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Pediatric Infectious Disease Journal:
doi: 10.1097/INF.0b013e3181a51c24
Online-Only Abstracts

27th Annual Meeting of the European Society for Paediatric Infectious Disease, Brussels, Belgium, June 9–13, 2009

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Oral Abstracts  ABSTRACT  PAGE

ESPID OPENING SYMPOSIUM: ANTIBIOTIC RESISTANCE: ARE WE FACING A REAL PROBLEM IN PAEDIATRICS?

PART 1: COMMUNITY SETTINGS  O01–O02  e1

PART 2: HOSPITAL SETTINGS  O03–O04  e1–e2

ESPID SCIENTIFIC SESSION 1: INFECTION CONTROL: WHAT ARE THE NEW RESPONSIBILITIES AND WHY DO WE NEED TO CHANGE?  O05  e2

ESPID SCIENTIFIC SESSION 2: S. PNEUMONIAE: A PAEDIATRIC PATHOGEN  O06–O08  e2–e3

ESPID SCIENTIFIC SESSION 3: EMERGING AND RE-EMERGING SERIOUS BACTERIAL INFECTIONS  O09–O11  e3–e4

ORAL COMMUNICATION 1: IMMUNITY AND INFECTIONS  O12–O17  e4–e5

ORAL COMMUNICATION 2: BACTERIAL VIRULENCE IN CHILDREN: CLINICAL AND EPIDEMIOLOGICAL IMPLICATIONS  O18–O23  e6–e7

ROTAVIRUS VACCINE EXPERIENCES FROM USA, BELGIUM AND BRAZIL  O24–O26  e7–e8

ESPID SCIENTIFIC SESSION 4: BACTERIOLOGY: CLINICAL AND BASIC BACTERIOLOGY: WHAT'S IN IT?  O27  e8

ESPID SCIENTIFIC SESSION 6: EPIDEMIOLOGY AND PAEDIATRIC INFECTIOUS DISEASES  O28–O30  e8–e9

ORAL COMMUNICATION 3: INFECTIONS AND SURVIVAL IN IMMUNOCOMPROMISED CHILDREN  O31–O35  e9–e10

ORAL COMMUNICATION 4: RESISTANCE IN BACTERIAL PATHOGENS  O36–O41  e11–e12

ESPID SCIENTIFIC SESSION 7: PERSPECTIVES FOR BACTERIAL INFECTIONS IN PAEDIATRICS  O42–O44  e12–e13

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Poster Abstracts  ABSTRACT  PAGE

BACTERIAL ANTIBIOTIC RESISTANCE  P001–P025  e14–e21

BACTERIAL INFECTIONS AND BACTERIAL VIRULENCE  P026–P105  e21–e43

BONE, JOINT AND SOFT TISSUE INFECTIONS  P106–P121  e43–e48

CONGENITAL INFECTIONS  P122–P137  e48–e52

EMERGING AND RE-EMERGING INFECTIONS  P138–P153  e52–e57

EPIDEMIOLOGY  P154–P221  e57–e77

FUNGAL INFECTIONS, INFECTIONS IN THE IMMUNOCOMPROMISED AND HIV/AIDS  P222–P272  e77–e92

GASTROINTESTINAL INFECTIONS  P273–P303  e92–e100

IMMUNITY AND INFECTIONS  P304–P336  e101–e110

INFECTION CONTROL IN HOSPITAL AND IN THE COMMUNITY  P337–P352  e110–e114

NEONATAL INFECTIONS  P353–P399  e114–e128

PNEUMOCOCCAL INFECTIONS  P400–P435  e128–e139

RESPIRATORY TRACT INFECTIONS  P436–P484  e139–e154

SURGICAL INFECTIONS  P485–P486  e154–e155

URINARY TRACT INFECTIONS  P487–P502  e155–e159

VACCINE AND PREVENTION  P503–P666  e159–e209

VIRAL INFECTIONS  P667–P739  e209–e230

ZOONOSIS, PARASITIC INFECTIONS AND INFECTIONS IN MIGRANTS AND TRAVELERS  P740–P766  e230–e238

OTHERS  P767–P795  e238–e246

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ESPID OPENING SYMPOSIUM: ANTIBIOTIC RESISTANCE: ARE WE FACING A REAL PROBLEM IN PAEDIATRICS?

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PART 1: COMMUNITY SETTINGS

O01

EUROPEAN SURVEILLANCE OF ANTIMICROBIAL CONSUMPTION (ESAC): OUTPATIENT ANTIBIOTIC USE IN CHILDREN IN EUROPE

S. Coenen,*† N. Adriaenssens,* A. Muller,* V. Vankerckhoven,* E. Hendrickx,‡ and H. Goossens,* *Vaccine & Infectious Disease Insitute, University of Antwerp—Campus Drie Eiken, Antwerp, †Research Foundation—Flanders; and ‡Scientific Institute of Public Health, Brussels, Belgium.

Background and Aims: ESAC (www.esac.ua.ac.be) adopted the anatomic therapeutic chemical (ATC) classification and the defined daily dose (DDD) measurement unit. The DDD has some disadvantages. An ESAC subproject aims to describe the outpatient antibiotic use by age and gender, complementing the DDD with other measurement units.

Methods: Data on outpatient use of antibacterials for systemic use (ATC J01) in 2005, 2006 and 2007, expressed in DDD (WHO version 2009), and package or prescriptions per 1000 inhabitants per day (DID, and PID or PrID, resp.) were collected by age and gender, and will be described in detail, focussing on use in children.

Results: A preliminary analysis of the 2005 data showed that use in children (0–14 years) on average represented 11.2% of the total use in DID compared to 20.5% of the total use in PID. Use in children in DID on average was lower than in other age groups (12 DID (0–14 y) vs 17 (15–59 y), 22 (60–79 y) and 34 (80+)), whereas in PID only use in 80+ was higher (2.6 vs 1.7, 2.3 and 3.4, resp.). Only in children use was higher in boys. Nearly 80% were beta-lactam antibiotics (J01C+J01D) compared to less than 60% in other age groups.

Conclusions: Other measurement units need to complement the DDD to assess use in children and the effect of campaigns on appropriate antibiotic use (in children), e.g. the ECDC campaign for the first European Antibiotic Awareness Day. In addition, antibiotic use data should be linked to the patient's age (and gender).

On behalf of the ESAC Project Group, European Centre for Disease Prevention and Control (ECDC) Stockholm, Sweden.

O02

EU POLICIES AND RESEARCH PROGRAMMES

A. Lonnroth Sjoden, Infectious Diseases, DG Research, European Commission, Brussels, Belgium.

Abstract: Ensuring that children have access to high-quality effective and safe medicines is crucial in order for doctors to make informed decisions about disease treatment. However, no more than about half of all medicines prescribed to children in hospitals today are either unlicensed for their age group or licensed off-label. In intensive care units, the situation is even worse with 9/10 medicines given to children not having been properly tested for paediatric use. The Paediatric Medicines Regulation aims to facilitate the development of medicinal products for use in the paediatric population and ensure that these are based on high quality and ethical research. An important new marketing incentive is the Paediatric Use Marketing Authorisation (PUMA) with aims at the development of off-patent medicinal products for exclusive use in children. The Seventh Framework Programme of the European Community for Research and Technological Development and Demonstration activities (2007–2013) offers funding for off-patent medicines for children. Research projects need to address medicinal products selected as priority by the European Medicines Agency (EMEA) and the Paediatric Committee (PDCO). Although vaccines and other preventive measures fall outside the scope of these actions, they constitute a second but equally important component in the overall European research policy to tackle paediatric infections. Currently funded research projects in both these areas will be presented.

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PART 2: HOSPITAL SETTING

O03

ANTIBIOTIC RESISTANCE IN PAEDIATRIC HOSPITAL SETTINGS

L. Saiman, Pediatrics, Columbia University, New York, NY, USA.

Abstract: Antibiotic resistance is a growing public health crisis among hospitalized patients. Patients infected with antibiotic-resistant pathogens have increased mortality and morbidity, increased duration of hospitalization, and higher healthcare costs. Hospitalized children, including infants hospitalized in the neonatal intensive care unit, are at risk of developing infections caused by antibiotic resistant organisms (AROs). Such pathogens are frequently multidrug-resistant and include methicillin-resistant coagulase negative staphylococci, methicillin-resistant S. aureus (MRSA), vancomycin-resistant enterococci (VRE), extended spectrum beta-lactamase-producing or carbapenemase-producing gram negative bacilli. Furthermore, a lack of pediatric pharmacokinetic and pharmacodynamic data and/ or an unacceptable toxicity profile for some antimicrobial agents, may limit effective therapeutic options for infections caused by multidrug-resistant pathogens.

Strategies to prevent such infections are multifaceted and require sustained implementation by an interdisciplinary team. Such strategies include:

[1] Active surveillance for infections caused by AROs and dissemination of the epidemiology of local resistance patterns to clinicians to guide empiric and targeted antimicrobial therapy.

[2] Judicious use of surveillance cultures to detect children colonized with AROs who can serve as a reservoir for potential pathogens for other hospitalized children.

[3] Accurate antimicrobial susceptibility testing to detect resistance phenotypes.

[4] Implementation of an antimicrobial stewardship program which includes administrative support, clinician education, appropriate diagnostic strategies for potential pathogens, a restricted formulary, and prescriber feedback.

[5] Compliance with hand hygiene by all staff.

[6] Implementing transmission precautions (contact, droplet, and respiratory) for children colonized or infected with multidrug-resistant pathogens.

O04

MEDICINES AND VACCINES FOR CHILDREN: NEW REGULATION IN EUROPE

D. Brasseur, AFMPS, Brussel, Belgium.

Abstract: The new regulation 1901/2006 “Better medicines for the Children of Europe” has dramatically changed the way Industry has to consider their global drug development. For all new or protected compounds, a full paediatric development plan (PIP) should be submitted to the European Agency not later then the completion of the pharmaco-kinetic programme in adults. The PIP should be agreed with the PDCO and is compulsory on Industry. It can be amended and if complied to might lead to a reward (6 months of additional patent protection) even if the outcome does not allow granting the paediatric indication. The same requirement applies to any extension of indication, new route of administration and new pharmaceutical form. Compounds having no foreseeable paediatric indication or use are waived by PDCO from this obligation. Medicines no longer protected can apply on a voluntary basis for a PIP and seek for a specific marketing authorisation (PUMA) granting 10 years of specific protection if successful in their development. The importance of proposing an age appropriate formulation is key. As of January 2009, the PDCO had reviewed more than 600 indications and issued more than 160 decisions on PIPs or waivers. The legislation also foresees that the PDCO should established a list of paediatric unmet medical needs, an inventory of the drug use (on & off label) and work with the EMEA to contribute to the networking of investigators across the Union in order to facilitate the conduct of necessary clinical trials.

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ESPID SCIENTIFIC SESSION 1: INFECTION CONTROL: WHAT ARE THE NEW RESPONSIBILITIES AND WHY DO WE NEED TO CHANGE?

O05

INFECTION CONTROL IN SPECIAL PAEDIATRIC SETTINGS

L. Saiman, Pediatrics, Columbia University, New York, NY, USA.

Abstract: Infection control for infants in the Neonatal ICU (NICU), children undergoing solid organ or bone marrow transplantation, and patients with cystic fibrosis (CF) requires an understanding of transmission of specific pathogens and effective strategies to minimize transmission. Seasonal viruses such as respiratory syncytial virus, influenza, noroviruses and rotavirus can cause sporadic infections or outbreaks among vulnerable patients. Active surveillance for healthcare-acquired viral infections, rapid diagnostic strategies and instituting presumptive transmission precautions for suspected viral illnesses prior to definitive diagnosis, appropriate vaccination of staff, and screening for ill visitors and staff can prevent transmission of seasonal viruses.Infants in the NICU and transplant recipients are at risk for catheter-related bloodstream infections (CR-BSI). Endogenous skin and intestinal flora are usually implicated in such infections although outbreaks are well described. Preventive strategies for CR-BSI include bundle strategies to implement best clinical practices for catheter insertion and maintenance, institution of transmission precautions (contact, droplet, and respiratory), when appropriate, and minimizing duration of device use.CF patients may transmit respiratory tract pathogens to others with CF. While Burkholderia cepacia complex are the best known example of such transmission, other pathogens including Pseudomonas and MRSA can be spread among CF patients. Such transmission can occur in inpatient, outpatient, and non-healthcare settings via the contact and droplet routes. Strategies to prevent transmission include: segregating patients with CF from each other, containing respiratory tract secretions, maintaining the 3 foot rule to reduce droplet transmission, and appropriately processing respiratory tract specimens to maximize detection of potential pathogens.

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ESPID SCIENTIFIC SESSION 2: S. PNEUMONIAE: A PAEDIATRIC PATHOGEN

006

STREPTOCOCCUS PNEUMONIAE COLONIZATION: THE KEY TO PNEUMOCOCCAL DISEASE

P.W.M. Hermans, Laboratory of Pediatric Infectious Diseases, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.

Abstract: Streptococcus pneumoniae is an important pathogen causing invasive diseases such as sepsis, meningitis, and pneumonia. The burden of disease is highest in the youngest and oldest sections of the population in both developed and developing countries. The treatment of pneumococcal infections is complicated by the worldwide emergence in pneumococci of resistance to penicillin and other antibiotics.

Pneumococcal disease is preceded by asymptomatic colonization, which is especially high in children. The current seven-valent conjugate vaccine is highly effective against invasive disease caused by the vaccine-type strains. However, vaccine coverage is limited, and replacement by non-vaccine serotypes resulting in disease is a serious threat. Therefore, the search for new vaccine candidates that elicit protection against a broader range of pneumococcal strains is important. Several surface-associated protein vaccines are currently under investigation. An important issue is whether the aim should be to prevent pneumococcal disease by eradication of nasopharyngeal colonization, or to prevent bacterial invasion leaving colonization relatively unaffected, and hence, preventing the occurrence of replacement colonization and disease.

To illustrate the importance of pneumococcal colonization in relation to pneumococcal disease and prevention of disease, the mechanism and epidemiology of colonization, the complexity of relations within and between species, and the consequences of the different preventive strategies for pneumococcal colonization will be discussed.

O07

“HANDLING PNEUMONIA”

S. Madhi, DST/NRF Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa.

Abstract: Pneumonia is leading cause of childhood morbidity with incidence rates ranging from 0.05 episodes per child year in developed countries to 0.29 episodes per child year in developing countries. Additionally, pneumonia is a leading cause of death in developing countries and directly proportional to under-5 mortality rates.

Reducing mortality and prevention of pneumonia is partly limited by the lack of sensitive diagnostic tools with which to make an aetiological specific diagnosis. Nevertheless, empirical antibiotic-regimens targeting S. pneumoniae coupled with epidemiological changes observed following the introduction of pneumococcal conjugate vaccine into developed countries confirm S. penumonaie to be a leading pathogen causing pneumonia. Despite respiratory viruses being frequently identified in children with pneumonia, their role in the pathogenesis of severe pneumonia appears to be related to enhancing the susceptibility of the host to superimposed pneumococcal infection.

Whilst reducing mortality by early empiric treatment with antibiotics has been highly effective in certain settings, constraints with regard to accessing curative health care for many children in developing countries has limited the success of this strategy. Evidence from The Gambia suggest that significant strides can be made in reducing under-5 mortality through pneumococcal conjugate vaccination (PCV), a more structured intervention that is more readily available to children in developing countries. However, PCV vaccination may vary geographically in preventing the total burden of pneumococcal pneumonia, because of limitations in the serotype formulation of current vaccines.

O08

MANAGEMENT OF ACUTE OTITIS MEDIA IN CHILDREN - IS IT TIME TO MOVE TO PREVENTION?

J. Liese, Antimicrobial Therapy and Infectious Diseases Immunolgy, Ludwig-Maximilians-University, Munich, Germany.

Abstract: Due to its frequency and its complications acute otitis media (AOM) constitutes a significant burden for infants, their family and the society. Since AOM also is the most frequent reason for antibiotic prescription in children, it contributes to the development of antibiotic resistance, a growing problem in daily medical practice.

Management of AOM includes diagnosis, treatment and prevention. Education is the key, which enables physicians to make the correct clinical diagnosis, thereby limiting overdiagnosis and overtreatment in children with suspected AOM. The primary focus in AOM treatment should be symptomatic pain relief and restrictive use of antibiotics. Potential antibiotic side effects as diarrhoea and post-treatment colonization with resistant bacteria have to be weighed against their rather small clinical benefit. Most guidelines agree, that AOM in children >2 years can be usually handled without antibiotics using a “watchful waiting” approach. In children between 6 and 24 months antibiotics should be reserved for severely ill children, or children with specific clinical symptoms.

Preventive measures should be targeted early in life, including the promotion of breast feeding and avoiding of tobacco smoke exposure. The concept of vaccination against AOM has recently gained new attention by a 40% reduction of AOM visits and antibiotic prescriptions following the introduction of PCV-7 in the USA. Future vaccines will target a broader range of AOM pathogens, including more pneumococcal serotypes, non-typeable H. influenzae and viral pathogens. Thereby the preventive options increase against an infectious disease, where antibiotic treatment strategies have come to a limit.

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ESPID SCIENTIFIC SESSION 3: EMERGING AND RE-EMERGING SERIOUS BACTERIAL INFECTIONS

O09

RESURGENCE OF TB IN WESTERN EUROPE

D. Shingadia, Great Ormond Street Hospital, London, UK.

Abstract: Although TB in Europe makes up a small percentage of the global burden of disease, its epidemiology reflects worldwide trends. Within the WHO European Region, there are major disparities between the rates of disease between resource-poor Eastern countries and those countries in the West who have the resources to fund TB control programmes. In Western Europe, overall notification rates have declined over the last century and have remained relatively low and stable over the last decade. However there have been significant increases in some of the large metropolitan centres, such as London, which have seen fourfold increase in TB rates over the last decade. Reasons for this resurgence include increased migration/travel from high prevalence countries, poor TB control and ongoing transmission. Along with overall TB incidence, increasing rates of childhood TB in some areas, can be largely attributed to recent transmission from an infectious adult. Rates of TB in children therefore give an early indication of changes in the patterns of TB in a population and therefore represent sentinel events within those communities indicating recent transmission.

O10

GROUP A STREPTOCOCCUS—CAN HORIZONTAL GENE TRANSFERS EXPLAIN CHANGES IN STREPTOCOCCAL EPIDEMIOLOGY?

K.S. Sriprakash, Bacterial Pathogenesis Laboratory, Queensland Institute of Medical Research, Brisbane, Australia.

Background: Group A streptococcus (GAS) is the most common aetiological agent for pharyngitis, impetigo, cellulitis, necrotising fasciitis, scarlet fever, toxic shock, rheumatic fever (RF) and post-infectious glomerulonephritis. However, in recent years reports of association of human group G and C streptococci (GGS) with similar spectrum of diseases have appeared frequently. In some communities, GAS isolation rates from the throat are not commensurate with the burden of RF and rheumatic heart disease in the communities. By contrast, the frequency of GGS recovery is high in the same population. In general, the GGS genome has about 50% of GAS genes for virulence or surface proteins. Horizontal genetic transfers (HGTs) between GAS and other streptococci are common.

Methods: The extent to which different mobile genetic elements (MGEs), such as phages and conjugative transposons, may contribute to differences in strain structure by genomic subtraction, screening, and in vitro mobilization of MGEs.

Results: HGTs between GAS and GGS are ongoing events and are not just evolutionary relics. Therefore, streptococcal strain structure in a given region is dependent of the endemicity of the region for GAS infection. Some phages move between GAS and GGS. We have also demonstrated mobilization of a conjugative transposon between GAS, GGS and group B streptococcus (GBS) in vitro. However, in nature movement of the transposon is more common between GGS and GBS than between GGS and GAS.

Conclusions: Emerging changes to epidemiology may be explained by HGTs among closely related streptococci. HGTs have implications to long term effectiveness of a vaccine.

O11

WHAT IS CHANGING WITH STAPHYLOCOCCUS AUREUS IN CA INFECTIONS

S. Kaplan, Pediatrics, Baylor College of Medicine, Houston, TX, USA.

Abstract: Methicillin-resistant S. aureus isolates causing community-acquired infections (CA-MRSA) in children is major problem in several areas around the world. These isolates have a unique chromosomal cassette (SCCmec IV) that carries the antibiotic resistant genes and is lower in molecular weight than the cassette carried by the typical nosocomial MRSA isolates. Different CA-MRSA clones are circulating around the world. CA-MRSA generally are susceptible to clindamycin and trimethoprim-sulfamethoxazole. CA-MRSA are associated with both skin and soft tissue infections and invasive infections. Recurrent soft tissue infections and infections within the family caused by CA-MRSA isolates are common. CA-MRSA isolates containing genes encoding for pvl have been associated with serious staphylococcal pneumonia and complicated osteomyelitis, although the role of pvl in the pathogenesis of disease is not certain. Treatment of superficial skin and soft tissue infections involves surgical drainage ± an oral agent such as TMP-SMX or clindamycin. Empiric vancomycin is typically administered for more serious invasive infections such as osteomyelitis, septic arthritis or suspected Staphylococcal pneumonia. The need for targeting trough vancomycin levels of 15–20 μg/mL or adding gentamicin or rifampin in children with serious MRSA infections is uncertain. Clindamycin is efficacious in treating CA-MRSA infections caused by susceptible organisms. Linezolid is another option in selected circumstances. The role of daptomycin and other newer agents in treating children with serious CA-MRSA infections is under study.

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ORAL COMMUNICATION 1: IMMUNITY AND INFECTIONS

O12

IMMUNITY AND BACTERIAL INFECTIONS

A. Finn, University of Bristol, Bristol, UK.

Abstract: Although medicine promotes use of antiseptic and antimicrobial agents assiduously, there are approximately ten times more bacterial cells in a human than human cells. It follows that symptomatic bacterial infection is an exception rather than a rule and that we may learn more from the study of the physiology of colonisation than of the pathophysiology of infectious diseases. From the perspective of the bacterium, inducing symptoms may be a costly mistake - while from the perspective of the human, immune responses, once induced, may sometimes do more harm than good.

Human vaccines have been developed with the primary aim of protecting the recipient from later developing symptomatic disease. Almost invariably, when the primary mode of transmission is human to human, indirect or herd immunity effects have turned out to be as or more important for effectiveness.

Despite this, immunological studies have tended to focus on the mechanisms of individual protection (and generally on serum antibody concentrations) which are the commonest surrogates and correlates.

However, the evidence that systemic and mucosal immunity are distinct and separate from eachother is beginning to look insecure - in contrast, it begins to seem hard to have one without the other.

Recognising this has profound implications for the future of vaccinology. What are the long term implications of significantly changing the ecology of the upper respiratory tract, the gut or the skin? Are there ways to elucidate - or at least accurately observe this? Are there potential strategies to compensate if this proves necessary?

O13

HOW LONG ARE NEONATES PROTECTED BY MATERNAL ANTIBODIES AGAINST MEASLES IN A LOW ENDEMIC COUNTRY?

E. Leuridan,* N. Hens,† V. Hutse,‡ M. Ieven,§ M. Aerts,† and P. Van Damme,* *Centre for the Evaluation of Vaccination; Vaccine and Infectious Disease Institute, University of Antwerp, Antwerpen; †Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Hasselt; ‡National Laboratory for Measles and Rubella, Scientific Institute of Public Health, Brussel; and §Department of Medical Microbiology, University of Antwerp, Antwerpen, Belgium.

Abstract: Kinetics of maternal measles, rubella and varicella antibodies in neonates was investigated in a large prospective study involving 221 women and their offspring. Differences between children of women vaccinated against measles (VAC) and naturally immune women (NAT) were studied.

IgG concentrations were measured using different ELISA tests (Dade Behring) in blood samples taken from children at 6 time-points from birth until age 1 year and from women at week 36 of pregnancy. Linear mixed models were used to model maternal antibody decay in infants with time, taking heterogeneity between, and homogeneity within infants into account.

