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Resumen Introduccion Adecuar la duracion del tratamiento antibiotico es uno de los puntos claves de los programas de optimizacion del uso de antimicrobianos (PROA) dada la relacion entre el riesgo de aparicion de resistencias con los dias de exposicion a antimicrobianos. Metodos Monitorizacion de tratamientos antibioticos por via intravenosa de > 7 dias de duracion en el Hospital Infantil Vall d’Hebron, Barcelona, mediante cortes transversales semanales durante 24 semanas, con recomendaciones posteriores a los prescriptores para adecuar su uso. Resultados Se realizaron 190 revisiones de 146 tratamientos antibioticos prolongados, prescritos en 81 pacientes. El 78,7% de prescripciones fueron adecuadas. Se realizaron 36 intervenciones sobre las prescripciones inadecuadas, con 52,7% de adaptacion a la recomendacion. Se optimizaron 19 tratamientos (14 suspendidos, 5 desescalados) reduciendo su duracion un 8,75%. Conclusiones La intervencion activa del grupo PROA-NEN permite mejorar la adecuacion antibiotica, reduciendo los tratamientos innecesariamente prolongados, especialmente en ambitos con mayor margen de mejora.

Introduction The duration adequacy of antibiotic regimens is one of the key points of Antimicrobial Stewardship Programs (ASP) given the relationship between the risk of resistance and days of exposure to antimicrobials. Methods Monitoring activities of intravenous antibiotics longer than 7 days at Hospital Infantil Vall d’Hebron, Barcelona, by reviewing data over a 34-weeks period from weekly cross-sectional analysis, followed by recommendations to prescribers to adapt their use. Results A total of 81 patients with 146 prolonged intravenous antibiotic treatments (78.8% of prescriptions were adequate) were reviewed. A total of 190 revisions were performed. 31 interventions on inappropriate prescriptions were carried out (61.3% of adherence to recommendation). Nineteen treatments were optimized (14 suspended, 5 de-escalated) reducing their duration by 8.75%. Conclusions Active intervention of ASP group is an effective tool to improve antibiotic optimization, reducing unnecessarily prolonged treatments, mainly on these areas with a greater range of improvement.

INTRODUCTION: Invasive Pulmonary Fungal Infections (IPFI) represent a diagnostic and therapeutic challenge. The exact role of surgery is not well defined. This study aims to analyze our experience with surgical treatment of IPFI in immunocompromised pediatric patients and, secondarily, to compare the IPFI caused by Aspergillus spp. with other fungal infections. METHODS: retrospective review (2000-2019) of patients with IPFI surgically treated at our pediatric institution. Statistical analysis was used to compare data between Aspergillus spp. and non-Aspergillus IPFI. RESULTS: twenty-five patients (64% females) underwent 29 surgical lung resections. Median age at surgery was 7.19 years (1.63-19.14). The most frequent underlying condition (64%) was acute leukemia. Surgical indications included persistence or worsening of symptoms and pathological image findings (52%) or asymptomatic suspicious lesions in patients scheduled for intensive cytotoxic treatments or HSCT (48%). All patients underwent atypical lung resections, except one lobectomy. Aspergillus spp. was the most frequently isolated pathogen (68%). Follow up was 4.07 years (0.07-18.07). Surgery-related mortality was 0% but 4 patients died in the 100 days following surgery (2 due to disseminated fungal infection); the remaining 21 didn’t show signs of IPFI recurrence. Non-specific consolidations on CT scan were more frequent in non-Aspergillus IPFI (p

