B. Respiratory Syncytial Virus was detected in 100 children from Group A (41.8%), Adenovirus in 11 (4.6%), Influenza A virus in 2 (0.8%), and Parainfluenza virus in one child (0.4%). In Group A, aerobic bacteria were found in 14 cases (5.8%). Respiratory Syncytial Virus was associated to other viruses and/or bacteria in six cases. There were two seasonal trends for Respiratory Syncytial Virus cases, which peaked in May and June. All children affected by the virus were younger than 3 years of age, mostly less than one year old. Episodic diffuse bronchial commitment and/or focal alveolar condensation were the clinical patterns more often associated to Respiratory Syncytial Virus cases. All children from Group A survived. In conclusion, it was observed that Respiratory Syncytial Virus was the most frequent pathogen found in hospitalized children admitted for severe respiratory diseases. Affected children were predominantly infants and boys presenting bronchiolitis and focal pneumonias. Similarly to what occurs in other subtropical regions, the virus outbreaks peak in the fall and their occurrence extends to the winter, which parallels an increase in hospital admissions due to respiratory diseases.

A detailed examination of each child including anthropometry was carried out. During the general physical examination, emphasis was laid on assessing general condition of the child, respiratory rate (counted over one minute), presence of fever and other signs such as cyanosis and pallor, detailed systemic examination of the respiratory, cardiovascular and central nervous system as done. Any associated illness such as septicemia, meningitis and congestive cardiac failure if present was noted. Other pertinent information such as immunization status (Immunized, partially immunized or unimmunized), feeding practices and degree of malnutrition (IAP classification) were also recorded.

Human rhinovirus (HRV) is typically associated with mild upper respiratory tract infections and exacerbation of asthma in children (Gern & Busse 1999, Manoha et al. 2007, Mackay 2008, Kelly & Busse 2008). HRV is a mem- ber of the Picornaviridae family and is composed of a non- enveloped particle with a positive-sense single-stranded RNA genome. The genome consists of 11 genes that are translated as a single polyprotein, which is divided into three regions (P1, P2 and P3) that are subsequently cleaved into four mature structural (VP4, VP2, VP3 and VP1) and seven non-structural proteins (2A, 2B, 2C, 3A, 3B, 3C PRO

To date, Costa Rica’s experience suggests that developing country efforts against acute respiratory infections could focus most profitably on epidemiologic and etio-[r]

There is a lack of data on tracheal secretion cultures in tracheostomized children and adolescents in Brazil. As a result, the main pathogens responsible for colonizing and/ or infecting the patients’ tracheae are not known. Some Brazilian hospitals may perform routine research on the microorganisms present in their patients’ tracheae, but access to that data is limited, since published data are scarce. It is still impossible to know if the treatment for lower respiratory tract infections in these patients is handled empirically or if it is based on guidance from laboratory diagnosis. Considering these facts, the evaluation of the tracheal secretion cultures of children and adolescents from our hospital could provide information with immediate as well as future impacts on the care provided to these patients.

Shortly after the advent of severe acute respiratory syndrome (SARS) and the avian influenza, the emergence of the influenza virus A (H1N1) 2009 pandemic caused significant vibrations to the public health authorities and stressed the health systems worldwide. This highlighted our weaknesses regarding the diagnosis and assessment of SARI. China is the biggest developing country with largest population of child. However, we have found no published case-control studies regarding comprehensive viral etiology and clinical characterization of children SARI using commonly acknowledged reliable test in China. To better understand the role of respiratory viruses in children with SARI during 2009 H1N1 pandemic and postpandemic era, and help diagnosis and antiviral treatment, we conducted a comprehensive evaluation of viral etiology and clinical characterization among hospitalized children with SARI admitted to the Beijing Children Hospital from May 2008 to March 2010. This study has increased our knowledge on the management of SARI and community-acquired pneumonia.

Percentage overprescription of antibiotics (cases where antibiotics were prescribed over the total number of cases seen) for mild ARI episodes in study children un[r]

against respiratory infectious agents may lead to chronic type of inflammation of the airways and tissue damage. Recently, Kim et al. [10] introduced a mouse model that provided new evidence of how chronic lung disease may develop after infection with a respiratory virus. They infected mouse with a parainfluenza virus Sendai, which is similar to common human respiratory viruses. An acute immune defense against infection was followed by a chronic inflammatory response, where activation of natural killer T cells and macrophages in the lung promoted persistent production of IL-13. Persistent IL-13 then caused chronic mucous cell metaplasia and airway hyperreactivity. They also showed that similar innate immune axis operated in humans with asthma and chronic obstructive pulmonary disease. Thus, the innate immune system may have a pathogenic role in asthma onset after respiratory infection. So respiratory infections could act as the primary inducers of inflammation leading to the development of asthma, or they may act as triggers of onset in subjects already experiencing inflammation due to other factors, such as environ- mental exposures.

The primary objective of the present study was to estimate the prevalence of HRSV as the etiologic agent of ALRI in this population and we did not interfere with the patients’ treatment. The laboratory tests for identiication of HRSV were performed after the collection of all samples at the end of the study and were not available upon hospital admission. Therefore, the high frequency of antibiotic use observed in our study corresponded to use in the daily clinical practice, with uncontrolled use of this kind of medication. 3,28,29 The results show the need for

Most cases are treated successfully with supportive cares and appropriate antibiotics, but sometimes surgical intervention may be required consisting of complicating pneumonia with lung abscess, empyema, bronchiectasis and pneumatoceles. In some other cases, foreign body aspiration, hydatid cyst, pulmonary sequestration or other congenital pulmonary abnormality may need surgical treatment.

During the study, NPA of infants with respiratory problems was routinely collected for viral testing. Because of the hours of the Virology Laboratory of the Institute of Biomedical Sciences of Universidade de São Paulo, patients admitted between Sunday and Friday (up to 5 pm) had NPA collected on the irst hospitalization day and sent to the virology laboratory on the same day. The material from patients hospitalized after 5 pm on Fridays, Saturdays and holidays was collected and sent to the laboratory on the irst working day after hospitalization. The cases in which material was collected on the irst 5 hospitalization days were analyzed. Laboratory tests were conducted using PCR/RT-PCR for RSV, hMPV, PIV 1, 2, and 3, Flu A and B, and ADV. Oligonucleotide primers were used for each virus (Table 1). RT-PCR assays were performed using the High Capacity cDNA Archive kit (Applied Biosystems, Carlsbad, USA). Ampliications were run separately (not multiplex). After RT-PCR, ampliication products (plate column) were puriied and transferred to sequencing tubes (Applied Biosystems, Carlsbad, USA). Ampliied fragments were analyzed using an ABI Prism 310 genetic analyzer (Applied Biosystems, Carlsbad, USA) and the GeneScan 3.1.2 software. 8

this monovalent vaccine possibly created conditions in which G2P[4] could acquire selective advantage over P[8] genotypes. Morillo et al. showed that the G2P[4] genotype was the only strain observed in 2007 during a 5-year surveillance study of RV strains in children < 5 years with acute gastroenteritis from day care centers in the state of São Paulo, Brazil. 9 However, more detailed investigations