VAC had significantly less measles antibodies (GMT 764 mIU/mL) compared to NAT (GMT 2674 mIU/mL) (P < 0.0001). Maternal values were highly predictive for neonatal values (P = 0.931 at birth): children of VAC had significantly lower amount of antibodies at birth compared to children of NAT (P < 0.0001). However, the rate of decay was identical, leaving few children protected at 6 and none at 9 or 12 months of age. Likewise, for varicella and rubella, all children had lost maternal protection by 6–9 months.

The results of this unique study question protection by maternal antibodies in infants before starting immunization and confirm that vaccination should start in time.

GMT Measles children...
GMT Measles children...
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O14

A GENOME-WIDE ASSOCIATION STUDY OF MENINGOCOCCAL DISEASE IDENTIFIES NOVEL SUSCEPTIBILITY AND SEVERITY GENES IN A PAEDIATRIC MENINGOCOCCAL PATIENT COHORT

V. Wright,* S. Davila,† H. Betts,* D. Inwald,* S. Nadel,* H. Eleftherohorinou,‡ L. Coin,‡ A. Binder,§ M. Emonts,¶ W. Breunis,∥ J. Hazelzet,** E. Carrol,†† T. Kuijpers,∥ R. de Groot,¶ W. Zenz,§ M. Hibberd,† and M. Levin,* *Paediatrics, Imperial College London, London, UK, †Infectious Diseases, Genome Institute of Singapore, Singapore, Singapore; ‡Epidemiology & Public Health, Imperial College London, London, UK; §General Paediatrics, Medical University of Graz, Graz, Austria; ¶Radboud University Nijmegen Medical Centre, Nijmegen; ∥Paediatrics, Emma Children's Hospital, Academic Medical Centre, Amsterdam; **Department of Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands; and ††Institute of Child Health, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.

Background and Aims: Genetic factors contribute to both susceptibility and severity of meningococcal disease (MD) and a number of genes have been associated with the disease in previous studies. However most of these case-control studies used relatively small patient cohorts and many of the associations have not been replicated in larger studies. We have established an ESPID supported European collaborative study which has collected 1, 500 MD cases from the UK, Holland and Austria. This unique cohort has been used to undertake a genome-wide association study (GWAS) to identify novel genetic determinants as well as confirm known genetic associations.

Methods: We used a staged study design with both discovery and confirmatory cohorts. In the first stage, 800 Caucasian paediatric MD cases were genotyped using the Illumina™ Infinium 550K chip. SNPs that deviated significantly from HWE, had significant Mendelian errors or failed genotyping QC were excluded. For controls, genotyping data from the UK 1958 Birth Cohort was analyzed.

Results: Genotyping and data analysis of the GWAS is currently underway and results from single SNP as well as pathway-based analysis will be presented. These genes identified will be replicated in the second confirmatory phase.

Conclusions: This is the first GWAS of MD and the largest cohort yet studied. We expect the study to identify novel variants involved in both susceptibility to and severity of MD. The study provides an example of the strengths of European collaborative research within ESPID and should make a significant contribution to understanding of the disease.

O15

INVASIVE STRAINS OF NEISSERIA MENINGITIDIS HAVE WEAKER IMMUNOSTIMULATORY EFFECTS IN COMPARISON TO COLONIZING STRAINS

R. Potmesil, M. Holub, and O. Beran Charles University of Prague-1st Medical Faculty, Prague, Czech Republic.

Background and Aims: Neisseria meningitidis is an important human pathogen, which can cause severe invasive disease. Carriage state of the bacteria is common and reasons why the infection becomes invasive are not fully elucidated. The bacteria are recognized by cells of innate immunity, which detect the pathogen using different receptors including toll-like receptors (TLR). Therefore, we aimed our study at differences between expression of TLR2, TLR4, CD14 and HLA-DR as well as cytokine production after in vitro stimulation of monocytes by heat-killed invasive and colonizing strains of N. meningitidis.

Methods: In the whole blood model, we tested 23 N. meningitidis strains (14 invasive and 9 noninvasive) after 24-hr incubation at 37°C in concentration of 107 CFU/ml. Expression of TLR2, TLR4, CD14 and HLA-DR on monocytes was performed using flow cytometry as well as analyses of cytokines in supernatants (CBA assay, BD Biosciences USA).

Results: Invasive strains in comparison to colonizing strains caused significantly higher increase of TLR2 expression and decrease of HLA-DR expression on monocytes. Also, the changes of both parameters correlated significantly. Moreover, the colonizing strains in comparison to invasive strains of N. meningitidis elicited significantly more intensive cytokine production.

Conclusion: These findings indicate a weaker immunostimulatory potency of invasive strains of N. meningitidis contrary to colonizing strains, which could be one of the reasons why invasive strains of N. meningitidis gain entry into the bloodstream, whereas the colonizing strains are contained in the epithelia of the upper airways.

Acknowledgement: The study is supported by the grant MSM 0021620806.

O16

DEVELOPMENT OF ANTI-PSPA ANTIBODY LEVELS IN CHILDREN WITH AND WITHOUT RECURRENT ACUTE OTITIS MEDIA

S. Wiertsema, M. Whinnen,† A. Fuery,* R. Thornton,* and P. Richmond,† *School of Paediatrics and Child Health, University of Western Australia; and †Vaccine Trials Group, Telethon Institute for Child Health Research, Perth, Australia.

Introduction: Streptococcus pneumoniae (Pnc) is one of the main pathogens causing recurrent acute otitis media (rAOM). Pneumococcal surface protein A (PspA) is a conserved surface expressed protein. The aim of this study was to investigate antibody levels against PspA family 1 and family 2 in children with and without a history of rAOM and study how antibody levels develop over one year. We hypothesize that children with rAOM will initially have lower anti-PspA antibody levels and a slower increase in anti-PspA antibody levels over one year.

Methods: We recruited children with (n = 75) and without (n = 44) rAOM between 12 and 24 months of age. Anti-PspA antibody levels were determined in serum samples collected at the initial visit and one year later using an ELISA method developed in our laboratory.

Results: At the initial visit, children with rAOM (n = 18) showed a trend of lower antibody levels compared to healthy controls (n = 29) against PspA1 (38.7 vs 71.1, respectively; P = 0.11) and PspA2 (39.75 vs 181.2, respectively; P = 0.07).

Antibody levels in children with rAOM increased over 1 year from 38.7 to 189.3 for PspA1 (P = 0.0004) and from 39.5 to 284.8 for PspA2 (P = 0.005). In healthy controls anti-PspA1 antibody levels increased from 71.1 to198.7 (P = 0.001). However, anti-PspA2 antibody levels did not increase due to initial high antibody titres (181.2 to 233.9; P = 0.9).

Conclusions: Delayed antibody production against surface exposed protein antigens may contribute to the development or rAOM. Further studies investigating antibody levels against additional surface expressed proteins are needed.

O17

INFLUENCE OF PRIOR CARRIAGE OF STREPTOCOCCUS PNEUMONIAE ON ANTIBODY RESPONSE TO 11-VALENT PNEUMOCOCCAL CONJUGATE VACCINE (11PCV) IN YOUNG FILIPINO CHILDREN

M. Väkeväinen,* A. Soininen,* L. Marilla,† H. Nohynek,* J. Upgo,† E. Herva,‡ V. Tallo,† M. Lechago,† K. Auranen,* P.H. Mäkelä,* G. Williams,§ and H. Käyhty,* *National Institute for Health and Welfare, Helsinki, Finland; †RITM Research Institute for Tropical Medicine, Manilla, Philippines; ‡National Institute for Health and Welfare, Oulu, Finland; and §Australian Centre for International & Tropical Health & Nutrition, Brisbane, Australia.

Background: The influence of nasopharyngeal (NP) colonization by Streptococcus pneumoniae (Pnc) on subsequent antibody response to an investigational 11PCV in Filipino infants was analysed.

Methods: 1,111 infants were recruited into an immunogenicity and carriage study nested in a phase III trial (ARIVAC) and received 11PCV or saline placebo at scheduled 6, 10, and 14 weeks of age. Antibody concentrations to Pnc capsular polysaccharides were measured by enzyme immunoassay at 18 weeks and at 9 months of age. Antibody response was compared between groups of children among 11PCV vaccinees stratified according to their previous carriage status at 6 or 18 weeks of age; carriers (N = 8–25, depending on a serotype) vs. non-carriers (N = 492–522 depending on a serotype). Only the most frequently carried vaccine serotypes (6B, 19F, 23F) and vaccine-related serotypes (6A) were included in these analyses (NP swabs positive for each serotype; N ≥ 8).

Results: Antibody response to 6B, 19F, and 23F after vaccination with 3 doses of 11PCV was significantly lower at 18 weeks and 9 months of age among children who were carriers of the specific serotype at 6 or 18 weeks of age than among non-carriers of the specific serotype. Prior carriage of 6A had no effect on antibody response to 6B. Carriers and non-carriers of these serotypes had similar antibody response to serotypes other than the one carried.

Conclusions: Nasopharyngeal colonization at young age by Pnc of serotypes 6B, 19F, and 23F results in a significantly impaired antibody response to the specific serotype after vaccination with PCV.

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ORAL COMMUNICATION 2: BACTERIAL VIRULENCE IN CHILDREN: CLINICAL AND EPIDEMIOLOGICAL IMPLICATIONS

O18

STAPHYLOCOCCUS AUREUS AND TOXIN-ASSOCIATED DISEASES

J. Etienne, Faculté de Médecine Lyon Est, Université Lyon I, Lyon, France.

Abstract: Staphylococcus aureus represents the dominant supplier of suppurative infections or diseases caused by secreted toxins.

As example, Panton-Valentine leukocidin (PVL)-positive Staphylococcus aureus, regardless of methicillin susceptibility, has been linked to skin and soft tissue infections but also for deep-seated infections such as necrotizing pneumonia, fasciitis or severe bone and joint infections. Skin and soft tissue infections due to PVL-positive S. aureus strains are mainly furuncles and primary skin abscesses. One possibility to explain the pathogenicity of PVL-positive strains on the normal skin surface, is that PVL exerts its necrotic action along the hair shaft, thus allowing S. aureus to invade the hair follicle. Necrotizing pneumonia mainly affects children and young adults (median age 14 years) and is fatal in one-half to three-quarters of cases. Death usually occurs rapidly, with a median survival time of only 4 days. Leukopenia below 3 × 109/L and hemoptysis appear to be predictive of fatal outcome. PVL expression can be blocked by combining a toxin-suppressing agent (clindamycin, linezolid or rifampicin) with bactericidal antibiotics acting on the cell wall. In addition, intravenous immunoglobulin (IVIg) blocks the lytic effect of PVL on polymorphonuclear cells (PMN) in vitro.

Exfoliatins are associated with bullous impetigo and staphylococcal scalded skin syndrome. Exfoliatins are serine proteases that specifically target desmoglein-1, one of the main cell-cell adhesion molecules of the epidermis.

Toxin-shock syndrome and scarlet fever are associated with the toxic shock syndrome toxin-1 (TSST-1) and with staphylococcal enterotoxins (SE), especially SEB. All of these staphylococcal toxins act as superantigens.

O19

CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME TRIGGERED BY PANTON-VALENTINE-LEUKOCIDIN-ASSOCIATED STAPHYLOCOCCAL PNEUMONIA IN A CHILD

V. Guinard-Samuel,* C. Rozé,* V. Proulle,† C. Guitton,* I. Koné-Paut,* M. Dreyfus,† and T.A. Tran,* *Pediatrics; and †Laboratory of Haematology, Bicêtre University Hospital, Le Kremlin-Bicêtre, France.

Introduction: Anti-phospholipid antibodies are common in children with acute infection. In most cases, they are transient and have no clinical consequence. In adult, symptomatic antiphospholid syndrome associated with infections has been widely reported, especially in its severe microthrombotic form, the Catastrophic Antiphospholipid Syndrome (CAPS). In children, the association between infections and CAPS is rare. We report here a case of CAPS triggered by a Panton-Valentine-leukocidin-producing Staphylococcus aureus (PVLPSA) infection.

Case Description: A 17-month-old boy was admitted in ICU for severe dyspnea, fever and hypoxemia. Investigations concluded to a pleuropneumonia. Pleural tap found a strain of meticillin-susceptible PVLPSA. The patient was treated with Cloxacillin and had good clinical response. Three days later, he developed a severe microthrombotic condition with ischemia of feet and hands with skin necrosis, associated with acute encephalopathy, renal failure, elevated liver enzymes and thrombocytopenia. Haematological investigations showed the presence of anticardiolipin IgG, without any associated haemostatic anomaly prone to induce thrombosis, leading to the diagnosis of CAPS. Low molecular weight heparin was started. The symptoms resolved completely. However, the fingers of a foot required surgical amputation. The anticardiolipin antibodies persisted 3 months after this event without any other auto-antibody, thus leading to the diagnosis of primary SAPL.

Discussion and Conclusion: PVLSA has not been reported to cause microvascular skin necrosis. However, our case suggests that PVLPSA can be involved in triggering CAPS. Our report also stresses that CAPS must be remembered as a possible cause of multivisceral failure during sepsis, even in children with no underlying disease.

O20

EMM TYPES, SUPERANTIGENS AND DRUG RESISTANCE ANALYSIS OF STREPTOCOCCUS PYOGENES ISOLATED FROM CHINESE CHILDREN

Y. Ma, Y. Yang, and X. Shen, Beijing Children's Hospital, Affiliated to Capital Medical University, Beijing, China.

Background and Aims: No systemic epidemiologic analysis of GAS was reported in China. We investigated the epidemiology and characteristics of 359 GAS isolates collected from Chinese pediatric patients from 1993 to 1994 and from 2005 to 2006.

Methods: Antimicrobial susceptibility test was performed using the agar dilution methods. Emm types and the eight superantigen genes (speA, speC, speH, speI, speG, speJ, ssa, and SMEZ) were performed by PCR and sequencing.

Results: The resistance rates of Macrolides were high for the two period’s isolates, with MIC50 and MIC90 were all 512 mg/L; moreover, it found that all of strains were susceptible to penicillin, with MIC90 increased from 0.0625mg/L to 0.012 mg/L after 12 years. 24 emm types were identified, emm1 and emm12 were consistently the prevalent types during the two periods, while variations in the frequencies of the other types were noted. The GAS isolates carried six or more than six SAg genes increased from 46.53%to 78.39%, with the ssa, speH, and speJ genes (P < 0.05) increasing and the speA decreasing (P < 0.05) after 12 years. We analyzed nine mainly prevalent superantigen gene profiles among the prevalent emm types (emm1, emm3, and emm12), the SAg genes appeared to be associated with the emm type.

Conclusions: The resistance rates of GAS isolates to macrolides were extremely high. The emm type and SAg profiles of prevalent GAS exhibited significant changes over a 12-year period of observation. Moreover, the SAg was closely associated with the emm type and were independent of the disease type.

O21

PHYSIOLOGIC COLD SHOCK OF MORAXELLA CATARRHALIS PROMOTES ADHERENCE TO AND PROINFLAMMATORY ACTIVATION OF RESPIRATORY TRACT EPITHELIAL CELLS

V. Spaniol,* R. Troller,* M. Jetter,* and C. Aebi *Infectious Diseases, †Pediatrics, University of Bern, Bern, Switzerland.

Background and Aims: Moraxella catarrhalis (Mc), a nasopharyngeal respiratory tract pathogen, is exposed to downshifts of temperature (“cold shock”) when humans breathe cold air for prolonged periods of time. We investigated the effect of cold shock on the ability of Mc strain O35E to adhere to, invade into and induce inflammatory responses in respiratory epithelial cells.

Methods: Cold shock consisted of exposing bacteria during mid-log phase to 3 hours at 26°C vs. 37°C before conducting mRNA stability assays, fibronectin and sIgA binding assays (FACS), and adherence and invasion assays, respectively.

Results: Increased expression of UspA1, a major Mc adhesin, after cold shock, resulted from greater mRNA stability (3.0 min vs. 1.8 min at 37°C, P < 0.0001), led to a 65% increase in binding to fibronectin, which mediates adherence through binding to a5b1 integrin and a 45% in sIgA-binding. Cold shock enhanced bacterial cell-association (adherence) to both Chang, Detroit 562 and A459 lung cells. Cellular invasion was not affected by cold shock. Cold-shocked Mc induced a significantly greater release of the proinflammatory mediator IL-8 in lung epithelial cells as compared to bacteria incubated at 37°C. Similarly, a significantly enhanced proinflammatory response was observed when epithelial cells were stimulated with outer membrane proteins isolated from strain O35E exposed to 26°C. In contrast, both a LOS-deficient mutant and purified LOS did not exhibit a cold shock response.

Conclusion: These data indicate that cold shock at physiologically relevant temperatures around 26°C may affect the nasopharyngeal host-pathogen interaction in vivo and contribute to Mc virulence.

O22

CEREULIDE-PROVEN BACILLUS CEREUS FOOD POISONING IN A FAMILY INCLUDING A FATAL CASE AND A FULMINANT ONE RECOVERED RAPIDLY AFTER HEMODIALYSIS

M. Shiota,* K. Saitou,* H. Mizumoto,* A. Hata,* M. Matsusaka,† S. Yamaguchi,‡ Y. Okamoto,§ M. Ohta,¶ and D. Hata,* *Department of Pediatrics, Kitano Hospital; †Department of Emergency, Nakakawachi Medical Center of Acute Medicine, Osaka; ‡Department of Pediatrics, Shimane University School of Medicine, Izumo; §Department of Pediatrics; and ¶Department of Bacteriology, Nagoya University School of Medicine, Nagoya, Japan.

Abstract: Bacillus cereus food poisoning is usually self-limiting and recovery occurs within 6 to 24 hours. However, previous reports showed a few fatal cases. In October 2008, 26 year-old mother, 2 year-old sister, and 1 year-old brother ate reheated fried rice that had been prepared one day earlier. Thirty minutes after eating, they became sick and began to vomit frequently. The brother was taken to the emergency department of a local hospital 6 hours after eating, but died after intensive resuscitation for 30 minutes. Postmortem findings revealed severe brain edema which was considered as the cause of death. The others were admitted to our hospital. The mother suffered from nausea and abdominal cramping, but became well in 12 hours just by fluid infusion. The sister was lethargy and only responsive to pain. Her blood examination revealed hypoglycemia, metabolic and lactic acidosis, and hyperammonemia. Even after intravenous administration of glucose and subsequent fluid therapy, she still suffered from impaired consciousness, but rapidly became well after hemodialysis. Bacillus cereus was isolated from the stool of all three patients, whereas cereulide, the emetic toxin produced by the bacteria, was detected in the vomit and the serum only in brother and sister. Their serum concentrations of cereulide were equal. This is the first report of measuring the exact values of cereulide in food poisoning. Hemodialysis may be one of the options to remove cereulide rapidly in severely affected patients suspected of suffering Bacillus cereus food poisoning.

O23

EPIDEMIOLOGY OF INVASIVE HAEMOPHILUS INFLUENZAE INFECTIONS IN INFANTS YOUNGER THAN ONE YEAR IN THE ERA OF ROUTINE HIB CONJUGATE VACCINATION

S. Ladhani,* M.P.E. Slack,* P.T. Heath,† M. Chandra,* and M.E. Ramsay,* *Immunisation Department, Centre for Infections, Health Protection Agency, London; and †Vaccine Institute and Division of Child Health, St George's, University of London, London, UK.

Background and Aims: To describe the epidemiology of invasive Haemophilus influenzae (Hi) infections in infants in countries with routine Hib conjugate vaccination.

Methods: In 1996, an international collaboration was developed to monitor the impact of Hib vaccination on the epidemiology of invasive Hi disease. From 2000 onwards, fourteen European countries had established national Hib infant vaccination programmes and routinely serotyped all clinical Hi isolates (www.euibis.org).

Results: Between 2000 and 2006, 897 cases of invasive Hi infections were reported in infants. Of the 781 cases where the serotype was known, 391 (50.1%) were due to non-capsulated Hi (ncHi), 344 (44.0%) were due to Hib and 46 (5.9%) due to non-type b encapsulated Hi. Although the overall incidence of ncHi and Hib were similar (2.0 vs. 1.8 per 100,000), the incidence of ncHi was almost ten-fold higher in the first month of life (11.4 vs. 1.2 per 100,000) compared with 1.4 vs. 1.9 per 100,000 at 1–5 months and 1.8 vs. 1.0 per 100,000 at 6–11 months. ncHi cases were more likely to present with bacteraemia (228/391 [58.3%] vs. 74/344 [21.5%], P < 0.0001) while Hib cases were more likely to present with meningitis (198/344 [57.6%] vs. 43/391 [11.0%], P < 0.0001). The case fatality ratio for ncHi was 17.4% (68/391 cases) compared with 2.9% (10/344 cases) for Hib (age-adjusted OR 5.7, 95% CI 2.8–11.6, P < 0.0001).

Conclusions: In infants, invasive ncHi infections have a much higher incidence than Hib in the first month of life and have a significantly higher case fatality ratio.

FOR EU-IBIS

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ROTAVIRUS VACCINE EXPERIENCES FROM USA, BELGIUM AND BRAZIL

O24

MONITORING UPTAKE AND IMPACT OF THE NEW US ROTAVIRUS VACCINATION PROGRAM

U. Parashar, C. Panozzo, D. Bartlett, J. Tate, H. Clayton, D. Payne, M. Cortese, M. Patel, A. Curns, W. Williams, and J. Gentsch, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Background: The implementation in 2006 and 2008 of two new vaccines for routine vaccination of US infants against rotavirus makes it imperative to assess vaccine uptake and impact of vaccination.

Methods: Vaccine uptake was assessed using data from six sentinel immunization information systems (IIS). Vaccine impact is being examined using data on reports of rotavirus detections from a national network of sentinel laboratories. Strains are being characterized from rotavirus-positive specimens obtained from a subset of laboratories.

Results: By late 2007, >10 million doses of rotavirus vaccine had been distributed in the United States and 50%–67% of infants 3 months of age at IIS sites had received at least one vaccine dose. Coverage with full 3-dose vaccine series ranged from 27%–45% at 7 months of age and 18%–32% at 13 months of age. In 2008, onset of rotavirus activity was delayed by up to 2–3 months across the country. The vast majority of sentinel laboratories reported declines in rotavirus detections of >60%–70% compared with data from the 7–8 years prior to vaccine implementation. More than 85% of rotavirus strains circulating during 1996–2007 contain antigens that are included in the licensed vaccines; data for 2007–2008 are awaited.

Conclusions: With relatively modest levels of vaccine uptake, marked delays in onset of rotavirus activity and reductions in rotavirus detections have been reported early in the 2007–2008 rotavirus season. Monitoring is ongoing to assess disease activity through the full season and to determine whether the observed changes in disease activity can be attributed to vaccination.

O25

EPIDEMIOLOGICAL IMPACT OF ROTAVIRUS VACCINES IN BELGIUM

G. Hanquet,*† M. Sabbe,* G. Ducoffre,* and T. Lernout,* *Epidemiology Section, Scientific Institute of Public Health, Brussels; and †Health Care Knowledge Centre, Brussels, Belgium.

Background and Aims: Two rotavirus vaccines were introduced in Belgium in June 2006 and 2007 respectively. Rotavirus vaccination is recommended and reimbursed for children 2–6 months since January 2007. This study analyses the impact of rotavirus vaccination after its introduction.

Methods: An active surveillance system, based on a national laboratory-network, records all positive rotavirus cases since 2005. Data from the post-vaccine period (2007–08) are compared to those from the pre-vaccine years (2005–06).