Patients with primary immunodeficiency disease (PID) have an increased risk of experiencing physical activity limitations, social difficulties, and psychological problems due to their chronic condition. Evaluation of their health-related quality of life (HRQOL) and fatigue is crucial in these patients to help understand their complex disease and provide adequate medical care. In this study, we evaluated HRQOL and fatigue in pediatric and young adult patients with PID attending our center. Participants completed the Pediatric Quality of Life Inventory (PedsQL), version 4.0, and the PedsQL multidimensional fatigue module, standard version. Fifty-three PID patients were recruited (age range: 2–23 years). The mean HRQOL score obtained was 66.61 (SD: 18.73) out of 100, and the emotional and work/school dimensions were the ones most highly affected. There were no significant differences in reported quality of life between patients and their caregivers. The mean patient-reported fatigue value was 68.81 (SD: 17.80) out of 100, and the rest-related dimension was the one most highly affected. In the caregivers’ assessment, general fatigue was the most highly affected dimension. The results of this study show that quality of life is poor and fatigue measures are considerably increased in our young adult and pediatric patients with PIDs. These findings can indicate areas requiring more intensive interventions, and they will serve as a basis for comparison of future results.

Introduction Pneumocystis jirovecii pneumonia (PJP) is a life-threatening condition in immunocompromised children. Our aim is to analyze the epidemiologic and clinical characteristics of PJP cases in our setting, describing the prognosis and related risk factors. Methods Retrospective study including all pediatric patients (≤18 years) with PJP admitted to our hospital (January 1989–December 2016). Case definition: patient with acute pneumonitis and P. jirovecii detection in bronchoalveolar lavage or tracheal aspirate using methenamine silver or direct antibody fluorescence staining, or Real-Time Polymerase Chain Reaction. Results Twenty-five cases (0.9 cases/year) were identified. Median age was 2.2 years (interquartile range: 0.5–12.3), 64% were male, and 12% were receiving appropriate antimicrobial prophylaxis. Cytomegalovirus coinfection was detected in 26% cases. The most common underlying diseases were primary immunodeficiencies (36%) and 16% were human immunodeficiency virus (HIV)-infected children. Eighteen were admitted to the pediatric intensive care unit (PICU) and overall 30-day mortality was 20% (31.25% in HIV non-infected vs 0% in HIV-infected patients; OR: 0.33, 95% CI: 0.02–7.24, p = 0.55). Clinical outcome was worse in girls and those patients requiring adjuvant steroid therapy. HIV non-infected patients, higher initial LDH, younger age and shorter time elapsed between diagnosis of PJP and the underlying disease were identified as risk factors to be admitted to the PICU (p = 0.05, p = 0.026, p = 0.04 and p = 0.001 respectively). Conclusion Accompanying the widespread use of combined antiretroviral therapy, PJP has been diagnosed almost exclusively in HIV non-infected children at our institution. Moreover, significant higher morbidity rates associated with PJP are seen in this group of patients.

Nens; Influenza humana; Isavuconazol Niños; Influenza humana; Isavuconazol Children; Human influenza; Isavuconazole A previously healthy 9-year-old girl developed fulminant myocarditis due to severe influenza A infection complicated with methicillin-resistant Staphylococcus aureus pneumonia, requiring extracorporeal membrane oxygenation (ECMO) support. Twelve days after admission, Aspergillus fumigatus was isolated in tracheal aspirate, and 12 h later she suddenly developed anisocoria. Computed tomography (CT) of the head showed fungal brain lesions. Urgent decompressive craniectomy with lesion drainage was performed; histopathology found hyphae in surgical samples, culture-positive for Aspergillus fumigatus (susceptible to azoles, echinocandins, and amphotericin B). Extension workup showed disseminated aspergillosis. After multiple surgeries and combined antifungal therapy (isavuconazole plus liposomal amphotericin B), her clinical course was favorable. Isavuconazole therapeutic drug monitoring was performed weekly. Extensive immunological study ruled out primary immunodeficiencies. Fluorine-18 fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) follow-up showed a gradual decrease in fungal lesions. Influenza-associated pulmonary aspergillosis is well-recognized in critically ill adult patients, but pediatric data are scant. Clinical features described in adults concur with those of our case. Isavuconazole, an off-label drug in children, was chosen because our patient had severe renal failure. To conclude, influenza-associated pulmonary aspergillosis is uncommon in children admitted to intensive care for severe influenza, but pediatricians should be highly aware of this condition to enable prompt diagnosis and treatment. This work received no external funding.