Results: In 2007, the number of rotavirus cases reported by the network decreased by 53% compared to 2005–06 (from an average of 9034 in 2005–06 to 4228 cases). A reduction was observed in all age groups, with the highest decline in children <1 year (from 4481 to 1819 cases, -59%). The epidemiological season was delayed compared to previous seasons (peak on week 14 vs. week 6–10). Vaccine coverage was estimated at 60–80%. Preliminary 2008 data show a further decline and a lower seasonal peak. Information on hospitalization and vaccination status of cases is not available.

Conclusions: One year after rotavirus vaccine introduction, the annual number of laboratory-diagnosed rotavirus cases have halved compared to the pre-vaccine period. A decline is observed in all age-groups. The participation in the surveillance was stable in the study period. Delayed onset and diminished magnitude of the rotavirus season is also reported in the US, where rotavirus vaccination was introduced in 2006. Laboratory data provide a crude estimation of vaccine impact. In-patient data will be analyzed to assess the impact on severe cases.

O26

EXPERIENCE OF ROTAVIRUS VACCINES IN BRAZIL

A. Linhares, Virology Section, Instituto Evandro Chagas, SVS, Belém, Brazil.

Abstract: Rotavirus imposes a high burden of disease in Brazil, accounting for hospitalization rates as high as 48%. Health economic studies estimate that vaccination would prevent more than three-fourths of all rotavirus gastroenteritis, including 1,804 deaths, with total medical savings of US$19.3 million.

Brazil has participated in multi-country phase II and III trials with Rotarix™, with 778 and 3,218 infants, respectively. A major finding was the high protection against G9 strains.

Brazil was the largest single country in the world to introduce Rotarix™ into the public sector in March 2006. As factors leading to universal vaccination were political decision from the Ministry of Health; representative epidemiological data; and cold-chain storage capacity throughout most of Brazil. Approximately 12 million doses have been administered to date and, during 2008, Brazil has reached 89.9% and 76.4% vaccination coverage for first and second doses, respectively. Full-course vaccination coverage varied across the country, ranging from 53% to 83.4% in the Northern and South-Eastern regions, respectively. Although vaccination has been well accepted by the population and medical community, problems have been reported including

(a) age-restrictions,

(b) larger storage space required, and

(c) several steps for reconstitution.

Brazil has implemented a monitoring system for adverse events and a collaborative study has initiated focussing on intussusception. As from May 2008 a case-control study is underway in Belém, to assess vaccine effectiveness. This includes an extended period of strain surveillance of at least 3 years that will be essential to fully elucidate the current issue of predominance of G2P[4] strains.

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ESPID SCIENTIFIC SESSION 4: BACTERIOLOGY: CLINICAL AND BASIC BACTERIOLOGY: WHAT’S IN IT?

O27

ESPID SESSION 4—CLINICAL AND BASIC BACTERIOLOGY: WHAT'S IN IT FOR THE CLINICIAN?

J. Van Eldere,* and M. Struelens,* *KUL-Gasthuisberg Hospital, Leuven, †ULB- Erasme, Brussels, Belgium.

Objectives and Format: This interactive session will propose a series of clinical vignettes with a special focus on pertinent diagnostic test prescribing, interpretation of test results, and their implications for medical decision in the management of bacterial infections in children. Management issues will include selecting appropriate antibiotic therapy, assessing the cause of treatment failure, identifying the need for additional infection control precautions and assessing the epidemiological significance of multi-drug resistant organisms. We will highlight the need for intensive communication between the paediatrician, microbiologist and infection control team for optimal use of laboratory resource and microbiological expertise. Insights from basic research into the clonal diversity and phenotypic adaptation of bacterial pathogens in cystic fibrosis and foreign-body infections will be discussed. Technological breakthroughs will be demonstrated to illustrate the potential for new diagnostic assays to drive changes in clinical practice, and identify unresolved issues and areas of possible future clinical research.

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ESPID SCIENTIFIC SESSION 6: EPIDEMIOLOGY AND PAEDIATRIC INFECTIOUS DISEASES

O28

PREDICTIVE TOOLS IN PEDIATRIC INFECTIOUS DISEASES

M. Chalumeau,* D. Gendrel,† and G. Bréar,* *Department of Pediatrics, Hopital Saint Vincent de Paul, Inserm U149—APHP—Paris Descartes University; †Department of Pediatrics, Hopital Saint Vincent de Paul, APHP—Paris Descartes University; and ‡Inserm U149, Hopital Saint Vincent de Paul, Paris, France.

Abstract: Predictive tools can be very useful in managing paediatric patients with infectious diseases. They can be used to:

(i) identify patients at high risk of severe infectious disease,

(ii) reach a diagnosis without using an invasive or distressing or very expensive gold-standard test,

(iii) distinguish as early as possible between viral and bacterial infections,

(iv) identify patients for whom a given infectious disease reveals an underlying condition, and

(v) predict the early outcome and sequels of serious infections.

Predictive tools may be a single clinical sign or laboratory test or various signs and tests combined in a score, an algorithm, or a clinical decision rule. Whatever their form, before any widespread clinical use, predictive tools must be derived and validated according to rigorous internationally accepted methodological standards such as the STARD initiative (www.stard-statement.org). Clinicians can also use these standards for a critical appraisal of the literature. Key issues for predictive tools in paediatric infectious diseases are:

(i) ensuring that predicted variable (the outcome) is independent of the predictors, and

(ii) validating the tool across various epidemiological settings (e.g., age groups, spectrum of disease severity, and causative agents).

Example of both the successes and the pitfalls of predictive tools in paediatric infectious diseases can be found in a variety of clinical settings: office-based paediatrics, emergency departments, neonatal medicine, ICU, and tropical medicine.

O29

CEREBROSPINAL FLUID PLEOCYTOSIS IN CHILDREN IN THE ERA OF BACTERIAL CONJUGATE VACCINES: DISINGUISHING THE CHILD WITH BACTERIAL AND ASEPTIC MENINGITIS

L. Nigrovic, Division of Emergency Medicine, Children's Hospital Boston, Boston, MA, USA.

Abstract: Although bacterial meningitis remains an important cause of childhood morbidity and mortality, the incidence of bacterial meningitis has greatly decreased with the advent of polysaccharide-protein conjugate vaccines in the past two decades. The vast majority of children with CSF pleocytosis have aseptic rather than bacterial meningitis, raising the possibility that some patients may be managed as outpatients. First we will review the changing epidemiology of bacterial meningitis. Then we will discuss the available clinical decision rules that may assist the clinician in distinguishing aseptic from bacterial meningitis in patients with CSF pleocytosis. Last, we will describe the effect of antibiotic pretreatment on the CSF profiles of children with bacterial meningitis.

O30

EVIDENCE-BASED PAEDIATRIC INFECTIOUS DISEASE: HOW TO SEARCH THE LITERATURE

D. Isaacs *Infectious Diseases, Children's Hospital at Westmead, Westmead; and †Paediatrics and Child Health, University of Sydney, Sydney, Australia.

Abstract: In this presentation, I will decribe how even an aged technophobe can learn how to search the literature for evidence quickly and with acceptable accuracy.

Someone may already have found the best available evidence and analysed it in a high quality systematic review. The Cochrane Library contains many such systematic reviews and the rigour demanded of these ensures that almost all Cochrane systematic reviews are high quality and up to date. I recommend you always begin by searching the Cochrane Library (http://www.thecochranelibrary.com/) using various general search terms, e.g. urinary tract infection.

Even if there is no Cochrane systematic review, you may still find a non-Cochrane systematic review in Index Medicus. The easiest route is via PubMed (http://www.pubmed.gov/) which is a service provided free to all users by the NIH. After entering PubMed you should click on Clinical Queries. Clinical Queries has two different boxes which allow queries about systematic reviews and about randomised controlled trials. Finally, I urge courage and practice. Do not be afraid to start searching the literature, be adventurous and repetition will improve your searches.

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ORAL COMMUNICATION 3: INFECTIONS AND SURVIVAL IN IMMUNOCOMPROMISED CHILDREN

O31

CLINICAL EPIDEMIOLOGY OF INVASIVE CANDIDA INFECTIONS IN A CHILDREN'S HOSPITAL DURING A 13-YEAR PERIOD

J.W.M. van der Linden,* F.G. Ropers,† A.M.C. Mavinkurve-Groothuis,‡ K.D. Liem,§ P.E. Verweij,* and A. Warris,¶ *Department of Medical Microbiology and Nijmegen Institute for Infectious Diseases, Inflammation and Immunity, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; †Institut für Experimentelle Pädiatrische Endokrinologie Otto-Heubner Zentrum für Kinder- und Jugendmedizin, Charite Universitätsmedizin Berlin Campus Virchow Klinikum, Berlin, Germany; ‡Department of Pediatric Hematology and Oncology; §Subdivision of Neonatology, Department of Pediatrics; and ¶Department of Pediatric Infectious Diseases and Immunologic Disorders and Nijmegen Institute for Infectious Diseases, Inflammation and Immunity, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

Background and Aims: Invasive candidiasis (IC) has been well characterized in adults, but only a few studies are performed in large cohorts of children. Differences in underlying diseases between children and adults preclude extrapolation of epidemiology, management and outcome from adults to children. Our aim was to get a better insight in the clinical epidemiology of invasive Candida infections in pediatrics.

Methods: All children (0–18 years) with positive mycology from blood, CSF, biopsies and peritoneal-fluid in our hospital between January 1991 and December 2003 were retrospectively analyzed. Questionnaires were used to retrieve the demographic and clinical data for each patient.

Results: Of the 61 patients (mean age 2.7 yrs) included, 51% were premature newborns (55% birth weight < 1000 gram) and 23% were oncology patients. The majority (87%) were diagnosed with candidemia, 5 with peritonitis (8%) and 3 with meningitis (5%). C. albicans (CA) was the most prevalent (59%), followed by C. parapsilosis (CP) (20%). No shift in species distribution over time was seen. The species found was significantly related to the underlying disease (P < 0.05). Newborns < 1000 gram were more often infected with CP compared to the other neonates and older children. Treatment with (liposomal) amphotericin B or fluconazole were most commonly prescribed without differences in outcome. Having a central venous access device or catheter was significantly related to mortality (P < 0.05). Overall mortality was 43%, infection-related mortality was 23%.

Conclusions: Clinical epidemiology of invasive Candida infections in children differs considerably from those in adults.

O32

BORDETELLA HOLMESII BACTEREMIA IN 4 ASPLENIC PATIENTS

M.I. Panagopoulos,* M. Saint Jean,*† N. Guiso,‡ P. Ovetchkine,* and B. Tapiero,* *Division of Infectious Diseases, Department of Pediatrics; †Department of Microbiology and Immunology, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada; and ‡National Reference Center for Pertussis and Other Bordetellose, Institut Pasteur, Paris, France.

Abstract: Bordetella holmesii is a fastidious asaccharolytic oxidase-negative Gram-negative rod. It has been reported as a rare cause of bacteremia, primarily in patients with functional or anatomical asplenia. We describe 4 cases of B. holmesii bacteremia in unrelated children with hematologic conditions.

Patients were aged between 9 and 17-year-old. Three were suffering from sickle-cell disease, two of whom had undergone splenectomy. In the last patient, elective splenectomy was performed due to autoimmune hemolytic anemia. They all presented with fever but no other complaint, appeared well and had no remarkable findings on physical examination. Two of the patients were treated with IV ceftriaxone followed by oral ciprofloxacin for a total of 10 days. The remaining patients received only IV ceftriaxone, for 2 and 7 days respectively. The clinical outcome was uniformly favorable, without complications.

Blood cultures drawn upon presentation were detected positive for Gram-negative rods after a mean incubation time of 40h (range 30h - 47,3h). Initial identification attempt through the VITEK 2 automated system (bioMérieux Inc.) reported each time Acinetobacter lwoffii (99,9% excellent identification), but some basic characteristics were discordant. B. holmesii was identified in all cases by 16SrDNA gene sequencing. Biochemical and antibiotic susceptibility testing showed no difference among isolates and Pulse Field Gel Electrophoresis revealed great similarity between these B. holmesii isolates and others previously encountered worldwide.

Our cases support the growing evidence that B. holmesii is a cause of bacteremia in asplenic patients. It should always be considered, particularly when the VITEK 2 system reports Acinetobacter lwoffii.

O33

PAEDIATRIC MORTALITY FROM HIV IN THE UK AND IRELAND: A CHIVA NETWORK SURVEY

R. Crossley,* K. Doerholt,† J. Masters,‡ M. Sharland,§ E. Lyall,¶ and M. Erlewyn-Lajeunesse,* *University of Southampton, Southampton, †United Bristol Healthcare Foundation Trust, Bristol; ‡Institute for Child Health, University College London; §St George's Hospital NHS Trust; and ¶Imperial College Healthcare NHS Trust, London, UK.

Aims: We aimed to explore the reasons for deaths in HIV-infected children in the United Kingdom and Ireland from 2000 to 2007.

Methods: Analysis of questionnaire based results of deaths in HIV infected children reported to the National Study of HIV in Pregnancy and Childhood (NSHPC) and followed up in the Collaborative HIV Paediatric Study (CHIPS).

Results: We received reports for 49 (98%) of the 50 deaths. 44.9% (22/49) died within 3 months of diagnosis. Cause of death was related to HIV in 87.8% (43/49), with 18.4% (9/49) caused by bacterial infection, 10.2% (5/49) Pneumocystis pneumonia, and 10.2% (5/49) HIV encephalopathy. Infants had a high risk of disease progression; 18 (36.7%) died before one year of age, with the majority (12/18) within 3 months of diagnosis and 11/18 before the advent of routine antenatal screening in 2003. 15 (30.6%) died between 5–10 years old and 9 (18.4%) after 10 years. Adverse social circumstances contributed to the child's death in 38.8% (19/49) and were noted in 50% (11/22) of those who presented late.

Conclusion: Late diagnosis is a major contributory factor to the continued mortality of children infected with HIV. The adverse social circumstances of affected families may contribute to late presentation. Paediatricians should consider the diagnosis early, and perform HIV tests as part of routine care. Missed prevention of mother to child transmission continues to occur but the number of infant deaths decreased over the audit period, which is likely to be due to improved screening during pregnancy.

O34

COGNITIVE AND MOTOR DEVELOPMENT AT THE AGE OF 7 YEARS IN HIV-UNINFECTED CHILDREN PERINATALLY EXPOSED TO ANTIRETROVIRALS

M. Simó,* M. Casartelli,* A. Noguera,* P. Martos,* R. Colomé,* E. Sánchez,† A. Sans,* and C. Fortuny.* *Hospital Sant Joan de Déu, Esplugues; and †Agència d'Avaluació de Tecnologia i Recerca Mèdiques, Barcelona, Spain.

Background and Aims: Infants exposed to antiretrovirals (ARV) during pregnancy are at risk for mitochondrial toxicity. When symptomatic, mitochondrial toxicity presents with neurologic symptoms. To date, normal neurodevelopmental status up to the age of 3 years in these otherwise healthy patients has been reported; data on the long-term outcome is lacking.

Methods: A cross-sectional study in 7-year-old HIV-uninfected children perinatally exposed to ARV was performed to assess their long-term neuropsychological development; a control group of healthy children born to HCV-infected mothers was used. Upon inclusion, a comprehensive neuropsychological test battery was administered by a blinded pediatric neuropsychologist: WISC-IV, Tomal and FCR, K-BIT, Peabody and ITPA, FRC and VMI, Trail making test, FAS and CARAS test, Purdue pegboard and TALEC, and Achenbach parent and teacher rating scales. Results were controlled for the following confounders: age and gender, caregiver education level, birth weight and prematurity, and exposition to other drugs during pregnancy.

Results: Fifty-six antiretroviral-exposed and 21 control children were assessed. No significant differences were observed between groups. When compared to age-related normative values, no cognitive or motor deficits were detected, except for Purdue Pegboard Assembly test, in the low range of normality in both groups. When the covariates were taken into account no further findings were observed.

Conclusions: Normal cognitive and motor function was observed in 7-year-old children perinatally exposed to ARV. When compared to non-exposed healthy children, no differences were neither observed. Despite low numbers, the blinded design of our study and the long-term follow-up make our results reassuring.

O35

IMPROVING SURVIVAL OF CHILDREN WITH AIDS: CONTINUING IMPROVEMENT IN BRAZIL

L. Matida,* A.N. Ramos Jr.,† H.H.S. Marques,‡ M. Della Negra,§ R.C.M. Succi,¶ and N. Hearst,∥ *State Program of STD/AIDS, Sao Paulo; †Federal University of Ceara, Fortaleza; ‡University of Sao Paulo; §Infectology Institute ’Emilio Ribas’; and ¶Federal University of Sao Paulo, Sao Paulo, Brazil, ∥University of California, San Francisco, CA, USA.

Background: Brazil is well known internationally for its AIDS control programs. Brazil provides universal access to HAART, in adults and children, following national treatment guidelines, including prenatal HIV testing for all pregnant women. The first national study of survival in pediatric AIDS (1983 to 1998) showed the first evidence of the widespread impact of treatment as measured by substantially increasing survival time among AIDS cases infected through mother to child transmission. We examined more recent trends in survival by conducting a second national study among pediatric AIDS cases diagnosed in 1999 to 2002 and followed until 2007.

Methods: This retrospective cohort study was a probability sample (n = 1120) of all cases reported in the 27 states of Brazil. The sampling frame was all children diagnosed with AIDS under age 13 in the national AIDS reporting data base between 1999 and 2002. Using life table analysis, the probability of survival 60 months after diagnosis was calculated. For children not known to have died, the date of censure was their most recent clinic visit.

Results: The probability of survival 60 months after AIDS diagnosis was.863 (95% c.i..841-.885). In the first national study, this probability had been.528 (95% c.i..419-.608.) These results thus demonstrate a substantial improvement in survival in recent years.

Conclusions: These results reinforce previous data showing increased survival among Brazilian children with AIDS on a national level. Universal access to treatment and testing can have a significant public heath impact in a developing country like Brazil.

For Brazilian Group of Survival Study in Children with AIDS, Sao Paulo, Brazil

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ORAL COMMUNICATION 4: RESISTANCE IN BACTERIAL PATHOGENS

O36

INTEGRONS AND THE ANTIBIOTIC RESISTANCE GENES DISSEMINATION

D. Mazel, Unite Plasticite du Génome Bactérien, Institut Pasteur, Paris, France.

Abstract: Overcoming multi-drug resistance phenomena in bacteria is a key issue in medicine for the 21st century. In most gram-negative species, the multi-drug resistance phenotype development and spread is linked to the presence of integrons. Working as natural genetic engineering platforms, these elements are able to incorporate open-reading frames and convert them to functional genes by ensuring their correct expression. They owe their success to their aptitude to assemble multi-resistance operons from a pool gathering about 130 different gene cassettes so far, which encode resistance to all class of antibiotics active against Gram-negative bacteria. These structures are also found in the genomes of numerous environmental bacterial species, specifically in most Vibrio species where they can gather hundreds of adaptive gene cassettes in structures called superintegrons. Evidence suggests that the integrons from the environmental species are a source of resistance gene cassettes for the mobile multi-resistant integrons observed within clinical isolates. We have recently shown that cassette recruitment involved a novel mode of recombination using single stranded DNA substrates, which likely accounts for the unique aptitude of this site-specific recombination system to recombine distantly related sequences. We now have data showing that the SOS response controls expression of the integrase, and as a result, the gene cassette recruitment. These elements point to single strand DNA being a central metabolite for the adaptive response of integrons and to the antibiotics, especially those inducing the SOS response, as triggers for the resistance cassette recruitment, which results in a vicious circle favoring the resistance development.

O37

SALMONELLA BLOODSTREAM INFECTION IN RURAL CENTRAL AFRICA

N. Zozo,* P. Mitangala,† O. Vandenberg,‡§ R. Hendriksen,¶∥ C. Schirvel,** A. Aidara Kane,†† and F. Aarestrup, ¶ *Provincial Public Health Reference Laboratory, Centre de Recherche en Sciences Naturelles de Lwiro, Bukavu; †Provincial Infectious Disease Epidemiological Unit, Centre de Recherche en Sciences Naturelles de Lwiro, Goma, Zaire; ‡Department of Microbiology, Saint-Pierre University Hospital; §Infectious Diseases Epidemiological Unit, Public Health School, Université Libre de Bruxelles, Brussels, Belgium; ¶WHO Collaborating Centre for Antimicrobial Resistance in Food Borne Pathogens, National Food Institute; ∥EU Community Reference Laboratory for Antimicrobial Resistance, National Food Institute, Technical University of Denmark, Copenhagen, Denmark; **Centre Scientifique et Médical de l'Université Libre de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium; and ¶WHO Global Salm-Surv Program, World Health Organization, Geneva, Switzerland.

Background and Aims: Salmonella bloodstream infections represent a major health problem in sub-Saharan Africa. The incorporation of the Democratic Republic of Congo (DRC) in the WHO Global Salmonella surveillance training program allowed us to improve laboratory facilities ensuring appropriate treatment of bacteraemic children in the country. During a period of 5 years, we have evaluated clinical features, antimicrobial susceptibility patterns and molecular epidemiology of Salmonella isolated from blood.

Methods: Between 2002 and 2006, Salmonella spp. strains isolated from blood at the Lwiro Paediatric Hospital were identified and resistance to eight antimicrobials were determined. Random selections of the isolates were typed utilizing Pulsed Field Gel Electrophoresis (PFGE) to determine the genomic finger print.

Results: S. Typhimurium (60.5%) and S. Enteritidis (22.3%) were the most common serotypes found. 93.4% of them were multidrug resistant with the following proportion of strains resistant to: ampicillin (86%), chloramphenicol (92%), co-trimoxazole (95%), and tetracycline (34%). Among the 29 S. Typhimurium tested, 24 belonged according to dendrogramme of the PFGE to the same clonal cluster. The related strains were isolated during the first 48 hours after hospital admission as well as during a wide period after hospitalization indicating the isolates being both nosocomial and community acquired.

Conclusions: Our findings indicate the need of to use drugs rationally in order to control the spread of multi-drug resistance strains and the necessity of effective infection control practices to reduce the mortality and morbidity caused by Salmonella spp. DRC.

O38

ESBL COLONISATION AND INFECTIONS IN A PAEDIATRIC INTENSIVE CARE UNIT

R. Rossignol, M. Doyen, C. Fonteyne, D. Biarent, G. Mascart, P. Lepage, A. Vergison, Queen Fabiola Children's Hospital, Brussel, Belgium.

Introduction: ESBL producing gram-negative pathogens (GN) are commonly encountered in intensive care patients. Very few data are available from PICUs.

Objectives: To describe epidemiological and clinical characteristics of children colonised and/or infected with ESBL GN in our PICU.

Material and methods: PICU is a 12 beds unit in a 170-beds paediatric hospital. Annually, around 150 Algerian cardiac children are admitted for surgery. Upon admission from North Africa (NA) or PICU/NICU, patients are screened for ESBL GN. PICU patients are screened once weekly. Patients colonised and/or infected with ESBL GN are recorded. Epidemiological and clinical data were completed retrospectively for all patients for the years 2003–2006.

Results: 142 children were colonised and/or infected by an ESBL GN. Most (n = 129) had stayed in cardiac ward and/or PICU. Screening was performed on admission in 82%. On admission, 31% (44/142) patients were ESBL positive, 84% of which were from NA. 75 children became ESBL positive in PICU. In 25 children rectal swab became positive within 72 hours after surgery. Among 15 infections attributed to ESBL GN, 4 were colonised on admission and 4 became positive within 72 hours. There were 9 septicaemia/bacteraemia, 4 pneumonias, 1 UTI and 1 osteomyelitis. All infected patients, but one, who died from a KP catheter related septicaemia were treated with meropenem. Median length of stay to infection was 10 days.

Conclusion: Targeted screening allowed for identification of ESBL colonised patients and appropriate antibiotic treatment in 93% of our PICU infected patients. Screening was performed as recommended in most children.