Background Infections related to non-surgical manipulation of the biliary tract (NSMBT) are common events despite periprocedural antibiotic prophylaxis (PAP). Since June 2017, our local protocol has indicated a 24-h regimen of intravenous piperacillin–tazobactam for this purpose. Objective We aimed to describe the incidence and characteristics of NSMBT-related paediatric infections, define risk factors for their development, and analyse adherence to our PAP protocol. Materials and methods Epidemiological, clinical, and microbiological data were collected in consecutive NSMBT procedures performed in paediatric patients ( Results 113 procedures in 37 patients, median age 4 years (IQR 1–8), were included. Main underlying diseases were biliary atresia (32%) and cancer (14%). Sixty-eight percent had undergone liver transplant and 70% hepaticojejunostomy. In 44 procedures (39%), the intervention was performed during the course of infection and previously prescribed antibiotic treatment was maintained. In the other 69, PAP was specifically indicated for NSMBT; antibiotic adequacy increased from 35% to 100% after June 2017. In total, 32 NSMBT-related infections (28%) occurred, mainly in the first 24 h post-procedure (72%); no deaths happened. Causative pathogens were Gram-negative rods (64%), Gram-positive cocci (28%), and Candida spp. (8%). Main related risk factors were hepaticojejunostomy, biliary obstruction, and liver transplant. Conclusions NSMBT in children entails a significant infection risk, even under antibiotic prophylaxis, being hepaticojejunostomy the main risk factor. Infectious complications mainly occurred immediately after the procedure. After establishing a PAP protocol, 100% of interventions received appropriate prophylaxis, decreasing antibiotic exposure time and potentially, the length of hospital stay.

Background Primary antifungal prophylaxis in paediatric allogeneic HSCT recipients is mainly based on azoles, which can have related toxicity and drug interactions. Low-dose liposomal amphotericin B (L-AmB) is an attractive intravenous alternative because of its low toxicity and lower risk of interactions. Objectives To evaluate the effectiveness and safety of L-AmB (1 mg/kg/day) for primary antifungal prophylaxis in pre-engraftment paediatric HSCT patients. Patients and methods Retrospective, observational study including all consecutive patients aged ≤18 years who underwent HSCT and received antifungal prophylaxis with intravenous L-AmB (1 mg/kg/day, from day −1 to 48 h before discharge) between January 2012 and December 2016. Results In total, 125 HSCT procedures in 118 patients were included, median age 7.2 years (IQR 4.2–11.5). Haematological malignancies were the main underlying condition (63.6%), and 109 (87.2%) were considered at high risk for invasive fungal infection (IFI). Ten patients (7.7%), all high risk, developed breakthrough IFI (three Candida spp., seven invasive mould infections) and tended to have higher overall mortality. The only statistically significant risk factor for IFI was cytomegalovirus co-infection. Adverse events, all grade I, occurred in 25 (20%), requiring L-AmB withdrawal in one case. Overall survival at 30 days was 99.2%. At study completion, one patient had died of IFI. Conclusions The incidence of breakthrough IFI was comparable to that of previous reports, with a very low rate of significant toxicity. Thus, prophylactic L-AmB may be a safe, effective option for antifungal prophylaxis in the pre-engraftment phase for children undergoing HSCT, even those at high risk.

the duration adequacy of antibiotic regimens is one of the key points of Antimicrobial Stewardship Programs (ASP) given the relationship between the risk of resistance and days of exposure to antimicrobials.monitoring activities of intravenous antibiotics longer than 7 days at Hospital Infantil Vall d'Hebron, Barcelona, by reviewing data over a 34-weeks period from weekly cross-sectional analysis, followed by recommendations to prescribers to adapt their use.a total of 81 patients with 146 prolonged intravenous antibiotic treatments (78.8% of prescriptions were adequate) were reviewed. A total of 190 revisions were performed. 36 interventions on inappropriate prescriptions were carried out (52.7% of adherence to recommendation). Nineteen treatments were optimized (14 suspended, 5 de-escalated) reducing their duration by 8.75%.active intervention of ASP group is an effective tool to improve antibiotic optimization, reducing unnecessarily prolonged treatments, mainly on these areas with a greater range of improvement.