O39

USE OF INTRAVENOUS COLISTIN (COLISTIMETHATE) IN NEONATES AND CHILDREN

E. Iosifidis,* M. Mitroudi,† M. Ioannidou,* C. Antachopoulos,* M. Sdougka,† A. Violaki,† V. Drossou-Agakidou,‡ C. Dimitriou,§ and E. Roilides.* *3rd Pediatric Department, Aristotle University of Thessaloniki; †Pediatric Intensive Care Unit, Hippokration Hospital; ‡1st Department of Neonatology, Aristotle University of Thessaloniki; and §Department of Orthopedic Surgery, Hippokration Hospital, Thessaloníki, Greece.

Background and Aims: Colistin has been increasingly used as salvage therapy of serious infections due to multi-drug resistant Gram-negative bacteria. Very little is known about its safety and efficacy in pediatric patients. We present a case series of critically ill children treated with colistin.

Methods: The records of pediatric patients who received colistin intravenously in a tertiary-care hospital (October 2007–November 2008) were reviewed.

Results: Seven children (median age 5.5 months, range 40 days to 8 years) received 8 courses of colistin. Colistin was used for the treatment of pneumonia (3 courses), CNS infection (3 courses), bacteremia (1 course) and complicated soft-tissue infection (1 course). The isolated pathogens were multidrug-resistant Acinetobacter baumannii, Enterobacter cloacae, Klebsiella pneumoniae and Stenotrophomonas maltophilia. Colistin was administered at a maximum daily dose of 3 mg/kg (40,000 IU/kg) in 3 courses and 8–16 mg/kg (100,000–200,000 IU/kg) in 5 courses, thrice a day. Duration of administration ranged between 12 to 70 days (>21 days in 7 courses). In 7/8 courses there was co-administration of other antimicrobial agents. In 3 courses (CNS infection) intravenous colistin was combined with intraventricular administration. In general, colistin was well tolerated. Temporary increase of serum creatinine in one patient was associated with co-administration of gentamicin. Six of 8 patients were cured. Colistin resistance developed in one patient after >6 weeks of therapy.

Conclusions: Intravenous colistin appears to be safe even at doses that are higher than those previously recommended. More data are needed to evaluate efficacy of colistin therapy in pediatric patients.

O40

ANTIMICROBIAL SUSCEPTIBILITY OF H. PYLORI STRAINS IN CHILDREN: RISK FACTORS FOR RESISTANCE AND EVOLUTION DURING THE LAST 5 YEARS

U. Halac,* P. Bontems,* S. Cadranel,* Y. Miendje Deyi,† and M. Scaillon,* *Gastroenterology—Hepatology, Queen Fabiola Children's University Hospital; and †Microbiology Department, Brugmann University Hospital, Bruxelles, Belgium.

Aim: The effectiveness of Helicobacter pylori eradication regimens is influenced by antibiotic susceptibility and compliance of patients. In this study, we evaluated risk factors associated with antibiotic resistance.

Patients and Methods: January 2003—March 2007, H. pylori gastritis was diagnosed by endoscopy with biopsies for histology and culture in 337 children (329 before and 40 children after eradication failure).

Results: Resistance to amoxicillin was not observed. Primary resistance was 103/329 = 31,4% (16.7% for Metronidazole, 5.8% for Clarithromycine, 3.7% for Metronidazole and Clarithromycine, 1.2% for Ciproxine, 0.3% for Clarithromycine and Ciproxine, in 3.7% we found discordant value between the antrum and the fundus). Significant independent risk factors for Metronidazole resistance are ethnical background (Sub-Saharan Africa, OR 7.57, P < 0.0001), and country of birth (Sub-Saharan Africa, OR 7.6, P < 0.0001). For Clarithromycine resistance, independent risk factors are children country of birth (North Africa, OR 4.03, P = 0.008), and chronic ENT infection (OR 6.68, P = 0.0004). After eradication failure, 35% (14/40) of isolated H. pylori strains are resistant to at least one antibiotic (22.5% for Metronidazole, 7.5% for Clarithromycin, 2.5% for both Metronidazole and Clarithromycine, et 2.5% for other combinations of antibiotic resistance).

Conclusions: Clarithromycin resistance rate seems decreasing in our population (was above 20% in 2000–2002). Metronidazole resistance rate is stable. Ethnical background and country of birth as well as some clinical features such as recurrent respiratory infection appear to be independent risk factors for antimicrobial resistance, probably due to different prescription habits in different countries and in different medical fields.

O41

EMERGENCE OF VACCINE ESCAPE RECOMBINANT STREPTOCOCCUS PNEUMONIAE 7B IN CHILDREN OF BANGLADESH WITHOUT SELECTION PRESSURE OF PNEUMOCOCCAL VACCINATION?

M. Rahman,* S. Shoma, and * R.R. Reinert,† *Laboratory Sciences Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh; and †Medical Microbiology, National Reference Center for Streptococci, Institute for Medical Microbiology, University Hospital Aachen, Aachen, Germany.

Background: Streptococcus pneumoniae take up exogenous DNA by natural transformation or fratricide induced by antibiotics, vaccination and other factors for phenotypic and genotypic diversification.

Aims and Methods: Studied capsule switching, seroconversion and genomic similarity among pneumococci from children with invasive diseases by antibiotics resistance, serotyping and MLST analysis in Bangladesh where pneumococcal vaccines are not used routinely.

Results: Of 136 pneumococci, 11 common serogroups, representing 77% of invasive-isolates were 6, 14, 19, 5, 12, 1, 7, 45, 2, 9 and 23 (in descending order), where as 11 most common serogroups of colonized-isolates comprising 77.6% were 6, 19, 14, 23, 9, 7, 13, 15, 21, 22 and 37. 71.3% were resistant to one or more drugs, MDR in 11.7%. Six (4.4%) macrolide-resistant-isolates included four 7B, one 9V and 18C each. All four 7B had MDR, three had sequence type (ST) 1553 and one ST 1586, a single locus variant of ST 1553. 9V strain had MDR and ST 1553 indicating genomic similarity with 7B and capsule switching where prevalent MDR 9V appeared to acquire 7B capsule resulting in seroconversion. eBURST analysis of MLST 1586 and 1553, and 2681 different MLSTs of pneumococci in MLST database (www.mlst.net) showed that ST 1553 and ST 1586 were not closely related to any other clone in database.

Conclusion: Thus, newly emerged MDR pneumococcus 7B strains appeared to originate by capsule switching by non-vaccine selection pressure caused invasive disease in children. To our knowledge, this unique pneumococcal clonal complex was not described elsewhere in the world.

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ESPID SCIENTIFIC SESSION 7: PERSPECTIVES FOR BACTERIAL INFECTIONS IN PAEDIATRICS

O42

SYNERGISTIC LETHALITY OF BACTERIAL AND VIRAL PNEUMONIA

K. Klugman, Hubert Department of Global Health, Emory University, Atlanta, GA, USA.

Abstract: Viral upper respiratory infections may progress to bacterial pneumonia, but the extent of the contribution of bacterial pathogens to viral associated pneumonia morbidity and mortality is unknown. Pneumococcal conjugate vaccine (PCV) may be used a probe to determine the role of the pneumococcus in super-infection of viral associated pneumonias. In a double blind randomized trial of 9 - valent PCV, it was shown that PCV prevented clinical pneumonia associated with a wide range of viral respiratory pathogens, including influenza, para-influenza, RSV and HMV. The large fraction (41%) of influenza associated pneumonias prevented by PCV suggests that the majority of influenza associated pneumonias in children may be due to pneumococcal super-infection. An analysis of the contemporary literature of the 1918 influenza pandemic suggests that >80% of deaths occurred ≥ 7 days after onset of symptoms. The time to mortality of untreated pneumococcal bacteremia follows an identical time course to the 1918 influenza deaths. In autopsy studies pneumococci were isolated from lung or heart blood in up to 2/3 of victims. In studies of blood cultures taken from living soldiers with pandemic influenza associated pneumonia in 1918, pneumococci were isolated in up to 50% of patients. The data from endemic influenza hospitalization in children and from pandemic influenza mortality during 1918 suggest a significant role for pneumococci in influenza - associated morbidity and mortality. Data from both endemic influenza and past pandemics suggest that the prevention of pneumcococcal super - infection should be an essential part of pandemic influenza planning.

O43

BACTERIA, VIRUSES, AND ANTIMICROBIAL AGENTS

F. Baquero, and R. del Campo, FIBio-RYC, Department of Microbiology, Ramón y Cajal University Hospital, Madrid, Spain.

Abstract: The classic etiological concepts of infectious diseases, based on “one germ-one disease-one treatment” are under collapse. The acquisition of pathogenic organisms depends on and influences the entire microbial community ecology of the organic area under risk. On the other hand, the local mucosal immune-response, the anti-infective measures, from vaccination to antibiotic therapy, also shapes the microbial populations’ landscape.

Direct interactions among bacteria of the respiratory tract, including allelopathic or amensalistic competitive suppression, should be considered at the time of deciding interventions. In some cases, bacterial viruses are mediating such interactions; for instance, remote-control bacteriophage induction in Staphylococcus aureus by Streptococcus pneumoniae mediates displacement of the former (lysogenic) organism. Coevolution with viruses might also driven the evolution of bacterial mutation rates, and hence of its mechanisms of genetic adaptation. Streptococcus pneumoniae-Moraxella catarrhalis-Haemophilus influenzae competitive interactions are also frequent and relevant in the ecology of orpharynx, as was demonstrated by biofilm-invasion procedures. The impact of respiratory viruses in enhancing bacterial colonization, sometimes mediated by neuraminidase activity, and consequently on the bacterial population size and transmission rates (favoured by symptoms associated with viral infections) is of great concern in the pediatric arena. The role of the inflammatory response mediated by viruses in the bacterial population ecology (for instance altering the total bacterial density in the pharyngeal crypts) is certainly worth to be investigated.

Finally, the effect of antimicrobial agents on microbial ecology of the respiratory tract should be considered. Available metagenomic approaches to ascertain the complexity of both the viral and the bacterial organisms in the respiratory tract should help to understand the changing ecology of the respiratory tract infections.

O44

FUTURE CHALLENGES IN BACTERIAL INFECTIONS MANAGEMENT

M. Levin, Spain Paediatrics, Imperial College London, London, UK

Abstract: Life threatening bacterial infections including septicaemia, meningitis, and focal infections continue to be important causes of childhood mortality worldwide. An increasing proportion of cases are caused by gram positive organisms including Staphylococcae and Group A streptococcae.

The pathophysiology of septic shock is known to involve a complex inflammatory reaction to a range of bacterial products and toxins. The techniques of gene expression profiling and proteomic methods have enabled a new picture to emerge of the complexity of this process. Rather than being solely due to a small number of inflammatory mediators such as TNF, IL1 and IL6, the new molecular methods have revealed a far more complex process involving multiple cells and signalling pathways as well as released mediators and including activation of the complement, and coagulation pathways.

The early attempts to develop novel immuno-modulatory treatments of septic shock were largely disappointing and a large number of therapeutic trials conducted over the past two decades of anti-endotoxin, anti-cytokine and anti-mediator treatment have produced very few therapeutically applicable interventions. In this talk the reasons for the failure of previous treatments, and the use of the new molecular and proteomic approaches to identify other candidate treatments will be discussed. Novel approaches to blocking myocardial depression and inhibiting coagulation will also be addressed.

Finally, the role of genetic factors in determining the complexity of the host inflammatory response and outcome and in guiding novel forms of treatment will be discussed

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BACTERIAL ANTIBIOTIC RESISTANCE

P001

PATTERN OF RESISTANCE AND SEROTYPE DISTRIBUTION AMONG GROUP B STREPTOCOCCUS IN KUWAIT

N. Al-Sweih,* N. Gadallah,† and E. Al Mutawaa,† *Microbiology, Faculty of Medicine, Kuwait University; and †Faculty of Medicine, Kuwait, Kuwait.

Introduction: Penicillin is the first line agent used to treat and prevent group B Streptococcus (GBS) infections. The long-term impact of widespread of intrapartum prophylaxis on penicillin susceptibility has not explored. However, resistance to second-line antimicrobials, clindamycin and erythromycin, has increased since 1996. Our goal was to assess whether there are differences in susceptibility profiles between colonizing and invasive GBS strains by capsular type. To address the issue we evaluated different antibiotics, MIC trends over 5-years period in relation to different serotypes and isolate sets.

Methods: We evaluated 534 different GBS isolates from Kuwait hospitals compromising three different sets, 59 invasive isolates (blood &CSF), 378 non-invasive isolates (urine &wound swabs) and 97 colonizing isolates (vaginal & neonatal swabs). MIC to penicillin, erythromycin, clindamycin, tetracycline and gentamicin were tested by E test, and serotyping by latex agglutination.

Results: Serotype III (40.6%) was the most common isolate from invasive set while serotype V from non-invasive (42.3%) and colonizing (37.3%) isolates. Serotype VI, VII and VIII were isolated from non-invasive and colonizing sets only. All isolates were sensitive to penicillin however; invasive strains had lower MICs than others did. Isolates with high MIC (>0.064) form 11% and 35.4% of 2004 and 2007 isolates while serotype VIII, NT and Ia were less sensitive than other serotypes. Overall resistance to erythromycin, clindamycin, tetracycline, and gentamicin was 11.8%, 8.7%, 93.6% and 100% respectively.

Conclusion: GBS remains susceptible to penicillin, however MIC to penicillin is changing and continuous monitoring is necessary to identify potentially resistant isolates.

P002

SEQUENTIAL THERAPY VS. STANDARD TRIPLE THERAPIES FOR HELICOBACTER PYLORI INFECTION IN CHILDREN

P. Bontems,* N. Kalach,† G. Oderda,‡ L. Muyshont,* A. Salame,* L. Waroquier,* Y. Miendje Deyi,§ S. Cadranel,* and M. Scaillon,* *Gastroenterology-Hepatology, Queen Fabiola Children's University Hospital, Bruxelles, Belgium; †Department of Paediatrics, Saint Antoine Paediatric Clinic, Lille, France; ‡Paediatric Department, University of Piemonte Orientale, Novara, Italy; and §Microbiology Department, Brugmann University Hospital, Bruxelles, Belgium.

Aim: Eradication rate of Helicobacter pylori with a sequential treatment regimen, impact of antimicrobial susceptibility on eradication rates.

Methods: Prospective multi-center study. Children with non-ulcer dyspeptic manifestations. Infection proven by histology and culture, no anti-H. pylori drugs during 4 weeks. Children received randomly either a 10-days sequential treatment (omeprazole-amoxicillin (AMO) 5 days and omeprazole-clarithromycin(CLA)-metronidazole(MET) the remaining 5 days or a 7-days treatment, (omeprazole-AMO-CLA when H. pylori strains susceptible to CLA or MET in case of resistance to CLA. H. pylori eradication assessed by 13C urea breath test at least 8 weeks after treatment.

Results: October 2007-September 2008, 98 children included (58 female/42 male, median age 11 y range 1,5 to 17). Eradication achieved in 74 children out of 88 who returned for a follow-up test. Intention-to-treat eradication rate (ITT) 76% (sequential 41/55 = 75%, triple therapy 33/43 = 77%) and per-protocol cure rate (PP) 84% (sequential 41/49 = 84%, triple therapy 33/39 = 85%). When CLA resistance, ITT eradication rate 9/14 (sequential 7/12 = 58%, triple therapy 2/2) and PP 9/13 (sequential 7/11 = 64%, triple therapy 2/2). When MET resistance, ITT eradication rate 13/18 (sequential 9/13 = 69%, triple therapy 4/5) and PP 13/15 (sequential 9/10 = 90%, triple therapy 4/5).

Conclusion: Sequential treatment seems highly effective with similar or higher eradication rate than with triple therapy prescribed in accordance with antimicrobial susceptibility. Since cure rate is decreased in case of CLA resistance, sequential treatment may not be used as first line therapy when CLA resistance rate exceed 20%.

P003

ANTIMICROBIAL RESISTANCE OF URINARY ESCHERICHIA COLI ISOLATES IN COSTA RICAN (CR) CHILDREN (CH)

K. Camacho-Badilla,* A. Soriano-Fallas,* M. Hernandez de Mezerville,* M.L. Herrera,* and R. Ulloa-Gutierrez,† *Hospital Nacional de Ninos de Costa Rica; and †Pediatric Infectious Diseases, Hospital Nacional de Ninos de Costa Rica, San Jose, Costa Rica.

Background: Urinary tract infections (UTI) are common in ch and can be associated with complications in patients (pts) with underlying genitourinary abnormalities. Knowing the local antibiotic (ATB) resistance pattern of Escherichia coli, the leading etiology of pediatric UTI, is crucial.

Methods: Retrospective review of all positive E.coli isolates in urine cultures obtained from ambulatory or hospitalized ch who were attended at the only paediatric tertiary referral hospital of CR. Information was retrieved from the database of the Bacteriology Laboratory Division. Antimicrobial susceptibility testing was performed using Vitek 2 Compact System (BioMerieux®). Study period: June 1, 2006–April 18, 2008.

Results: 1,713 E.coli positive urine cultures were identified. 34 (2%) of the tested strains were ESBL (+). ATB resistance rates (%) among all tested isolates are listed below:

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Conclusions: Resistance rates of E.coli to ampicillin and TMP-SMX, the 2 most commonly used oral ATB during many years for treating CR ch with UTI's, are high. New antimicrobial options for the management of these ch should be available at our institution.

P004

FOUR PEDIATRIC PATIENTS WITH THE IMIPENEM RESISTANT ACINETOBACTER BAUMANII (IRAB) INFECTION IN SINGLE INTENSIVE CARE UNIT

S. Cha, H.-S. Yoon, K.-S. Lee, A.-R. Choi, and M.-Y. Han, Department of Pediatrics, Kyunghee University Hospital, Seoul, South Korea.

Background and Aims: Acinetobacter baumanii is known as an important cause of nosocomial infection, especially intensive care unit (ICU). The known risk factors are invasive procedures such as tracheal intubation, central venous catheter (CVC) insertion and overuse of broad-spectrum antimicrobials. We had 4 cases of IRAB and to investigate the route of infection, and describe their clinical characteristics.

Methods: We retrospectively reviewed the medical records of 4 pediatric patients of culture proven nosocomial A. baumanii infection which occurred in ICU of Kyunghee University Hospital between October 2007 and July 2008.

Results: The median age was 1.5 yrs, the median length of hospitalization was 162 days. The times of culture proven infection was 2, 15, 66, and 135 th hospital days, respectively. Their underlying diseases were all neurologic diseases. The three had mechanical ventilator. Only one received carbapenem before A. baumanii infection. The sites of infection were ventriculo-peritoneal shunt in 1, CVC in 1, tracheal intubation catheter in 1, and blood in 1. All were resistant to imipenem. Three were susceptible to colistin. Infection was not associated with clinical features such as fever or elevated C-reactive protein in our study.

Conclusions: It is thought that Imipenem resistant A. baumanii infection occurred due to nosocomial spread in ICU other than overuse of antimicrobials in our study. This study suggest that constant surveillance about IRAB and antimicrobial resistance is needed for patients with prolonged ICU care even in patients without fever or without increased acute phase reactants.

P005

COMPARISON BETWEEN BACTERIAL ANTIBIOTIC RESISTANCES IN THREE CHILDREN COHORTS WITH URINARY INFECTIONS

M. Gafencu,* G. Doros,* I. Ebetiuc,† and M. Sandu,‡ *Pediatrics, Univ. of Medicine and Pharmacy V Babes; †Pediatrics; and ‡Children Hospital, Timisoara, Romania.

Abstract: The aim of the study was to compare the antimicrobial resistance of UTI causing bacteria in hospitalised children.

Methods: The three UTI children groups were: 36 in 2004 and 2005, 81 from 2006 to June 2007: 0–6 years-53, >6 years-28; 40 in 2008, 0–6 years-28, >6 years-12. They were treated with antibiotics and the antibiogram was performed.

Results: For the first group the cultures revealed 66,6% E.coli and 30,5% Proteus strains. 60% of E. coli and 86% Proteus were resistant to TMP/SMX. Best responses were obtained for cephalosporine and for Ciprofloxacin. In the second cohort: E.coli (40,74%), Proteus (12,31%), Klebsiella (2,46%). The intermediary resistant strains (54,54% -E.coli) were resistant to Ampicilin and TMP/SMX. Proteus and Klebsiella were resistant to Ampicilin, aminoglycozides, TMP/SMX, Colistin. Among the 40 cases of the 3rd cohort, 75% were with E. coli, 12,5% -Proteus, and 12,5% -Klebsiella. 45% of the cases received empirical oral antibiotics before admission and in those 84,6% of E. coli strains were resistant to Amoxyciline, 76,9% to TMP/SMX, and 30,7% to cephalosporine whilst 64,7% were resistant to Amoxyciline, 58,8% to TMP/SMX and 29,4% to cephalosporine in the other group. Klebsiella showed resistance to Ampicilin in patients previously treated and no resistance in the other group, and 60% of Proteus showed resistance to TMP/SMX in patients previously treated whilst 20% in the other group.

Conclusion: Is a modified resistance to antibiotics resistance in patients who received empirical treatment for UTI before admission and a disproportionate use of antibiotics that is still a problem.

P006

PREVALENCE OF DIFFERENT RESISTANCE PHENOTYPES OF HAEMOPHILUS INFLUENZAE ISOLATED FROM CHILDREN IN SPAIN: (SAUCE-4 PROJECT)

A. Gené,* A. Mazón,† J.-E. Martin-Herrero,‡ E. Pérez-Trallero,§ E. Cercenado,¶ M. Segovia,∥ L. Martinez,** J. García de Lomas,†† and R. Dal-Ré,‡ *Servicio de Microbiología, Hospital Sant Joan de Déu, Barcelona; †Servicio de Microbiología, Ambulatorio General Solchaga, Pamplona; ‡Medical Department, GlaxoSmithKline, S.A, Tres Cantos; §Servicio de Microbiología, Hospital Donostia, San Sebastián; ¶Servicio de Microbiología, Hospital Gregorio Marañóns, Madrid; ∥Servicio de Microbiología, Hospital Virgen de la Arrixaca, Murcia; **Servicio de Microbiología, Hospital Marqués de Valdecilla, Santander; and ††Instituto Valenciano de MIcrobiología, Valencia, Spain.

Background and Aims: Beta-lactamase (BLA) production in H. Influenzae is a well-known predictor factor for treatment failure in respiratory tract infections (RTI). Susceptibility patterns of H. influenzae and prevalence of resistance phenotypes are described.

Methods: This was a prospective, multicenter (34 hospitals) antimicrobial surveillance study performed between June-2006 and May-2007. A total of 2,736 H. influenzae isolates from patients with community-acquired RTI were collected and forwarded to a central laboratory. Susceptibility testing was performed by microdilution following CLSI M100-S18 guidelines and breakpoints. Chromogenic nitrocefin was used to test BLA-production. An ampicillin MIC of ≥2 mg/L was used to define BLA-negative ampicillin-resistant isolates (BLANAR). Capsular serotyping was performed with specific antisera against capsular antigen (Difco Laboratories).

Results: Up to 496 isolates from paediatric patients were identified. The origin of the samples was otical in 263 cases (53.0%), other respiratory samples in 224 (45.2%) and blood or pleural fluid in 9 cases. Ampicillin non-susceptible rate was of 21.4%. BLA-producing H. influenzae were 20.8%, whereas 3 isolates (0.6%) had a BLANAR phenotype. Another 2 isolates were found to be BLA-positive amoxicillin/clavulanate resistant (BLPACR) with 99.6% of isolates being susceptible to amoxicillin/ clavulanate. Macrolide non-susceptibility was 0.2% for azithromycin and 1.2% for clarithromycin. The majority of isolates (98.8%) were non-capsulated, whereas serogroups a, b, and c represented 0.8%, 0.2%, and 0.2%, respectively. Six non-capsulated strains were isolated from blood and 1 from pleural fluid.

Conclusions: BLA-producing H. influenzae rate remains similar to previous SAUCE study (2001–2002).