Escherichia coli early-onset sepsis (EOS) is an important cause of mortality and morbidity in neonates, especially in preterm and very low birth weight (VLBW) newborns. The aim of our study was to evaluate potential changes in the clinical and microbiological characteristics of E. coli EOS in our setting. Epidemiological, clinical, and microbiological data from all neonates with proven E. coli EOS from January 1994 to December 2014 were retrospectively collected in a single tertiary care hospital in Barcelona (Spain). Seventy-eight E. coli EOS cases were analyzed. A slight increase in the incidence of E. coli EOS was observed during the study period. VLBW newborns remained the group with higher incidence (10.4 cases per 1000 live births) and mortality (35.3%). Systematic use of PCR increased E. coli EOS diagnosis, mainly in the term newborn group. There was an increase in resistant E. coli strains causing EOS, with especially high resistance to ampicillin and gentamicin (92.8 and 28.6%, respectively). Nonetheless, resistant strains were not associated with poorer clinical outcomes.There is an urgent need to reconsider the empirical therapy used in neonatal EOS, particularly in VLBW newborns. What is Known: • E. coli early-onset sepsis (EOS) and E. coli resistant strains have been described as overall stable but increasing in VLBW neonates ( 1.500 g) in previous studies. What is New: • Our study shows an increasing incidence of E. coli EOS in all age groups, overruling group B Streptoccocus for the last 10 years. E. coli resistant strains also increased equally in all age groups, with high resistance rates to our first line antibiotics (ampicillin and gentamicin). • Empiric antibiotic therapy of EOS, mainly in VLBW newborns, should be adapted to this new scenario.

Resumen Objetivo Analizar el estado vacunal de los ninos diagnosticados de tos ferina y comparar las manifestaciones clinicas de los bien vacunados y de los no vacunados o con vacunacion incompleta. Metodos Se ha revisado la historia clinica y el carnet vacunal de los pacientes menores de 16 anos visitados en el servicio de urgencias del Hospital Universitario Vall d’Hebron de Barcelona con tos ferina confirmada por estudio microbiologico. El periodo de estudio comprende del 1 de enero de 2009 al 31 de diciembre de 2011. Resultados Se han investigado 212 casos: 35 en 2009, 28 en 2010 y 149 en 2011. La reaccion en cadena de la polimerasa en tiempo real (RT-PCR) fue positiva en 210 pacientes, y el cultivo, en 73. Los lactantes menores de 6 meses representan el 36,8% de los casos. No estaban vacunados 44 (21,5%) pacientes. Cuarenta y cuatro (21,5%) tenian entre 2 y 5 meses de vida y habian recibido una o 2 dosis de vacuna. Habian completado la primovacunacion y las dosis de recuerdo (3 a 5 dosis, segun la edad) 117 ninos (57%); el 76,9% (90 casos) habia recibido la ultima dosis de vacuna hacia menos de 4 anos. Al comparar las manifestaciones clinicas de los pacientes con vacunacion completa y con vacunacion incompleta o no vacunados, solo la cianosis se ha presentado con mas frecuencia en el segundo grupo (p Conclusiones El numero de casos de tos ferina atendidos en nuestro centro ha aumentado de forma importante en el ultimo ano. El 57% de los pacientes estaban bien vacunados y el 76,9% habian recibido la ultima dosis en los ultimos 4 anos. Se necesitan otras estrategias de vacunacion (adolescentes, adultos y embarazadas, y estrategia del nido) para proteger a los lactantes menores de 6 meses de edad, asi como vacunas mas efectivas.