BLNAR phenotype seems to be decreasing.

P007

ANTIMICROBIAL RESISTANCE TRENDS IN SHIGELLA SPECIES AMONG PATIENTS WITH ACUTE DIARRHEA IN CHILDREN HOSPITAL OF TABRIZ, IRAN

S. Hosseinpour Sakha,* and M.E. Rahbani NobarNobar,† *Infectious Disease; and †Pediatrics, Tabriz University of Medical Sciences, Tabriz, Iran.

Background & Objectives: The study was carried out to determine the pattern of antimicrobial resistance of shigella species among patients with acute diarrehea in children hospital of Tabriz.

Materials & Methods: The study included all of acute diarrhea patients who visited in the children hospital of Tabriz, Iran during 2002–2004. All children whose fecal cultures yielded shigella species and antibiotic sensitivity testing was done were included in the study.

Results: A total of 45 isolated of shigella, 39 of which were shigella flexneri and 4 shigella sonnei. The rate of resistence in shiglla flexneri to ampicilin and trimetoprim-sulfametoxazol were 89.6%, 89.1% respectively. Multidrug resistance were in 65.7% cases. Almost all isolated shigella sonnei were resistant to ampicilin and 75% were resistant to trimethoprim sulfamethoxazol All of shigella species were found to be sensitive to third generation cephalosporins and nalidixic acid.

Conclusion: These results suggest the shigella flexneri is the important spp in this region with high rate of resistance to commonly prescribed antibiotic and the need to reassess the use of antibiotic agent in treatment of shigllosis.

Keywords: Shigella species, Shigllosis, Antibiotic sensitivity.

P008

EMERGENCE OF GES-TYPE EXTENDED-SPECTRUM BETA-LACTAMASE PRODUCING ENTEROBACTERIACEAE IN A PEDIATRIC LIVER TRANSPLANTATION UNIT

T.-D. Huang,* P. Bogaerts,† E. Andre,* D. Van Der Linden,‡ E. Sokal,‡ and Y. Glupczynski,† *Clinical Microbiology, Cliniques Universitaires St-Luc (UCL), Brussels; †Clinical Microbiology, Cliniques Universitaires Mont-Godinne (UCL), Yvoir; and ‡Department of Pediatrics, Cliniques Universitaires St-Luc (UCL), Brussels, Belgium.

Backgrounds and Aims: Extended-spectrum beta-lactamases (ESBL) producing gram-negative bacteria are isolated with increasing frequency in pediatric populations. We report here for the first time in Belgium the emergence of Enterobacteriaceae carrying GES-type ESBL enzymes in a pediatric ward.

Methods: All patients admitted to this 14-bed ward mainly occupied by children hospitalized for liver transplantation were screened for multi-resistant gram negative bacteria in stools additionally to clinical samples. Identification and susceptibility testing of isolates were performed by BD Phoenix® automate and ESBL production was confirmed by double discs synergy test using Rosco® tablets. All phenotypic ESBL-producing strains were characterized by PCR targeting various ESBL genes.

Results: From January 2007 to January 2009, of the 2424 samples (562 stools) collected in 520 children, 50 ESBL-producing isolates (prevalence of 9.5%) were recovered including 10 GES-producing strains from 7 patients (6 fecal carriers). The GES ESBLs were found in 6 different Enterobacteriaceae species (two patients were colonized by more than one species); all isolates displayed identical resistance patterns. All patients but one were admitted for liver transplantation and originated from different countries of Eastern Europe. Patients and their families also stayed in the same hospital linked residency.

Conclusions: The diversity of the species, the multiple origins of the patients and the local clustering together highly suggest both cross-transmission and horizontal gene transfer of these GES plasmid-borne ESBL enzymes. Although no infection was diagnosed, GES ESBL-producing isolates may lead to outbreaks and represent a threat for fragile immunosuppressed patients such as liver transplanted children.

P009

SEROTYPES AND ANTIMICROBIAL SUSCEPTIBILITY OF STREPTOCOCCUS PNEUMONIAE FROM CHILDREN IN CYPRUS

M. Koliou,* K. Andreou,* C. Economou,† P. Iakovides,† P. Mama,‡ and E. Soteriades,§ *Paediatric Department, Archbishop Makarios Hospital; †Private Practice; ‡Archbishop Makarios Hospital, Nicosia, Cyprus; and §Harvard School of Public Health, Department of Environmental Health, Environmental and Occupational Medicine and Epidemiology (EOME), Boston, MA, USA.

Background and Aims: Resistance of streptococcus pneumoniae to antibiotics has increased in many countries. Since no previous data exist on the resistance of strep pneumoniae to antibiotics, our objective was to identify the resistance patterns and the circulating serotypes of strep pneumoniae in Cyprus.

Methods: A total of 150 nasopharyngeal isolates were recovered from 406 children younger than 5 years of age visiting the Government vaccination centers, the outpatient department of Archbishop Makarios Hospital and the offices of 4 private Paediatricians in Nicosia district. Sensitivity to penicillin, ceftriaxone, erythromycin, clindamycin, tetracycline, linezolid and vancomycin was tested by the disk diffusion and MIC tests. A questionnaire was also used to collect data including vaccination history.

Results: Forty percent of children involved were immunized by the conjugated pneumococcal vaccine. Resistance patterns of isolated strains were: Penicillin 39.4% Intermediate, 1.4% Resistant; Ceftriaxone 7.9% Intermediate, 5.8% Resistant; Erythromycin 40.6% Resistant, Clindamycin 30.8% Resistant, Tetracycline 31.9% Resistant. No resistant strains were detected to either linezolid or vancomycin. Twenty four percent of strains were multi-resistant. The most frequent serotypes identified were 15B (13.1%), 6B (12.3%), 23B (7.4%), 19F (6.6%) and 23A (6.6%). Of those serotypes 15B and 19F were associated with significant multi-resistance rates to antibiotics of 56% and 50% respectively.

Conclusions: The high prevalence of antibiotic resistant streptococcus pneumoniae strains colonising children under 5 years old in Cyprus, justify the need for systematic surveillance studies on the resistance characteristics of streptococcus pneumoniae in Cyprus in order to guide antimicrobial therapy and support the increase of vaccination coverage.

P010

ANTIMICROBIAL SUSCEPTIBILITY OF URINARY PATHOGENS IN CHILDREN WITH URINARY TRACT INFECTIONS

A. Koteli,* P. Kambouridou,† K. Kontopoulou,* and K. Tsepkentzis,† *Microbiology Laboratory; and †Paediatric Department, ‘G.GENNIMATAS’ Thessaloniki General Hospital, Thessaloníki, Greece.

Objectives: To determine the current antimicrobial susceptibility patterns of pathogens causing UTIs to pediatric patients from our Hospital during 2006–2008.

Methods: Data were collected from patients admitted in the paediatric unit during 3-year period (2006–2008). Identification and susceptibility testing were performed using the VITEK 2 system (BioMerieux(R), France). Susceptibility data were interpreted using CLSI breakpoint criteria. Double-disk synergy test and E-test were used for screening ESBLs.

Results: A total of 478 consecutive urine isolates from 465 children aged 1 month to 18 years with UTI were collected at our Hospital in 2006–2008. E.coli (n = 253, 52,93%) was the predominant pathogen, followed by P.mirabilis (n = 71, 14,85%) and Ps.aeruginosa (n = 31, 6,49%). Susceptibility rates to commonly used antimicrobial agents for E.coli and P.mirabilis were: ampicillin 58/73, amoxicillin/clavulanate 85/89, cefotaxime 94/97, ceftazidime 93/96, cefuroxime 80/85, ciprofloxacin 98/93, gentamicin 97/97, amikacin 97/100, netilnicin 97/96, trimethoprim/Sulfa 79/88. The susceptibility of Ps.aeruginosa was: amikacin 96, ceftazidime 93, ciprofloxacin 96, gentamicin 96, netilmicin 97, piperacillin/tazobac 100. ESBL produced 4% of E.coli and 0% of P.mirabilis.

Conclusions: E.coli is the primary bacterial pathogen causing UTIs in children, followed by Proteus mirabilis. Based on the resistance phenotype 15% of E.coli and 11% of P.mirabilis isolated from urine cultures in paediatrics patients were resistant to broad- spectrum beta- lactam antibiotics. The results reinforce the need for continuous local surveillance to show the current antimicrobial susceptibility data which can be used as aid to the empirical treatment of UTIs in children.

P011

DIFFERENCES IN ANTIBIOTIC SUSCEPTIBILITY PATTERNS OF BLOOD AND URINE E. COLI ISOLATES DERIVED FROM CHILDREN AND ADULTS

E. Mantadakis,* M. Panopoulou,† A. Tsalkidis,* A. Grapsa,† E. Alepopoulou,† A. Chatzimichael,* and S. Ktenidou Kartali,† *Department of Pediatrics; and †Department of Microbiology, Democritus University of Thrace, Alexandroúpolis, Greece.

Purpose: To compare antibiotic susceptibility patterns (ASP) of blood and urine E. coli isolates derived from children and adults with documented bacteremia and urinary tract infections.

Patients and Methods: ASP data were collected over a 69 month period from computerized records of the Department of Microbiology, while demographic and clinical data were collected from the pediatric medical records. Duplicates were excluded. Only microbiological data were available for adults. E. coli identification and resistance testing was carried out by the Vitek 2 identification and resistance testing system. MICs were determined, and the results were reported as sensitive (S), intermediate (I), and resistant (R) according to CLSI standards. I and R isolates were grouped together. Susceptibility comparison per antibiotic in children vs. adults was carried out by Fisher's exact test.

Results: Pediatric (n = 24) versus adult (n = 259) E. coli blood isolates were more resistant against aminoglycosides [amikacin (P = 0.03), gentamicin, netilmicin and tobramicin, P < 0.0001, for all three], ampicillin and ticarcillin (P = 0.03 for both). Adult E. coli blood isolates tended to be more resistant against nalidixic acid (P = 0.09). Pediatric (n = 419) versus adult (n = 838) E. coli urine isolates were more resistant against ampicillin (P = 0.0009) and ticarcillin (P = 0.003), while adult E. coli urine isolates were more resistant against quinolones (nalidixic acid, ciprofloxacin, norfloxacin, ofloxacin, P < 0.0001 for all four).

Conclusions: Significant differences exist in ASP of blood and urine E. coli isolates derived from children and adults. These differences likely reflect the more frequent use of ampicillin and aminoglycosides in children and of quinolones in adults.

P012

ANTIBIOTIC SUSCEPTIBILITY PATTERNS OF PEDIATRIC MRSA ISOLATES OVER A 67 MONTH PERIOD IN ALEXANDROUPOLIS, THRACE, GREECE

E. Mantadakis,* M. Panopoulou,† A. Tsalkidis,* A. Grapsa,† E. Alepopoulou,† A. Chatzimichael,* and S. Ktenidou Kartali,† *Department of Pediatrics; and †Department of Microbiology, Democritus University of Thrace, Alexandroúpolis, Greece.

Purpose: Methicillin-resistant Staphylococcus aureus (MRSA) isolates are on the rise, limiting the available therapeutic options. We studied the antibiotic susceptibility patterns (ASP) of pediatric MRSA isolates.

Patients and Methods: We collected demographic, clinical and ASP data for children with MRSA isolates cared for in the Department of Pediatrics over the period 1/2003 to 7/2008. ASP data were collected from computerized data of the Department of Microbiology. Duplicates were excluded. MRSA identification and resistance testing was carried out by the Vitek 2 identification and resistance testing system. MICs were determined, and the results were reported as sensitive (S), intermediate (I), and resistant (R) according to CLSI standards. I and R isolates were grouped together.

Results: A total of 58 MRSA strains were isolated in 35 boys (60%) and 23 girls (40%) with a median age of 14 months (range 0.5 to 120 months). One isolate was from blood, 1 from pleural fluid, 4 from urine/urethra, 12 were from eyes/nose/ears, and 40 were derived from skin infections. Three of 58 (5.2%) isolates were resistant to clindamycin, 9/58 (15.5%) to erythromycin, 47/58 (81%) to tetracycline, 45/58 to fusidic acid (77.6%), 2/58 to tobramycin (3.4%) and 1/58 to both rifampin and TMP/SMX (1.7%). There was no resistance to glycopeptides, quinolones, and gentamicin. D-test performed in 5 erythromycin resistant and clindamycin susceptible isolates showed 3 to have inducible clindamycin resistance.

Conclusions: In our area, clindamycin, rifampin, and TMP/SMX resistance is low, while tetracycline and fusidic acid resistance is exceptionally high among pediatric MRSA isolates.

P013

PREVALENCE OF ANTIBIOTIC RESISTANCE OF STREPTOCOCCUS PYOGENES, STREPTOCOCCUS PNEUMONIAE AND HÄMOPHILUS INFLUENZAE IN AUSTRIA IN THE PAST TEN YEARS

L. Masoud,* G. Feierl,* U. Wagner-Eibel,* E. Leitner,* and E. Marth,† *Bacteriology; and †Medical University of Graz, Graz, Austria.

Background: Bacterial infections of the respiratory tract are an important topic in paediatrics. The most important bacteria are: Streptococcus pneumoniae, Streptococcus pyogenes and Haemophilus influenzae. In the past years resistance problems have increased worldwide but a significant regional fluctuation can be noticed.

Material and Methods: Antibiotic resistance of isolates of all 0–16 year olds from the university hospital of Graz, and from settled paediatrics and general practitioners were analysed.

Results: In the 10 year period 1628 isolates of Streptococcus pneumoniae, 4197 Streptococcus pyogenes and 1843 Hämophilus influenzae could be detected.

Streptococcus pneumoniae: The number of penicillin-susceptibility has decreased considerably. While there were 99% susceptible in the year 2000, there were only 94% in 2008, but the number of high-level resistance was low. Macrolide resistance has shown some increase mostly combined with a decrease of susceptibility to penicillin and a resistance to Trimethoprim/Sulfamethoxazol.

No resistance was detected in Streptococcus pyogenes against penicillin. Macrolide susceptibility is subject to considerable fluctuations; nevertheless an overall increase of Macrolide-resistance can be noticed.

Haemophilus influenzae: An increase of the ß-lactamase-building isolates was registered from 6% in 2002 to 15% in 2007.

Conclusion: The number of the resistant strains is increasing considerably and a regional observance of the situation is definitely necessary. The trend of resistance in our region is emerging, but at a low level at the moment.

P014

PREVALENCE OF SEROGROUPS, SEROTYPES AND ANTIMICROBIAL RESISTANCE OF SHIGELLA ISOLATES AT GONDAR UNIVERSITY TEACHING HOSPITAL, NORTHWEST ETHIOPIA

A. Mulu,* and M. Tiruneh,† *Department of Microbiology, University of Gondar Ethiopia and Institute of Virology University of Leipzig, Leipzig, Germany; and †Department of Microbiology, University of Adelaide, Gondar, Ethiopia.

Background: The emergence and dissemination of multiple-drug resistance strains of Shigella are becoming a series global problem, particularly in developing countries. In Ethiopia, the diversity of Shigella strains and their antimicrobial susceptibility is not well studied.

Objective: This study was carried out to determine the prevalence of serogroups, serotypes & antimicrobial resistance of Shigella isolates from patients with acute diarrhea.

Methods: Consecutive stool specimens were received from patients and cultured for Shigella. Shigella isolates were confirmed by biochemical and serological tests. The antimicrobial susceptibility testing of all strains was carried using the single disc diffusion technique of Kirby and Bauer.

Result: Of the 1200 stool samples, 90(7.5%) yielded shigella isolates with the following serogroups:S. flexneri (72.2%), S. dysenteriae (10.0%), S. boydii (8.9%) and S. sonnei (8.9%). S. flexneri was found to be the predominant serogroup. The commonest serotypes were S. flexneri type IV (24.6%), S. dysentriae type 2 (33.33%), S. boydii types 2 and 5 (each 25%), and S. sonni phase I (75%). Eighty five (94.5%) of the isolates showed resistance to one or more drugs of which 71 (78.9%) of them were multiresistant. S. flexneri showed the highest multiresistance (91.2%). Emergence of resistant S. flexneri serotypes to ciprofloxacin (2.2%) and norfloxacin (1.1%) has been observed.

Conclusion: We recommend ciprofloxacin & norfloxacin for empirical treatment of shigellosis with continuous monitoring of the distribution of serogroups, serotypes and antimicrobial resistance patterns and reservation of nalidixic acid and ceftriaxone for very severe cases of shigellosis.

P015

COMMUNITY ACQUIRED METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS SKIN AND SOFT TISSUE INFECTIONS IN CHILDREN IN GREECE. AN EMERGING EPIDEMIC?

P. Petropoulos,* E. Lebessi,† G. Markogiannakis,* S. Kosteletos,* M. Matsas,† K. Giannakopoulou,† and G. Petousis,* *1st Surgical Department; and †Microbiology Department, Athens Children Hospital ‘P&A Kyriakou’, Athens, Greece.

Abstract: We present the results of skin and soft tissue abscesses in the children population of Athens Greece. These are patients who needed hospitalization because they needed sedation for the surgical procedure or because they were presented septic with fever and elevated markers of systemic infection.

A perspective study of hospitalized patients with skin and soft tissue infection due to Methicilline Resistant Staphylococcus aureus (MRSA) A total number of 28 patients from 1-1-08 to 31-12-08 were included in the study. The culture and identification were perfomed by conventional methods. A total of 23/28 (82%) had Staphylococcus aureus in the pus culture, 1/28 (3.5%) had Staphylococcal Coagulase Negative and 4/28 (14%) had infection from enterobacteriacae. From the Staphylococcal aureus infection 13/23 (57%) were detected Methicillin Resistant Staphylococcus aureus (MRSA) strain 9/13 (69%) of them had the phenotypic antibiotic patern characteristic of Panton-Valentine Leukocidin producing strain in Greece (Pen/Ox/kan/Tet/Fuci).

The age of the patients varied from 1 month old baby until 14 year old child. All cases were community acquired.

Our results show a possible emerging epidemic of the Panton-Valentine Leukocidin producing MRSA infection in the pediatric population in Greece and should be in consideration on the treatment of skin and soft tissue infections and on the other hand on the search for family endemics and Staphylococcal carriage.

P016

LONGER TIME SPENT FOR PATIENT IN OUTPATIENT SETTING IS ASSOCIATED WITH LOWER ANTIBIOTIC PRESCRIPTION

O. Serce, and M. Bakir, Division of Pediatric Infectious Diseases, Marmara Medical Faculty, Istanbul, Turkey.

Background and Aims: In order to guide the improvement in the national judicious antibiotic use policy, the socioculturel, sociodemographic, economic, and cognitive factors which potentially influence the prescribing habits of pediatricians, family physicians and general practitioners were investigated with a questionnaire study.

Methods: The questionnaire study included demographic characteristics of physicians, antibiotic expectation of parents, case scenarios reflecting judicious antibiotic prescribing patterns for upper respiratory tract infections and antibiotic choice. The questionnaire were distributed by letters, web address, office visits, telephone calls, congress and society meetings. Responses obtained from 1477 physicians who had been practising in the different regions of the country were evaluated by multivariate analysis to demonstrate independent effect of each factor influencing the prescribing habits.

Results: Our results have shown that being a pediatrician, working in medical school, and spending enough time with patient were independently associated with less antibiotic prescription. Most of the physicians (%94) suggest antibiotics for a scenario case with pneumococcal pharynx colonization. Family physicians and general practitioners were more likely to prescribe antibiotics for viral upper respiratory infections.

Conclusions: Our findings suggest that spending enough time during ourpatient visits and level of education are the most important factors associated with rational antibiotic prescribing for upper respiratory infections.

P017

PREVALENCE AND MOLECULAR ANALYSIS OF INDUCIBLE CLINDAMYCIN RESISTANCE AMONG METHICILLIN SENSITIVE STAPHYLOCOCCUS AUREUS ISOLATES FROM PEDIATRIC PATIENTS IN ISRAEL

D. Shouval,* Z. Samra,† I. Shalit,‡ R. Gadba,† O. Ofer,† and J. Amir,* *Department of Pediatrics C, Schneider Children's Medical Center of Israel; †Clincal Microbiology Laboratory, Rabin Medical Center; and ‡Infectious Diseases Unit, Schneider Children's Medical Center of Israel, Petah Tiqwa, Israel.

Background: Clindamycin is considered an attractive empirical treatment for suspected Staphylococcus aureus infections. However, there is concern about the use of this antibiotic in the presence of erythromycin-resistance-mediated genes, leading to inducible clindamycin resistance (ICR), which is not detected by routine antibiogram testing. Little information has been reported about its prevalence among methicillin sensitive Staphylococcus aureus (MSSA) infections, and in Israel the prevalence of ICR is unknown.

Aims: To assess the prevalence of ICR among MSSA infections of pediatric patients in Israel, and evaluate the clonality of these isolates.

Methods: Retrospective analysis of MSSA infections during January 2006 to June 2007. A full antibiogram was performed for all isolates (including D-test to identify ICR), and phage typing was also determined. Selected isolates were subjected to pulsed-field gel electrophoresis (PFGE) to assess their clonality.

Results: The study included 240 MSSA isolates recovered during the study period (median age 52.5 months). Inducible clindamycin resistance was detected in 62/240 cases (25.8%). Phage type analysis demonstrated that 38/61 (62.3%) of ICR isolates were sensitive to group II, compared to 42/172 (24.4%) of isolates not expressing ICR (P value < 0.01). Analysis by PFGE demonstrated that phage type II isolates expressing ICR belonged to the same clone, which was different from ICR isolates sensitive to other phages and different from phage II isolates not displaying ICR.

Conclusions: Clinicians should be aware of the ICR phenomenon when treating patients with suspected staphylococcal infections, and not rely on clindamycin only, especially in serious infections.

P018

EXTENDED-SPECTRUM BETA-LACTAMASE (ESBL)-PRODUCING ENTEROBACTERIA-RISKFACTORS FOR INTESTINAL COLONIZATION AT THE NEONATAL INTENSIVE CARE UNIT (NICU)

V. Strenger,* V. Dosch,* G. Feierl,† A. Grisold,† L. Masoud,† G. Zarfel,† W. Zenz,*‡ B. Resch,*§ B. Urlesberger,* and W. Müller,* *Department of Pediatrics and Adolescent Medicine, Medical University Graz; †Institute of Hygiene, Microbiology and Environmental Medicine; ‡Research Unit for Infection and Vaccinology, Medical University of Graz; and §Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University Graz, Graz, Austria.

Background: Colonization and infection with extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBL-E.) are a growing problem in Neonatal Intensive Care Units (NICU). Preterm low birth weight, prolonged mechanical ventilation, invasive devices and prior use of third generation cephalosporines were reported to be risk factors for colonization and/or infection with ESBL-E. In the last years several outbreaks of ESBL-E. colonization occurred at our NICU.

Methods: We retrospectively analyzed risk factors associated with colonization with ESBL-E. in newborns hospitalized at the NICU from Jan. 2005 to Jul. 2008. Patients were screened routinely at least twice a week for ESBL-E. in stool.

Fisher’s exact test and Mann-Whitney-U test (SPSS for Windows) were used for statistical analysis.

Results: 69 (5.9%) out of 1164 patients have been colonized with ESBL producing Klebsiella pneumoniae (n = 51), Klebsiella oxytoca (n = 11), Serratia marcescens (n = 6) and Escherichia coli (n = 1). For details see Tab. I.

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Cefuroxime/ampicillin were used as first line antibiotic combination. Third generation cephalosporines were not used during the observation period.

Conclusion: ESBL gene expression might be induced under therapy with second generation cephalosporines.

Factors associated with more severe illness (including lower gestational age and birth weight and more invasive therapeutic procedures) leading to longer stay at the NICU were significantly associated with colonization with ESBL-E. Longer hospital stay increases the risk of patient-to-patient transmission.

P019

EXTENDED-SPECTRUM BETA-LACTAMASE (ESBL)-PRODUCING ENTEROBACTERIA-FAECAL CARRIAGE AND INTRAFAMILIAL TRANSMISSION AFTER INTESTINAL COLONIZATION AT THE NEONATAL INTENSIVE CARE UNIT (NICU)

V. Strenger,* V. Dosch,* G. Feierl,† A. Grisold,† L. Masoud,† G. Zarfel,† W. Zenz,*‡ B. Resch,*§ B. Urlesberger,* and W. Müller,* *Department of Pediatrics and Adolescent Medicine; †Institute of Hygiene, Microbiology and Environmental Medicine; ‡Research Unit for Infection and Vaccinology; and §Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University Graz, Graz, Austria.

Background: Colonization and infection with extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBL-E.) are a growing problem in Neonatal Intensive Care Units (NICU). In the last years an increasing number of patients colonized with ESBL-E. were observed at our NICU. There are no data on duration of faecal carriage and the risk of intrafamilial transmission after intestinal colonization with ESBL-E. in newborns.

Methods: Patients colonized with ESBL-E. at our NICU between June 2007 and October 2008 and the respective household members were screened for intestinal ESBL-E colonization 1, 2, 4, 6, 9 and 12 months after discharge.

Results: 23 colonized patients (gestational age 24 + 1–40 + 2, median 31 + 1 weeks; birth weight 500–3320, median 1380 g; Klebsiella pneumoniae n = 5, Klebsiella oxytoca n = 11, Serratia marcescens n = 7, Escherichia coli n = 1) and 47 household members (16 mothers, 14 fathers, 16 siblings) were analyzed.

In former patients the percentage of colonized individuals showed a continuous decrease down to 0% 1 year after discharge (graph. 1).

Figure. Graph 1...
Figure. Graph 1...
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1 mother, 1 father and 5 siblings (including 2 twin siblings of former colonized patients) were colonized transiently with ESBL-E. During the observation period no infections with ESBL-E. were observed.

Discussion: After intestinal colonization with ESBL-E. at the NICU infants potentially remain carriers during the first year after discharge. Duration of carriage is varying. Intrafamilial transmission occurs infrequently.

P020

2.0 MCFARLAND ETEST METHOD FOR DETECTION OF HETEROGENEOUS VANCOMYCIN-INTERMEDIATE STAPHYLOCOCCUS AUREUS

C. Suankratay,* M. Pongkumpai,* and S. Trakulsomboon,† *Medicine, Chulalongkorn University; and †Medicine, Mahidol University, Bangkok, Thailand.

Background and Aims: The population analysis profiles (PAP) method, the gold standard method for detection of heterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA), is complicated, time-consuming, expensive, and needs well-trained microbiologists. Using a method with comparable sensitivity and specificity but more convenient, simpler, and cheaper would be a good alternative. We aimed to evaluate 2.0 McFarland Etest method in comparison with the PAP method for detection of h-VISA.

Methods: All methicillin-resistant S. aureus strains from clinical specimens obtained from consecutive patients at King Chulalongkorn Memorial Hospital (KCMH) and Siriraj Hospital, Bangkok, Thailand, from 2006 to 2007 were prospectively study studied.

Results: Of all 119 specimens, the PAP method detected 6 hVISA strains (5 and 1 from blood and pus cultures) from 4 patients at KCMH, accounting for the prevalence 6.35%. The MIC determined was in the range of 2–3 mg/mL. 2.0 McFarland Etest method detected 0 false positive and 5 false negatives (42%), and gave a sensitivity and a specificity of 16.7% and 100%. The one-point population analysis screening method detected 2 false positives and 1 false negative, and gave a sensitivity and a specificity of 83.3% and 98.2%.

Conclusions: This is the first prospective study to evaluate 2.0 McFarland Etest method for detection of hVISA without including homogeneous VISA. It has a very good specificity but a poor sensitivity for detection of hVISA. Due to its more convenience and less expensiveness in comparison with the PAP method, it may used as an alternative method to confirm the detection of hVISA.

P021

CLONAL SPREAD OF S. PNEUMONIAE AND H. INFLUENZAE ISOLATED FROM ACUTE OTITIS MEDIA IN JAPAN

R. Sugita,* M. Hotomi,† and N. Yamanaka,† *Otolaryngology, Sugita ENT Clinic, Chiba; and †Otolaryngology, Wakayama Medical University, Wakayama, Japan.

Abstract: Clinical pictures of acute otitis media (AOM) have dramatically changed mainly due to high prevalence of antimicrobial resistant pathogens. S.pneumoniae and H. influenzae are leading causative pathogens responsible for AOM. Recently antimicrobial resistant pathogens, especially penicillin resistant S. pneumoniae (PRSP) and beta-lactamase non-producing ampicillin resistant (BLNAR) H.influenzae, have shown high prevalence and become the major causes of intractable clinical course of AOM.

In this study, we studied the acquisition and carriage rate of S. pneumoniae in the nasopharynx. Furthermore, we evaluated the genetic diversity of S. pneumoniae and H. influenzae isolated from children with AOM. Serotype 6B strains first colonize the nasopharynx; subsequently serotype 19F strains and serotype 23F strains colonize the nasopharynx. Contrarily serotype 3 strains less colonize the nasopharynx. While all of serotype 3 strains were susceptible to penicillin (PCG), most of serotype 19F and 23 F were resistant to PCG. The genetic diversities of these serotypes were different. Serotype 6B strains show different patterns and are considered as heterogeneous strains. Serotype 23F and 19F show some identical strains and their relatives. On other hand, all of serotype 3 strains are identical and less frequent colonize the nasopharynx. On the clonal evaluation of pneumococcal strains, there are some major clones such as Taiwan 19F-14, Taiwan 23F-15 and their relatives in Japan.

Although penicillin-resistant S. pneumoniae showed clonal diversity and dissemination depending on the serotypes, the most of BLNAR strains in Japan were genetically diverse. The three clusters of BLNAR strains were identified in Japan.

P022

EVIDENCE FOR TRANSMISSION OF VANCOMYCIN RESISTANT ENTEROCOCCI IN NICU AND PEDIATRIC WARDS IN IRANIAN HOSPITALS

M. Talebi,* M.R. Pourshafie,* M. Saifi,* and S. Aghaii,† *Microbiology, Pasteur Institute of Iran; and †Microbiology, Azad University, Tehran, Iran.

Background: Neonates, particularly those born prematurely, are at an increased risk of bacterial infection. Enterococcus spp. are a component of the human intestinal flora and may be found naturally in the birth canals of women. Intrapartum antibiotic prophylaxis of pregnant women with vancomycin, has led to increased VRE in the parturient and her child. As bacterial strains become increasingly resistant to antimicrobial therapy, measures to control this problem are essential. Current effort have focused on monitoring the VRE in NICU and Pediatric wards in Iran.

Method and Material: The enterococci isolates were collected from patients in three hospitals in Tehran. The structure of vancomycin resistance genes of VRE isolates were studied by PCR amplification of the regions of ORF1, ORF2, vanS-vanH, vanHAX, vanX-vanY, vanY-vanZ, and vanZ. The isolates were typed by Pulsed- field gel electrophoresis (PFGE).

Results: Out of 50 VRE isolates, 4 were isolated from neonatal intensive care unit and Pediatric ward. All of 4 VRE isolates showed a high level vancomycin resistance (MIC ≥ 128) and harbored vanA gene. The amplification of internal regions in vanA cluster exposed the presence of 3 types among the 4 isolates. Genotyping by PFGE using SmaI enzyme revealed the presence of 3 types.

Conclusion: The prevalence of VRE infections among NICU patients and Pediatric ward have been rare in Tehran. Two isolates collected from NICU and Pediatric wards showed two identical types with the same vanA gene cluster. This result may suggest a possibility of transmission of VRE isolates between two wards.

P023

ANTIMICROBIAL RESISTANCE AMONG UROPATHOGENS THAT CAUSE COMMUNITY-AQUIRED URINARY TRACT INFECTIONS IN CHILDREN IN HAMADAN, WEST OF IRAN

R. Yousefi Mshouf,* and F. Eghbalian,† *Department of Microbiology; and †Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran.

Background and Aim: Community acquired UTI (CA-UTI) causes significant illness in the first 2 years of life and it is considered as an common disease in school and pre-school children. The aim of study was to identify the most common of bacteria causing UTI, clinical manifestations and detection of antibiotics susceptibility of isolates in children who referred to hospital of Hamadan, western Iran.

Methods: Overall 912 pediatric patients clinically-suspected cases of UTI were investigated for urine cultures, urinalysis, clinical findings and antibiotic resistance patterns. Data were analyzed for four pediatric age groups: infants, toddler, preteens and teens. Antibiogram for twelve antibiotics test was performed by method of Kirby-Bauer. The required data of patients were analyzed using spss system.

Results: Out of 456 children suspected to UTI, 156 children (%34.2) had positive bacterial culture that %88.5 of isolates was Gram-negative. The most common isolates were Escherichia coli (%58.4), Enterobacter sp.(9.6%), Kelebsiella sp (6.4%), Staphylococcus aureus (5.8%), Psuedomonas aeroginosa (5.1%). Fever (72.8%), dysuria (58.3%), flank pain (47.4%), urgency (43.6%), urinary frequency (39.8%) were the commonest clinical manifestations of patients. The most effective antibiotics against isolates were nitrofurantoin, ciprofloxacin, naledixic acid, amikacin, ceftizoxime and co-trimoxazole while most of isolates showed high resistance against ampicillin, tobramycin, tetracyline and amoxicillin.

Conclusions: This study showed that Gram-negative bacilli in particular E. coli and Enterobacter sp. are predominant causes of bacterial agents of UTIs in children in this region. Most species showed high resistance against routine antibiotics such as tobramycin, amoxicillin, ampicillin and tetracycline.

P024

PENICILLINASE-LIKE ACTIVITY OF WHOLE HUMAN BLOOD SERUM

I. Zhyltsou,* I. Veremey,† V. Semenov,* and I. Generalov,‡ *Department of Communicable Diseases; †Central Research Laboratory; and ‡Department of Microbiology, Vitebsk State Medical University, Vitebsk, Belarus.

Abstract: Bacterial antibiotic resistance is known as one of the most challenging problems of up-to-date infectology, but this phenomenon is still analyzed from the side of bacteria only. Examining human blood serum for presence of catalytic antibodies (abzymes) we accidentally found high level of penicillinase activity, significantly higher than those expressed by polyclonal IgG studied before (I. Zhyltsou, 2001). Thus, our study was undertaken to assess the blood serum activity found and to associate it with some blood substance(s) and pathologic conditions. We examined 31 patient with erysipelas and 35 patients with pneumonia hospitalized to Vitebsk Infectious Hospital for 2007/08. To determine presence and level of beta-lactamase activity of blood serum, we applied modified neocuproine technique (A. Menashi, 1988), ampicillin and penicillin G were used as substrates. Beta-lactamase activity was found in 94,29% (95% CI: 86,6–100) of all pneumonia cases (average level of antibiotic destruction for 30 minutes of incubation is 51,38% for ampicillin and 81,76% for penicillin G). Also, beta-lactamase activity was revealed in 92,86% (95% CI: 83,32–100) of erysipelas cases (average level of destruction is 50,73% for ampicillin and 75,42% for penicillin G). No reliable differences between two groups were found. Dialysis experiments demonstrated the activity observed is mainly associated with light proteins (molecular weight below 12.000) and some non-protein substances (bilirubin?). Our results indicate that a large piece of penicillinase activity observed in clinical conditions may be explained by some properties of human blood, and this activity is definitely not associated with abzymes as it was assumed previously.

P025

ANTIBIOTIC RESISTANCE RATES IN PEDIATRIC BLOOD STREAM INFECTIONS BY ENTEROCOCCUS (2000–2006)

M. Zlamy,* M. Fille,† R. Würzner,† L.-B. Zimmerhackl,* and M. Prelog,* *Department of Pediatrics I; and †Department of Hygiene, Microbiology and Social Medicine, Medical University Innsbruck, Innsbruck, Austria.

Abstract: Because of the emergence of multi-resistant Enterococci strains in pediatric patients the present study was aimed to analyze pediatric patients who had BSI (blood stream infection) due to Enterococci and determine their antibiotic resistance rates in a single-center experience from 2000–2006 (Department of Pediatrics I, Medical University Innsbruck, Austria).

Methods: Characterization of pathogens and susceptibility testing for the different antibiotics was performed according to standardized procedures in the laboratory of the Department of Hygiene, Microbiology and Social Medicine, Medical University Innsbruck, Austria.

Results: In the study period, 13 of 398 children (3.0%) (age mean 35.7 ± 65.7) had a BSI caused by Enterococci. Infants counted for 5 cases (38.5%), children older than 1 year of age counted for 8 cases (61.5%). Enterococcus faecalis was ascertained in 9 cases (69.2%), Enterococcus faecium in 4 cases (30.8%). Enterococcus faecium showed higher resistance rates according to ampicillin (100.0%), imipenem (100.0%), meropenem (100.0%) and vancomycin (25.0%) as Enterococcus faecalis. One patient died due to BSI with Enterococcus faecalis because of failure of empirical antibiotic treatment with a cephalosporine. Two patients died of Enterococcus faecium because of failure of empirical antibiotic treatment with vancomycin and macrolide.

Conclusion: Despite the low fraction of Enterococci in all BSI causing pathogens in the pediatric population, the present study demonstrated their clinical relevance. Increased alertness should be given to the occurrence of multi-resistant Entercoccus faecium and mechanisms causing its abundance, such as selection via antibiotic pre-treatement or ineffective empirical antibiotic treatment.

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BACTERIAL INFECTIONS AND BACTERIAL VIRULENCE

P026

INVASIVE GROUP A STREPTOCOCCAL DISEASE BETWEEN 2003 AND 2008: CLINICAL AND EPIDEMIOLOGICAL ASPECTS

A. Afonso,* G. Pereira,* C. Moreira,* A. Antunes,* A. Faustino,† and A. Gonçalves,* *Paediatrics Department; and †Clinical Pathology Department-Microbiology Unit, São Marcos Hospital, Braga, Portugal.

Background and Aims: Group A Streptococcus (GAS), a common cause of pharyngitis and uncomplicated skin/soft tissue infections, can also cause invasive disease, which may manifest as several clinical syndromes. The aim of this study was to describe epidemiological and clinical features of GAS invasive disease in children, in our area.

Methods: Cases of GAS invasive disease between January 2003 and December 2008 were detected by laboratory data. For each case, the hospital medical record was revised. GAS invasive disease was defined as Streptococcal Toxic Shock Syndrome (STSS), Necrotizing Fasciitis (NF) or sterile site infections that do not meet clinical criteria for STSS/NF.

Results: Twelve cases of GAS invasive disease were identified. The median age of the children was 5.5 years. Boys were affected more often than girls (8/12). The most common clinical presentations were bacteremia (4/12) and pneumonia with pleural effusion (4/12); one child was diagnosed STSS (probable). Five of the twelve patients had underlying chronic illness. Varicella virus infection preceded GAS invasive disease in two. Besides antibiotic therapy, 3/12 underwent surgery. The outcome was good in the majority (8/12) and there were no fatal cases.

Conclusions: Children with underlying medical conditions seem to be at greatest risk for GAS invasive disease, as are those with varicella virus infection. GAS infection should always be suspected when risk factors are present, and prompt institution of an adequate antibiotic should not be delayed. We ought to be aware of GAS potential to cause invasive infection, with its serious consequences.

P027

PANTON-VALENTINE LEUKOCIDIN PRODUCING STAPHYLOCOCCUS AUREUS-OUR EXPERIENCE

H. Ambrozova,* V. Maresova,* M. Fajt,† P. Pavlicek,‡ H. Rohacova,* I. Machova,§ and P. Petras,§ *Department of Infectious Diseases, 2nd Medical Faculty of Charles University in Prague; †Department of Pediatrics, University Thomayer Hospital; ‡Department of Anestesiology and Resuscitation, University Hospital Motol; and §National Referential Laboratory for Staphylococcal Infections, National Institute of Health, Prague, Czech Republic.

Abstract: Panton-Valentine leukocidin (PVL) is a necrotizing exotoxin produced by both methicilin-sensitive (MSSA) and methicilin-resistant Staphylococcus aureus (MRSA). PVL primarily causes skin infections, soft tissue infections and necrotizing pneumonia with high mortality. PVL producing strains are worldwide spread. In the Czech Republic have been monitored since the year 2004 when the first case was detected. Between the years 2004–2008 2981 strains of Staphylococcus aureus were examined in National referential laboratory for staphylococcal infections.190 strains were PV L+ (153 MSSA and 37 MRSA).7 strains of them were causative agents of pneumonia, four patients survived, three patients died. In our Department of Infectious Diseases University Hospital Bulovka two cases caused by PVL+ Staphylococcus aureus (both MSSA) were noted. Skin infection occurred in 27-year-old woman (recurrent furunculosis was caused by MSSA with significant production of PVL). We describe in detail the first case of fatal pneumonia with mediastinitis in 10-month-old boy who was treated consecutively in three Prague university hospitals. The disease began atypically with gastronitestinal symptoms and in causative agent (MSSA) hyperproduction of enterotoxin was prooved.

P028

PSEUDOMONAS AERUGINOSA ENDOCARDITIS IN A 3-YEAR-OLD BOY TREATED FOR ACUTE LYMPHOBLASTIC LEUKEMIA

E. André,* S. Moniotte,† T.-D. Huang,* J. Rubay,‡ B. Brichard,§ C. Chantrain,§ S. Dupont,§ C. Vermylen,§ and D. Van der Linden,¶ *Clinical Microbiology; †Pediatric Cardiology; ‡Division of Cardiothoracic and Vascular Surgery; §Pediatric Hematology and Oncology, Université Catholique de Louvain, Cliniques Universitaires St-Luc (UCL); and ¶Department of General Pediatrics, Université Catholique de Louvain, Cliniques Universitaires St Luc, Brussels, Belgium.

Background: Pseudomonas aeruginosa has been described as an uncommon cause of endocarditis in adults but to our knowledge no pediatric case has been reported in the literature for the past 20 years.

Clinical Case: We describe a 3-year-old boy diagnosed with acute lymphoblastic leukemia who first developed a fully susceptible Pseudomonas aeruginosa bacteremia while he was in neutropenia. An initial antibiotherapy was started using piperacillin-tazobactam and amikacin. Recurrent bacteremias occurred during the following 101 days despite central venous access device replacements and multiple courses of antibiotics, including meropenem, ceftazidime, ciprofloxacin, rifampicin and colimycin. Several cardiac ultrasound were performed but evidence of endocarditis was observed only after 60 days of bacteremia when both transoesophageal and transthoracic ultrasound showed the rupture of a tricuspid cord and the presence of a millimetric image on the atrial side of the tricuspid valve. Due to failure of medical treatment, cardiac surgery was performed. Peroperative findings confirmed a purulent granuloma and perforations on the tricuspid valve. The abcess was removed and the valve repaired. The valvular biopsy yielded Pseudomonas aeruginosa. Antibiotics were extended for 30 days after surgery with no further positive blood cultures at 5 months of follow-up.

Conclusion: Pseudomonas aeruginosa is an exceptional cause of endocarditis in children. Prompt removal of central venous device should be performed in case of Pseudomonas aeruginosa bacteremia. Surgical intervention must be considered without delay if not responding to targeted antibiotics, particularly in leukemic patients with a greater risk of negative impact on their hematological outcome.

P029

EVALUATION OF CLINICAL, LABORATORY AND THERAPEUTIC FINDINGS OF BRUCELLOSIS AMONG CHILDREN HOSPITALIZED AT ARDABIL'S HOSPITALS

R. Arab,* and G.H. Ettehad,† *Department of Clinical Science, School of Medicine; and †Department of Basic Science, School of Medicine, Ardabil University of Medical Science, Ardabil, Iran.

Goal and Precedents: Brucellosis is the common disease between human and animal and that is transmitted through contaminated animals. This study has been executed to determine clinical manifestation, laboratory findings and therapeutic approach of children afflicted by brucellosis, hospitalized at 2 hospitals (Aliasghar and Imam Khomaini) of Ardabil within 2000–2005.

Materials and Methods: This study is a retrospective one, based on existing data of 51 medical units, belonging to patients that were hospitalized within 2000–2005 at these two centers diagnosed as brucellosis patients.

Results: From all 51 patients 76.5% were male. Familial history of brucellosis was positive among 38% of patients. Precedent of no pasteurized dairy consumption was seen among 62% of cases. 69% of patients were belonging to high risk families. Clinical manifestations of disease were fever (84.2%) arthralgia (81.2%) perspiration (60.2%) lackingappetite (54%) Hepatomegaly (31%) splenomegaly (21%) and lympadenopathy (18%). Laboratory findings were anemia (52.3%) leukopenia (41.2%) thrombocytopenia (4.5%) and leukocytosis (1.96%). Treatment in the majority of patients (76.2%) was Cotrimoxazole beside Rifampin or Gentamycin. The brucellosis was the cause of FUO in the 17.6% of cases.

Conclusion and Advises: According to findings it seems that among children with fever and Arthralgia and especially with precedent of no pasteurized dairy consumption and being male this is essential to evaluate brucellosis possibilities. On the other hand it is advised to perform programs to inform members of high risk families about this disease.

Keywords: Brucellosis, Children, Clinical and laboratory findings, Therapeutic findings.

P030

PREVALENCE OF CHLAMYDIA PNEUMONIAE, MYCOPLASMA PNEUMONIAE AND ACUTE EXACERBATIONS OF ASTHMA IN CHILDHOOD

G. Aydemir,* C. Meral,† and A. Ulcay,‡ *Aksaz Military Hospital, Ahu Hetman Hospital, Mugla; †Department of Pediatrics, GATA Haydarpasa Teaching Hospital, Istanbul, Istanbul; and ‡Aksaz Hospital, Mugla, Turkey.

Background: Mycoplasma pneumonia and Chlamydia pneumoniae are frequent causative agent of acute respiratory disease and has been recently reported as a possible infectious triggers of asthma. In the present study we aimed to investigate the frequency of Mycoplasma pneumoniae and Chlamydia pneumoniae infections in asthmatic children. We investigated also whether there is a relationship between these agents and asthma attacks.

Method: Seventy asthmatic children were included in study. The study group was divided into two groups: group one consisted of 30 children with asthma attacks and group two consisted of 40 children with stable asthma. As a control group we studied 30 healthy children. Serum samples were obtained and tested for C. pneumoniae and M.pneumonia specific IgM antibody by Enzyme-Linked Immuno Sorbent Assay (ELISA).

Results: There was a statistically significant difference for Mycoplasma IgM (P < 0.05).) and Chlamidia IgM (P = 0.03) between group one and the other two groups.

Conclusion: M. Pneumoniae and C. Pneumoniae may play a role in development of asthma exacerbations in childhood.

P031

C-REACTIVE PROTEIN AS A MARKER OF SERIOUS BACTERIAL INFECTION IN FEBRILE INFANTS AGED ≤ 3 MONTHS–A PROSPECTIVE STUDY

E. Bilavsky,* H. Yarden-Bilavsky,† S. Ashkenazi,† and J. Amir,* *Departments of Pediatrics C; and †Departments of Pediatrics A, Schneider Children's Medical Center of Israel, Petah Tiqwa, Israel.

Objective: To determine the utility of C-reactive protein as a marker of serious bacterial infection in hospitalized febrile infants aged ≤3 months.

Patients and Methods: Data on blood C-reactive protein levels were collected prospectively for all infants aged ≤3 months who were hospitalized for fever at our center from 2005 to 2008. The patients were divided into two groups by the presence or absence of findings of serious bacterial infection.

Results: A total of 892 infants met the inclusion criteria, of whom 102 had a serious bacterial infection. Mean C-reactive protein level was significantly higher in the infants who had a bacterial infection than in those who did not (5.3 ± 6.3 mg/dL vs. 1.3 ± 2.2 mg/dL, P < 0.001). Analysis of various cut-offs of C-reactive protein yielded better sensitivity, specificity, and positive and negative predictive values than for total white blood cell count in predicting serious bacterial infection.

Conclusion: C-reactive protein level is a valuable laboratory test in the assessment of febrile infants ≤3 months old and serves as a better diagnostic marker of serious bacterial infection than total white blood cell count.

P032

CORRELATION OF SIZE OF PURPURIC LESIONS ON ADMISSION WITH OUTCOME IN SYSTEMIC MENINGOCOCCAL DISEASE

A. Binder,* J. Smolle,† and W. Zenz,* *Dept of General Paediatrics; and †Dept of Dermatology, Medical University of Graz, Graz, Austria.

Background and Aims: We have initiated a multi-centre prospective study in January 2000 including 97 paediatric hospitals from Germany, Southern Tyrol, Switzerland and Austria to analyse genetic polymorphisms in children with systemic meningococcal disease. In context with this study we were also testing for the correlation between extension and size of lesions on admission to the PICU and outcome.

Methods: Size of purpuric lesions on admission to the PICU was estimated and grouped into 6 classes (<0.5 cm, 0.5–1 cm, 1–5 cm, 5–10 cm, 10–20 cm, >20 cm). 359 patients have been included into this study.

Results: The size of the largest lesion on admission correlated very strongly with outcome (overall P = 1 × 10-11, see Table 1). Group assessment was crosschecked on the basis of photographed patients by an independent dermatologist.

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Conclusions: The size of purpuric lesions on admission correlates strongly with mortality of patients with meningococcaemia. These findings demonstrate a high relevance of this parameter for the calculation of a prognostic risk score in the near future.

P033

THE THR164ILE POLYMORPHISM OF THE B2-ADRENERGIC RECEPTOR ASSOCIATES WITH SUSCEPTIBILITY IN CHILDREN WITH SYSTEMIC MENINGOCOCCAEMIA

A. Binder,* W. Walcher,† and W. Zenz,* *Dept of General Paediatrics; and †Dept of Obstetrics and Maternal Foetal Medicine, Medical University of Graz, Graz, Austria.

Background and Aims: Meningococcal disease may present as sepsis, meningitis or a combination of both. The adrenergic system is a major factor for peripheral vascular resistance as well as cardiac output. Peripheral vascular failure, as seen in meningococcal septic shock, may be facilitated by distinct single nucleotide polymorphisms in the adrenergic receptors. A rare polymorphism in the β2 adrenergic receptor (B2AR) gene (Thr-164 to Ile-164) leads to “loss of function” of the receptor, dramatically reducing receptor densities on vascular smooth muscles. This prospective, multicentre study examined the relationship between meningococcal disease and this B2AR polymorphism.

Methods: Blood samples and clinical information of 287 previously healthy children with meningococcal infection were collected from 95 paediatric hospitals in Germany, Switzerland, Italy, and Austria between 2000 and 2004. Cord blood of 472 healthy newborns, all of Central European origin, served as population based healthy controls. The Ile164Thr polymorphism was analysed in all subjects using a TaqMan assay.

Results: The rare Ile164 variant was significantly more frequent in patients (2.8%) compared to healthy controls (0.6%, P = 0.016), resulting in a risk ratio for carriers of the Ile164 variant of 4.5 (95% CI: 1.2–17.0) for meningoccaemia.

Conclusion: In our study we provide first evidence that the Thr164Ile polymorphism of the human β2 adrenergic receptor is associated with the risk for meningococcal disease. As the Ile164 allele is associated with decreased B2AR levels, further studies evaluating the impact of adrenergic receptor variants on meningococcal disease might be worth considering.

P034

EXTERNAL VALIDATION OF THE BACTERIAL MENINGITIS SCORE

C. Boulanger,* D. Weynants,† K. Zakrzewska-Jagiello,† D. Van der Linden,† E. Bodart,* and D. Tuerlinckx,* *Université Catholique de Louvain, Cliniques Universitaires de Mont Godinne, Yvoir; and †UCL Cliniques Universitaires Saint-Luc, Brussels, Belgium.

Background and Aims: Sensitivity of the Bacterial Meningitis Score (BMS), based on five predictors (seizures, blood neutrophil count, cerebrospinal fluid (CSF) Gram stain, CSF protein and CSF neutrophil count) has been validated between 98.3% and 100% in four previous studies. To evaluate the BMS performance on our population of children hospitalized for meningitis.

Method: Retrospective cohort study including all children aged 29 days to 18 years who were admitted for meningitis between 1996–2006 and between 2007–2008 in two respective academic pediatrics departments. Inclusion criteria was meningitis (CSF white blood cells >10 μL) without purpura, clinical sepsis, predisposing factor and antibiotic treatment before lumbar puncture.

Results: Among the 211 patients included, 23 (11%) had bacterial meningitis and 188 had aseptic meningitis. Out of the 121 patients categorized as very low risk of bacterial meningitis by the BMS (score = 0), 2 had bacterial meningitis (sensitivity 91%; negative predictive value 98.3%). The 2 patients with bacterial meningitis not detected by the BMS were 2.5 and 15 years old, both infected with Neisseria meningitidis; one had petechial rash.

Conclusion: Sensitivity of the BMS was lower than previously reported. Before evaluating the BMS in clinical setting (safely reduce hospital admission), further refinements of the BMS including petechial rash may be warranted to reduce the false negative cases.

P035

WELL APPEARING NEONATES WITH EARLY ONSET FEVER: WHAT RELIABILITY FOR LABORATORY MARKERS IN PREDICTING SEVERE BACTERIAL INFECTIONS?

S. Bressan, B. Andreola, F. Cattelan, T. Zangardi, and L. Da Dalt, Dipartimento di Pediatria, Università di Padova, Padova, Italy.

Background and Aims: Few data exist on laboratory markers accuracy as predictors of severe bacterial infections (SBI) in febrile neonates. This study aimed to assess the diagnostic accuracy of white blood cell count(WBC), absolute neutrophil count(ANC), and C-reactive protein(CRP) in detecting SBI in well-appearing neonates with early onset fever without source (FWS) and in relation to fever duration.

Methods: Previously healthy neonates 7–28 days hospitalized with FWS from less than 12 h to a Pediatric Emergency Department, were prospectively enrolled over a 4-year period. Laboratory markers were obtained upon admission and repeated after 12 to 24 h from fever onset in those children with normal values on initial determination.

Results: Of the 99 patients finally studied, 25 had an SBI. ANC and CRP were significantly higher in patients with SBI compared to those without, while WBC did not differ between the two groups. Areas under ROC curves (AUC) at admission were 0.78(95%CI, 0.69–0.86) for CRP, 0.77(95%CI, 0.67–0.85) for ANC, and 0.59(95%CI, 0.49–0.69) for WBC. AUC for repeated determination obtained in 58 patients with normal values at admission resulted larger for all the parameters, with a significant improvement only for CRP, showing an AUC of 0.99(95%CI, 0.92–0.99; P = 0.002). Laboratory markers values turned abnormal after >12 h from fever onset for all the 5 patients with an SBI out of the 58.

Conclusions: In well appearing neonates with FWS laboratory markers studied were more predictive of SBI if fever duration was>12 h. CRP seems a better predictor than both ANC and WBC especially after >12 h from fever onset.

P036

CLINICAL PRESENTATION OF CHILDHOOD NEUROBORRELIOSIS: NEUROLOGICAL EXAMINATION MAY BE NORMAL

D. Broekhuijsen-van Henten,* K. Braun,† and T. Wolfs,‡ *Department of Pediatrics, Wilhelmina Children's Hospital; †Department of Child Neurology, Rudolph Magnus Institue of Neuroscience; and ‡Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, Utrecht, The Netherlands.

Background: Neuroborreliosis has its highest incidence in children and elderly. Signs and symptoms are different between the different age groups. The aim of this study was to describe the clinical spectrum of neuroborreliosis in children.

Methods: The Dutch Pediatric Surveillance system registered cases of childhood neuroborreliosis during a two year time period. All Dutch pediatric hospitals took part in this surveillance. Criteria for reporting cases were strictly defined.

Results: Eighty-nine cases of neuroborreliosis were reported, in 75 cases, data were obtained and diagnosis was confirmed. The mean age at presentation was 8.5 years with highest incidence during summer months. Facial palsy was one of the presenting symptoms in 55 cases and the only symptom in 10 children. The five complaints most frequently reported were: malaise, headache, fatigue, fever, neck pain. Sixty children had one or more neurological signs at presentation, of which facial palsy, other cranial nerve abnormalities and meningeal signs were most frequent. Fifteen patients, however, had no neurological abnormalities at physical examination. These patients displayed more symptoms and had a significant delay until diagnosis was made.

Conclusions: In this study, 80% of pediatric neuroborreliosis patients presented with neurological abnormalities, most often consisting of facial nerve palsy. Twenty percent presented in an atypical way without objective neurological signs. A thorough neurological examination is essential once neuroborreliosis is considered in children. Even in the absence of neurological signs, neuroborreliosis may be suspected in children with typical antecedents and multiple subjective complaints. CSF investigations are then required to confirm the diagnosis.

P037

ETIOLOGICAL ASPECTS OF SEPSIS IN A PEDIATRIC INTENSIVE CARE UNIT

A. Butnariu,* M. Marc,† R. Toma,‡ and C. Sabau,‡ *Pediatrics III; †Pediatrics II; and ‡University of Medicine and Pharmacy Iuliu Hatieganu, Cluj-Napoca, Romania.

Background and Aims: We have studied Sepsis defined as the clinical characteristics that include systemic inflammatory response syndrome (SIRS) installed in bacterial infection context, intending to detect the etiological particularities in relationship with the patient's age and to study the context of Sepsis installing.

Methods: During an 8-year period of time, 82 patients (age between 4 days and 18 years old) with Sepsis were admitted in the ICU of Pediatrics III Clinic, Cluj. The bacteriological diagnosis was run in the laboratory of the Pediatrics III Clinic.

Results: Most of the cases subscribe to the 1–12 months category (35%), followed by 0-1 month category (21%). Out of 82 cases in study, 50 (61%) were with well known etiology, the rest being unknown. The identified bacterial agents were: Staphylococcus aureus (28 cases), Klebsiella (7), Escherichia coli (6), Enterobacter (4), Bacillus cereus (3), others (2).

The Sepsis etiology in the newborn and the infants is dominated by Staphylococcus aureus and Klebsiella.

From the total of 82 cases, 20 were identified with risk factors: premature rupture of membranes, chorioamnionitis, catheterization of the umbilical cord veins etc (0–1 month), prematurity, malnutrition, congenital infections (infants), immunodeficiency, invasive procedures etc (other age categories).

The portal of entry was identified in 37% of the patients. There were 2 cases of iatrogenic etiology.

Conclusions: In 61% of the cases, we were able to determine the etiology of Sepsis through bacterial determinations. The Sepsis etiology in the newborn and the infants is dominated by Staphylococcus aureus and Klebsiella.

P038

INVASIVE STREPTOCOCCAL DISEASE–A POSSIBLE EMERGENCE OF MORE AGGRESSIVE GAS STRAINS

M. Cabral, L. Sancho, and M.J. Brito, Hospital Fernando Fonseca, Amadora, Portugal.

Background and Aims: During the last two decades, the incidence of invasive streptococcal disease (ISD) has been increasing in Europe, probably associated with the emergence of more aggressive strains. During 4 consecutive years there were admitted 6 cases of ISD, with an increase during 2004 and 2007. The objective was to evaluate the characteristics of ISD and identification of risk factors in a paediatric population of a general hospital at Lisbon.

Methods: Retrospective analysis of Streptococcus pyogenes positive cultures (blood, cerebrospinal, pleural, sinovial fluid and pus), between April 2004 and December 2008. Epidemiological, clinical, laboratorial and evolution parameters were analysed.

Results: A total of six children, mean age was 5 years (min-29 months, max-14 years). Risk factors identified: viral infection (2), throat diseases (1), varicella (1). The diagnosis were bacteraemia (4), streptococcal toxic shock syndrome (1) and septic arthritis (1). 3/6 were treated with penicillin and clindamycin, 2/6 penicillin only and 1/6 additionally another antibiotics. There were complications in 5/6 patients: septic shock (1), acute respiratory distress (1), renal failure (1), subcutaneous tissue abscess (1), lymphadenitis (1), inflammatory streptococcal arthritis (1), pneumonia (1), pneumonia/empyema (1). 2/6 requires intensive care with: hemodynamic support (1), oxygen (1) and mechanic ventilation (1). Three children had to be submitted to a surgical intervention. There was no mortality.

Conclusions: Six cases of invasive group A streptococcal disease in a short period of time suggests a possible emergence of more aggressive GAS strains. Screening for different strains may be important to the identification of invasive clones.

P039

CHARACTERISTICS OF GROUP A STREPTOCOCCAL INVASIVE DISEASE IN CHILDREN

J. Caetano,* P. Neto,* M. Alves,* A. Alves,† and F. Rodrigues,* *Unidade de Infecciologia, Hospital Pediátrico de Coimbra; and †Serviço de Patologia Clínica, Centro Hospitalar de Coimbra, Coimbra, Portugal.

Background and Aims: The aim of this study was to review all cases of Group A Streptococcal (GAS) Invasive Disease (ID) admitted to our tertiary hospital.

Methods: Retrospective analyses of all cases of GAS ID (positive culture isolated from usually sterile sites), from January 1996 to December 2008 (13 years).

Results: There were 22 cases, with a maximum of 4 cases/year. In the second half of this period occurred 16 cases (73%). Fifteen were boys and the median age was 3,5 years. The most frequent clinical manifestations were fever (71%), rash (48%) and arthalgia/limbs’ pain (43%). The diagnoses were bacteriemia (5), celulitis (3), osteoarticular infection (4), pyomyositis, surgical wound infection, streptococcal toxic shock syndrome (STSS), mastoiditis (2 each), necrotizing fasciitis and pneumonia (1 each). Four cases occurred during the course of varicella. Other risk factors were present in 5 cases. Median neutrophyl count was 9 427/μL (6 600–34 640) and median C reactive protein was 16.7 mg/dL (0.3–42.5). Bacteria were isolated mainly from blood (71%). The outcome was good for most cases but there were 2 deaths due to STSS. M typing and the presence of virulence factors genes were not assessed.

Conclusion: Although the small number of cases limits the conclusions, there was an increase of invasive disease in the second half of the study. Microbiological investigation is essential to understand which M types or virulence factors genes are involved. Several cases occurred in the course of varicella or other risk factors and fatal outcome was associated with STSS.

P040

POSSIBLE MECHANISM OF IMMUNOSUPPRESSION DURING PEDIATRIC SEPSIS: ROLE OF MONOCYTES CD40L TOLERANCE

F. Calo Carducci,* P. Rossi,*† and P. D'Argenio,* *Immunoinfectious Disease Unit, Pediatric Hospital, Bambino Gesù; and †Chair of Pediatrics, University of Rome Tor Vergata, Roma, Italy.

Background: CD40-ligand (CD40L) is a membrane protein expressed primarily on activated T cells. CD40L stimulation induces monocytes to secrete immunomodulatory cytokines and to up-regulate surface molecules (CD80, CD86), which are important in promoting and maintaining adaptive immune response.

Objective: To analyse the response of monocytes to CD40L, in pediatric patients with Gram-negative sepsis.

Methods: Twelve patients were enrolled. Inclusion criteria: age >30 days, <10 years and a diagnosis of sepsis. Exclusion criteria: congenital or acquired immunosupression. PBMC were stimulated in vitro with CD40L and analysed for TNF-a and IL-12 production, CD80 and CD86 surface expression and ability to induce interferon (IFN)-g production by autologous T lymphocytes.

Results: Cytokine production by monocytes during sepsis. (Fig. 1) TNF-a and IL-12 response of monocytes stimulated with CD40L from septic patients was significantly lower than that found in healthy controls. Effect of sepsis on the upregulation of surface molecules induced by CD40L. CD40L stimulation induced only a suboptimal CD80 and CD86 response in monocytes from septic patients (Fig 2). Sepsis interferes with the ability of CD40L to induce co-stimulatory functions in monocytes. PBMC were exposed to CD40L and then stimulated by immobilized anti-CD3 antibody. Significantly increased IFN-g expression was observed in T cells from control subjects as compared to septic patients. No selective defects of T cells were demonstrated in septic patients by anti-CD3 stimulation plus costimulation with anti-CD28 antibody.

Conclusions: We conclude that in vitro CD40L tolerance may be a model of monocyte alteration observed during sepsis.

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P041

CELL-MEDIATED IMMUNE RESPONSES AND PROTECTIVE EFFICACY AGAINST INFECTION WITH MYCOBACTERIUM TUBERCULOSIS BY HSP16.3 PROTEIN AND ITS SYNTHETIC PEPTIDE IN MICE

S. Changhong,* Z. Hai,* Z. Tingfen,* W. Xiaowu,† and X. Zhikai,‡ *Lab Animal Center, The Basic Medical Department; †Department of Radiation Medicine; and ‡Department of Microbiology, Fourth Military Medical University, Xi'an, China.

Abstract: Tuberculosis (TB) remains an urgent worldwide public health problem. Although some individuals initially control the infection by mounting a cell-mediated immunity, the majority of these individuals are latently infected. Several protein factors have been identified as contributing to latently infected. One of them is Heat shock protein 16.3 (Hsp16.3) of Mycobacterium tuberculosis (MTB), which plays an important role in the survival of MTB against macrophages. In this study, we compared the immune responses and protective efficacy against infection with MTB by Hsp16.3 protein and its synthetic peptide in mice. The results showed that both Hsp16.3 and its synthetic peptide induced specific antibodies in levels significantly higher than those of BCG. They also had similar stimulation indices in splenolymphocyte proliferation, which was remarkably higher than with BCG. Whether under Hsp16.3 or its synthetic peptide stimulation, the level of IFN-γ release of BCG was the highest with stimulation via the same two antigens, although BCG expressed a low Hsp16.3 level. A significant difference was observed between the IFN-γ levels of Hsp16.3 and its synthetic peptide groups stimulated by peptide, but not by those stimulated by Hsp16.3. In terms of resistance against H37Rv replication, BCG was more resistant than Hsp16.3 or the synthetic peptide in the spleens, but the difference in the lungs was not statistically significant. In conclusion, Hsp16.3 and its synthetic peptide had not only common immunological characteristics but also respective advantages, and so they should be considered new vaccines against TB, or components thereof.

P042

COMPARATIVE GENOMICS AND EXPRESSION OF PHENOL-SOLUBLE MODULIN-A OF TWO RELATED COMMUNITY-ASSOCIATED MRSA CLONES ASSOCIATION WITH NASAL COLONIZATION AND INFECTION

C.-J. Chen,* C.-L. Chen,† Y.-C. Huang,* T.-Y. Lin,* and J. Lindsay,‡ *Pediatrics; †Pediatric Research Center, Chang Gung Children's Hospital, Taoyuan, Taiwan R.O.C.; and ‡Department of Cellular and Molecular Medicine, St. George's Hospital Medical School, London, UK.

Background and Aim: A majority of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strains in Taiwan were belonged to sequence type 59 (ST59) and can be divided into two pulsotypes with or without Panton-Valentine leukocidin (PVL) genes. PVL(−) clone was dominant in strains colonizing healthy children, whereas PVL(+) clone was commonly identified in clinical isolates. The factors associated with CA-MRSA nasal colonization and infections were explored by comparing strains of the two related clonal types.

Methods: Genetic compositions were compared in 7 PVL(−) and 7 PVL(+) strains of ST59 by DNA microarray with 3626 open reading frames. Expression of phenol-soluble modulin-α (PSM-α) was measured in log-phase of bacterial growth using real-time reverse transcriptase PCR in 20 PVL(−) and 25 PVL(+) strains of ST59 and 15 strains of a pandemic nosocomial clone, ST239. Values are presented as folds relative to the measurement of MRSA252 strain.

Results: Important genetic differences included the presence of an immune evasion cluster consisting of sak and sep genes in PVL(−) strains. Except for PVL, no known virulence determinant specific to PVL(+) strains was identified. Expression of PSM-α was significantly greater for ST59 than ST239 strains (560 ± 610 vs. 5.5 ± 8.4, P < 0.0001). Among ST59, PVL(+) strains produced a higher mean level of PSM-α than did PVL(−) strains (648 ± 686 vs. 449 ± 494), but not statistically significant (P = 0.2821).

Conclusions: Harboring an immune evasion cluster may enhance the ability of nasal colonization of CA-MRSA ST59. PSM-α and PVL may both implicate in the CA-MRSA diseases.

P043

UNUSUAL HIGH FRECUENCY OF INTRACRANIAL COMPLICATIONS SECONDARY TO OTITIS MEDIA

B. Croche Santabder, A. Porras Gonzalez, and I. Obando Santaella, Pediatria, Hospital Virgen del Rocio de Sevilla, Sevilla, Spain.

Introduction: Intracranial complications (ICC) secondary to otitis media are unusual but potentially life-threatening. We report an unusual high frequency of these events, and describe their clinical and epidemiological features.

Material and Methods: A retrospective study of all pediatric patients with ICC admitted to our tertiary hospital from April 2004 through Nov 2007.

Results: Eight patients had ICC: sigmoid sinus thrombosis (4), lateral sinus thrombosis (1), meningitis (2), epidural abscess (1), otitic hydrocephalus (1). Four of the patients had acute mastoiditis. Pre-admission oral antibiotics were administered in 87.5% of the patients. Fever, otalgia, headache and VI and VII cranial nerves paralysis were the most frequent symptoms associated. The microorganism could be isolated in 3 patients: S pyogenes (2) and P mirabilis (1); the remaining patients had negative cultures. All of the patients received broad-spectrum parenteral antibiotics and 2 of them underwent a radical mastoidectomy.

Conclusions: We report a unusually high incidence of cranial complications secondary to acute otitis media. Multicentric studies are needed in order to asses a possible increase in the incidence of these events.

P044

SPREAD OF PVL POSITIVE S. AUREUS AMONG PATIENTS AT CHILDREN CLINICAL UNIVERSITY HOSPITAL

L. Cupane,* N. Pugacova,* L. Drukalska,* I. Selga,* A. Balode,† D. Gardovska,* and E. Miklasevics,† *Children Clinical University Hospital; and †P.Stradins Clinical University Hospital, Riga, Latvia.

Objectives: Althought S. aureus is considered to be an opportunistic pathogen certain clones are more prone to cause invasive disease due to the presence of virulence factors like Panton–Valentine leicocidin (PVL). PVL producing strains can cause severe skin infections and necrotizing pneumonia in previously healthy children and young adults. Aim of this investigation was to detect spread of invasive S. aureus among paediatric patients at hospital and presence of PVL.

Methods: Antibacterial susceptibility was determined according to CLSI standards (M2-A9, M100-S16). The luk-PV gene and the SCCmec type was detected by PCR. Chromatograms of the spa sequences were analysed by Ridom StaphType software (Ridom GmbH).

Results: Investigation of 370 invasive S. aureus (21 blood isolate, 349–from pus) from patients, who were admitted to Children Clinical University Hospital in Riga from November of 2006 through November 2008, revealed that 241 (65%) isolates carried genes for PVL synthesis. 8 of them were identified as MRSA. Investigation of clonal relationship among the luk-PV positive S. aureus showed that majority of the typed strains belongs to the spa type t435. Retrospective analysis of patients medical cards from November 2006 throught March 2007 showed, that majority of patients were hospitalised in surgery department–64%, others in therapeutical profile departments–27%. Patients were hospitalised mainly with purulent skin and soft tissues infections like furunculosis, absceses, limfadenitis and mastitis.

Conclusions: Molecular investigation of S. aurues isolates showed that possibly there is nosocomial spread of S. aureus in hospital.

P045

THE PREVALENCE OF MIDDLE EAR PATHOGENS IN THE OUTER EAR, INNER EAR AND NASOPHARYNX OF OME PATIENTS

T. De Baere,* M. Vaneechoutte,* J. Huyghe,† and I. Dhooge,† *Department of Clinical Chemistry, Microbiology and Immunology, Ghent University; and †Department of Oto-Rhino-Laryngology, Ghent University Hospital, Gent, Belgium.

Objective: The objective of this study was to investigate the prevalence of Alloiococcus otitidis (a putative middle ear pathogen) and the known middle ear pathogens Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae by means of species-specific PCR in OME-patients.

Methods: The patient group consisted of children which underwent surgical intervention at the ENT department of our hospital. During surgery middle ear fluid was collected using a Juhn tymp tap, and two swabs were taken from the nasopharyngeal cavity respectively the outer ear. In case the patient was treated for bilateral OME, samples were taken from both sides. DNA was extracted using the NucliSense EasyMag extractor.

Species-specific PCR was carried out on all samples for A. otitidis, S. pneumoniae, M. catarrhalis and H. influenzae.

Results: Percentage of positive PCR results

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Conclusion: The prevalence of A. otitidis (58%) is indeed very high in middle ear fluids of OME patients, and even much higher than the prevalence of the other tested organisms. The prevalence of the known middle ear pathogens is high (48% to 80%) in the nasopharyngeal swabs, which could be expected because the throat is the reservoir for organisms infecting the middle ear by the Eustachian Tube. A. otitidis is however totally absent from the nasopharynx, but has a very high prevalence in the outer ear (83%).

P046

SEROPREVALENCE OF POLYSACHHARIDE SPECIFIC IGG AND BACTERICIDAL ACTIVITY TO NEISSERIA MENINGITIDIS SEROGROUP C: PRE- AND POST-VACCINATION PERIOD IN THE NETHERLANDS

R.M. deVoer,*† L. Mollema,‡ R.M. Schepp,* S.C. de Greeff,‡ E.A. Sanders,§ H.E. de Melker,‡ G.A. Berbers,* and F.R. van der Klis,* *Laboratory for Infectious Diseases and Perinatal Screening, National Institute of Public Health and the Environment, Bilthoven; †Department of Immunology, University Medical Centre Utrecht, Utrecht; ‡Epidemiology and Surveillance Unit, National Institute of Public Health and the Environment, Bilthoven; and §Department of Pediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands.

Background/Aim: In 2002 a MenC conjugate (MenCC) vaccination was introduced into the National Immunization Program at the age of 14 months and a catch-up campaign was implemented targeting individuals between 1 and 18 years. We determined age specific seroprevalence of MenC polysaccharide (PS) IgG and MenC specific serum bactericidal antibodies (SBA) before and after introduction of MenCC vaccine.

Methods: Two population-based serum collections, established in pre- (1995/1996) and post-vaccination (2006/2007) period, were available. Using a multiplex immunoassay (MIA), MenC PS specific IgG was determined in 2303 and 6376 sera from pre-and post-vaccination period, respectively. In addition, in a subset of sera from both serum collections (735 and 1220 sera) MenC specific SBA titers were determined.

Results: Overall SBA seroprevalence was 22% [18.0–26.6.%] and 45% [41.1–49.3%] in pre- and post-vaccination period, respectively. SBA titers show a similar age-specific trend as MenC PS specific IgG (figure 1), except SBA titers are not significantly different between pre- and post-vaccination period in unvaccinated adult groups.

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Conclusions: MenCC vaccination induced higher IgG levels in vaccinated groups compared to natural exposure, but only older age groups seem to benefit from persistence of higher IgG levels. Due to mass vaccination, circulation of MenC probably decreased, resulting in lower IgG titers in unvaccinated adult groups. This may pose them at extra risk once MenC might start re-circulating.

P047

RECURRENT BACTERIAL MENINGITIS–CASE SERIES

A. Dias,* H. Rios,* A. Correia,† J.A. Costa,† and F. Rodrigues,* *Unidade de Infecciologia; and †Serviço de Neurocirurgia, Hospital Pediátrico de Coimbra, Coimbra, Portugal.

Background and Aims: Recurrent bacterial meningitis (RBM) is an unusual entity and generally poses a considerable diagnostic challenge. Different conditions can predispose for recurrence of episodes and the isolated pathogen can guide the diagnosis. The aim of this study was to characterize all RBM admitted to a tertiary paediatric hospital.

Methods: Retrospective analyses of the medical records of all children with RBM, between January 1994 and December 2007 (14 years).

Results: During this period, 107 children with bacterial meningitis (BM) were admitted. Among those, 10 (9.3%) had more than 1 episode of BM; 6 were male. Six children had the first episode of BM in the first 6 months of age (range: 7 days-12 years). Twenty three episodes of BM were identified (7 had 2 episodes and 3 had 3 episodes). N. meningitis and S. pneumoniae were isolated in 4 episodes each and Enterococcus faecium in 2. Underlying conditions were identified in 9 cases: neurosurgery shunt implantation (6) and CSF leakage in 3 (skull fractures). A predisposing condition hasn't yet been identified in 1 child and no immunodeficiency was found.

Conclusions: It was identified a high proportion of BRM. An anatomical defect was the most frequent cause. In cases without an obvious predisposing condition an exhaustive evaluation, including search for anatomical and immunological defects, needs to be performed in order to prevent recurrence and improve the outcome.

P048

LEMIERRE SYNDROME CAUSED BY ABIOTROPHIA DEFECTIVA IN A CHILD

E. Farmaki,* E. Vargiami,* M. Badouraki,† A. Anastasiou,† D. Zafeiriou,* N. Gombakis,* D. Sofianou,‡ and M. Athanasiou-Metaxa,* *1st Dept of Pediatric, Aristotle University of Thessaloniki, Thessaloníki; †Dept of Radiology; and ‡Dept of Clinical Microbiology, Hippokration General Hospital, Thessaloniki, Greece.

Background: Lemierre syndrome (LS) is characterized by anaerobic septicaemia, internal jugular vein (IJV) thrombosis, and septic emboli following oropharyngeal infections.

Methods: We describe a previous healthy 12-year-old boy presented with a 5-day history of sore throat and fever. Physical examination revealed a temperature of 39.6°C, toxic appearing and painful swelling of the neck. Laboratory evaluation revealed leukocytosis and elevated C-reactive protein. Ultrasound of the neck demonstrated an abscess in the left side of the neck and thrombosis of the left IJV. A CT and a MRI scan of the neck confirmed the above findings. Two blood cultures specimens yielded a microaerophilic Gram-positive coccus which was phenotypically identified as A. defectiva. Intravenous dalacin, vancomycin and gentamycin were administered for a total of 4 wks, based on reported data on the resistance of A. defectiva to various antibiotics. Five days after initiation of therapy, he became afebrile. The course of the disease was uncomplicated. Follow up CT scan documented resolution of IJV thrombosis.

Conclusions: LS, a rare but potentially lethal complication of otolaryngological infections, is usually caused by Fusobacterium necrophorum. A. defectiva, originally known as a member of the nutritionally variant streptococci, is part of the normal oral and intestinal flora. It has been associated with various infections including bacteremia, endocarditis, brain abscess, septic arthritis and total knee arthroplasty infections. To our knowledge, A. defectiva has not previously been described as a cause of LS. This case expands the spectrum of disease caused by A. defectiva to include typical LS.

P049

WHAT WE KNOW ABOUT MALIGNANT WHOOPING COUGH?

A. Felipe,* I. Jordan,† J. Ortiz,* E. Esteban,‡ M. Balaguer,‡ and A. Palomeque,‡ *Pediatric, †Intensive Care Unit, ‡PICU, Sant Joan de Deu H. Barcelona University, Barcelona, Spain.

Background and Aims: Increasing rates in incidence/mortality of whooping cough (WC) has been observed in nursing babies. The aim was To evaluate the malignant WC risk factors, in patients admitted to pediatric intensive care unit (PICU).

Patients and Methods: Retrospective-prospective observational study from patients with WC admitted to Sant Joan de Déu Hospital PICU (January 1999–December 2008).

Results: There were 252 WC cases, 38 (15%) admitted to PICU. From these, mean age was 6.23 weeks, 26 were females and nine patients had been premature. Microbiological confirmation was made in 24 patients by culture, in 8 by immunofluorescence and 5 by PCR. There was cyanotic cough in 85%, apneas 60% and acute respiratory failure (ARF) 54%. Thirteen patients need mechanical ventilation (MV).

Six patients (15.8%) died: were less than two months and had ARF and pulmonary hypertension. Five patients had pneumonia and one sepsis. All of them need HFOV and nitric oxide, and two required ECMO. There were found significant differences between fatal cases or not regarding to: oxygen treatment in intubated patients (FiO2>60% or <60%, P = 0,005), mean leucocytes number (69.957 leucocytes/mm3 vs. 19.933, P = 0.002) and platelets number (674.700 pl/mm3 vs. 571.140, P = 0.046), respectively.

Conclusions: Risk factors for WC malignant disease were: age; presence of pulmonary hypertension or ARF and pneumonia complication; leucocytosis or thrombocytosis and need of FiO2 in MV patients.

P050

INVASIVE NEONATAL GROUP B STREPTOCOCCAL INFECTIONS: STATISTIC REVIEW OF SANTO ANDRé HOSPITAL’S PEDIATRIC DEPARTMENT–PORTUGAL

S. Ferreira,* A. Luz,* G. Marrão,† J. Agro,* and L. Winckler,* *Paediatrics Department; and †Microbiology Department, Hospital de Santo André, Leiria, Portugal.

Background and Aims: Group B Streptococcus (GBS) remains an important cause of serious neonatal infection despite great progress in perinatal GBS disease prevention. The goal of this study was to describe the population of children admitted to our department for GBS disease.

Material and Methods: Retrospective review of all cases of GBS infection admitted to Pediatric Department from 2000 to 2008. Cases of GBS infection were defined as isolation of GBS from blood or cerebrospinal fluid and/or clinical evidence of disease in a colonized infant with GBS (detection of bacterial antigen in urine with latex agglutination test after first 24 hours of life).

Results: Data from 46 infants (39% girls and 61% boys) were collected and analyzed. 80% of the infants suffered from early-onset disease of whom 43% presented with septicemia, 22% with pneumonia and one with meningitis. Regardless of the site of involvement, respiratory signs were the initial clinical findings in almost 60% of neonates with early-onset disease. Main presentation of late-onset disease was also septicemia (50%) however, 38% presented with meningitis and there were no cases of pneumonia. Nearly 46% of infants had risk factors for GBS infection being intrapartum fever the most common (30%). There was no fatality but 50% of those who had meningitis suffered permanent neurologic sequelae.

Conclusions: No data of neonatal invasive GBS infections are available for Portugal. Nevertheless, our results are similar to those available in international literature. The serious sequelae encountered enhance the importance of guidelines compliance in prevention of perinatal GBS disease.

P051

CLINICAL PROFILE OF SERIOUS BACTERIAL INFECTION IN YOUNG FEBRILE INFANTS

S. Fouzas, A. Filias, N. Fotiadis, D. Papanastasiou, and S. Mantagos, University Hospital of Patras, Patras, Greece.

Background and Aims: Identifying febrile infants at risk of serious bacterial infection (SBI) continues to challenge clinicians. The aim of our study was to evaluate the clinical features associated with SBI in febrile young infants.

Methods: We retrospectively evaluated all infants aged 31–180 days, admitted for fever >38°C without a focus between 2000 and 2007. As SBI were considered all cases of occult bacteremia, urinary tract infection (UTI), bacterial meningitis, pneumonia and bacterial gastrenteritis.

Results: Of the 786 infants studied, 256(32.5%) had SBI: 217(27.6%) UTI, 19(2.4%) bacteremia, 14(1.8%) pneumonia, 4(0.5%) bacterial meningitis and 2(0.25%) bacterial gastrenteritis. The most common historical and physical findings on presentation were: decreased feeding 41.5%, ill contact 31.2%, nasal congestion 26.6%, cough 16.9%, grunting 15.6%, irritability 14.1%, diarrhea 12.5%, tachypnea 12%, lethargy/hypotonia 5%, mottled skin 3.9%, vomiting 3.4% and rash 2%. Completely asymptomatic were 99 infants with SBI (42.4% of SBIs) from which 88(96.6%) had UTI. Fever >39°C, tachypnea, and absence of upper respiratory symptoms (nasal congestion and/or cough), were identified by logistic regression as possible clinical predictors of SBI. The absence of upper respiratory symptoms was associated with UTI, whereas fever >39°C, decreased feeding, and grunting were associated with bacteremia. However, all these logistic regression models had poor goodness-of-fit coefficients.

Conclusions: The clinical profile of SBI in febrile infants was non-specific and an important number of these (especially with UTI) had a falsely reassuring well appearance. Physicians should not be based on historical and physical findings for assessing the risk of SBI in febrile young infants.

P052

AFTER ALL, IT WAS A MYCOBACTERIOSIS!

T. Francisco, M. Brito, and L. Varandas, Paediatrics, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.

Background: Mycobacterial infection, despite rare in developed countries, is still common in low socioeconomic level populations. The forms of presentation can be protean and constitute a real diagnostic challenge.

Aim: To analyse the cases of mycobacterial infection whose diagnosis was not straight forward.

Methods: Descriptive study, from January to December 2008, of mycobacterial infections admitted in our hospital. Demographic data, origin, vaccinal status, contacts with tuberculosis, cause of admission and final diagnosis, mean length of stay and evolution were analysed.

Results: Seven children were identified, 2–14 years old with African origin (6/7) predominance. In all cases the final diagnosis was different from the original. The initial unfavourable clinical course prompted a detailed investigation to get the final diagnosis. The initial diagnosis were: chronic osteomyelitis (3), lymphoprolipherative disease (1), parotid neoplasm (1), encephalitis (1) and chronic facial ulcer (1). The final diagnosis were osseous tuberculosis (3), ganglionar tuberculosis (2), meningeal tuberculosis (1) and cutaneous tuberculosis (1) by Mycobacterium tuberculosis (5) and Mycobacterium africanum (2). The vaccinal status was unknown in three patients and four children had BCG vaccine. Four patients had history of contact with tuberculosis. Six had tuberculinic test over 15 mm. The mean length of stay was 38 days. Six patients had a favourable evolution and one died (tuberculous meningitis).

Conclusions: In all these patients, the initial diagnosis was unclear and the etiological investigation revealed a mycobacterial infection. This entity should always be sought in patients with risk factors or with positive tuberculin test.

P053

PSEUDOMONAS AERUGINOSA AMONG BULGARIAN CYSTIC FIBROSIS PATIENTS TREATED WITH TOBI 300®

I. Galeva, R. Markova, and M. Yankova, Pediatric Clinic, University Hospital ‘Alexandrovska’, Sofia, Bulgaria.

Background and Aim: There is increasing consensus in using antibiotics threw inhalation against Pseudomonas Aeruginosa (PA) lung colonization in cystic fibrosis (CF) patients. To assess the influences of TOBI 300 on PA in sputum, the drug tolerance and changes in lung functional parameters, body mass index (BMI) and quality of life while using TOBI 300 in Bulgarian cystic Fibrosis (CF) patients.

Methods: 18 CF children aged 6–18 y and 25 CF adults aged 19 y–28 y have received TOBI 300 through inhalation, twice daily for 4 weeks, followed by interrupting the treatment during the next 4 weeks. All CF patients have received their common CF treatment and PA in their sputum had been established more than 3 times for the last two years. Clinical status, lung functional tests (LFT), PA in sputum, BMI and quality assessment of CF life have been followed.

Results: During the observation period (>4 months) PA in sputum has disappeared in 10 adult CF (40.0%) and in 12 CF children (66.7%). LFT's have shown improvement in a half of the CF children (n = 9) and in 28% of the adults (n = 7). Appetite in most patients has improved, nevertheless significant changes in BMI have not been found. Better quality of CF life (answering positive on 7 or more questions from the questionnaire) has been found in more than 80% of the CF patients. Drug adverse effects have not been noticed in any of CF patients.

Conclusions: Treatment with TOBI 300 has been well tolerated and shown adequate therapeutic results.

P054

VARICELLA AND STREPTOCOCCUS—A TOXIC COMBINATION. SYNDROME OF CELLULITIS TO NECROTISING FASCILITIS

S. Gardner, Paediatric A&E, Ormskirk District General Hospital, Ormskirk, UK.

Abstract: We describe 6 cases seen over a period of one month-all developing culture-positive Group A Streptococcus subsequent to varicella infection. All of the cases of varicella infection were mild to moderate.

2 cases developed necrotising fasciitis (one of whom subsequently developed leukaemia). 4 cases developed varying degrees of cellulitis-one affecting the under-chin area sufficiently that a period of intensive are was required.

All were treated with antibiotics including clindamycin when culture results were known. All of the cases showed variable levels of infection markers including C-reactive protein / erythrocyte sedimentation ratio. Both cases of necrotising fasciiitis required extensive surgery though both survived. Of the cellulitis cases all made a full recovery.

The combination of these pathogens is well-recognised and has been used as an argument for varicella vaccination in a climate of viewing varicella as a benign childhood infection.

Clinicians should be alerted to the possibility of these skin complications as they occur in previously healthy subjects. Also that varicella is the most common precipitant of necrotising fasciitis in adults-Streptococcus accounting for 50% of cases. They should also be alerted to the need for rapid and radical surgery to reduce spread in necrotising fasciitis.

P055

INTESTINAL YERSINIOSIS IN CHILDREN

I. Germanenka, and E. Serhiyenka, Childrens Infectious Diseases, Belarussian State Medical University, Minsk, Belarus.

Background and Aims: Nowadays the problem of yersiniosis infection remains vital. Disease indicators intestinal yersiniosis, caused Y.enterocolitica among children till 14 years in our country last years remain stable and make from 4.6 in 2006 to 9,78 in 2008 (on 100 thousand). The purpose of our research was the analysis of clinico-laboratory features of yersiniosis with determination of tactics for therapies.

Methods: There were 89 patients age 1–17 yo under supervision. The diagnosis was based on the epidemiological anamnesis, the general clinical examination, bacteriological and serological studies.

Results: The symptomatic form of disease began from fever (100%), vomiting (35.5%) and diarrhea (68%). Clinical manifestation include colicky abdominal pain (39%), headache (47%), anorexia (28%), exanthema (12%) and pain at joints (12%). Phenomena of enteritis and gastroenteritis are prevailed. 2 children have pseudoappendisitis syndrome and need consultation of surgeon. One boy with asymptomatic form of disease had such complication as arthritis. The following changes in the general analysis were determined: leucocytosis (83.8), increase of SSR (71%) and CRP (95%), neutrophilia (68%). High level of sensitivity to anitbiotics Y.enterocolitica had to carbopenem group (100%), cephalosporins of 3 generations (≥90%), aminoglycosids 2 and 3 generation (≥90%), fluorochinolons (≥96%) and just 53% for nalidixic acid.

Conclusions: Thus, polymorphism of clinical manifestations is characteristic for intestinal yersiniosis, and high sensitivity of microbes is kept to cephalosporins of 3 generations, aminoglycosids 2 and 3 generation, fluorochinolons and carbopenems.

P056

ICD-10 SURVEILLANCE OF INVASIVE PNEUMOCOCCAL DISEASE (IPD) IN HOSPITALIZED CHILDREN IN BAVARIA 2005/2006

N. Henrich,* A. Streng,* V. Grote,*† M. van der Linden,‡ and J. Liese,* *University Children's Hospital, University of Munich; †Institute for Social Paediatrics and Adolescent Medicine, University of Munich, Munich; and ‡National Reference Center for Streptococci, Institute for Medical Microbiology, University Hospital Aachen, Aachen, Germany.

Objective: To estimate the burden of IPD complications in Bavarian children ≤16 years before the introduction of general pneumococcal conjugate vaccination.

Methods: ICD-10 data specific to IPD (G00.1 meningitis, A40.3 sepsis) were reported from 28 out of 41 (68.3%) Bavarian paediatric hospitals from 01/01/2005 to 31/12/2006. Reports were matched to data of pneumococcal isolates sent to the National Reference Center for Streptococci (NRZ) for serotype distribution and capture-recapture analysis.

Results: In 2005/2006, 98 children with IPD were reported by ICD-10 from 28 hospitals (mean 3.5/hospital; range 0 to 12). There were 41 IPD cases with meningitis (41.8%) and 57 with sepsis (58.2%). During the same period, 87 S. pneumoniae isolates from 85 children with IPD (meningitis: 25/29.4%; sepsis: 60/70.6%) were reported to NRZ from 25 hospitals. Thirty datasets could be matched and serotype information was available. The most frequent serotypes were 14 (n = 5; 16.7%), 1 (n = 3; 10.0%) and 19F (n = 3; 10.0%). Fifteen serotypes (50.0%) are covered by 7-valent, 19 (63.3%) by 10- valent and 23 (76.7%) by 13-valent pneumococcal conjugate vaccination. By using the capture-recapture method, we calculate a number of 278 IPD corresponding to a yearly incidence of 6.5/100,000 for 2005/2006.

Conclusion: ICD-10 is a reliable surveillance instrument of hospitalized IPD, which can be used to monitor the effects of general pneumococcal conjugate vaccination. These results, however, show that ICD-10 can be combined to a second case source to account for potential underreporting.

P057

NOVEL HYPOTHESIS FOR UNEXPLAINED SUDDEN UNEXPECTED DEATH IN INFANCY (SUDI)

A. Highet,*† A. Berry,† and P. Goldwater,†‡ *Microbiology & Infectious Diseases, Discipline of Paeditrics, University of Adelaide, †Microbiology & Infectious Diseases, SA Pathology at the Women's & Children's Hospital, ‡Discipline of Paeditrics, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia.

Background and Aims: In 2008, two key retrospective studies independently reported typically pathogenic bacteria in normally sterile sites of infants succumbing to sudden unexpected death, questioning whether a proportion of unexplained SUDI were simply undetected cases of bacteraemia. In these instances, evidence of bacteraemia was presumably overlooked in the investigation of death. On the other hand these findings pointed to an asymptomatic “bacteraemia” limited to a restricted period of development. We aimed to collate the data to formulate this hypothesis.

Methods: Using pathologic and epidemiological clues, an hypothesis is introduced that is based upon three contributing factors: Transient bacteraemia, pathogen pattern recognition insufficiency, and a prenatal infectious event.

Results: Sterile site infection with Staphylococcus aureus or coliforms was found in about 1/4 SIDS cases. Polymorphisms in key innate immune response genes were demonstrated. Organ growth anomalies (thymomegaly and megencephaly and cardiac growth retardation associated with SIDS (not sudden unnatural comparison deaths) were shown to have prenatal origins.

Conclusions: Sterile site infection could represent a “footprint” of a transient bacteraemic event. Prenatal infection is likely to explain organ growth anomalies in SIDS/SUDI. These, together with innate immune system gene polymorphisms could provide a coherent explanation for SIDS/SUDI.

P058

STAPHYLOCOCCUS LUGDUNENSIS INFECTIVE ENDOCARDITIS: REVIEW OF THELITERATURE, CLINICAL PROFILES AND OUTCOME

Y.-F. Huang, P.-Y. Liu, and K.-S. Hsieh, Pediatric, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan R.O.C.

Background and Aims: Infective endocarditis Staphylococcus lugdunensis is rare. We conducted a retrospective cohort study to identify the prognostic factors of this disease.

Methods: We retrospectively reviewed articles reported from 1988–2008.

Results: The mean age of all cases was 53.88 years. Left-sided valves endocarditis represents 82.5% (52/67) and native valves endocarditis was 78.7% (48/67). Although most strains (80.4%) of staphylococcus lugdunensis were penicillin susceptible but 66.7% (42/67) patients received valve replacement operations. 41.3% (26/67) of cases fully recovered.

Conclusions: The virulence of S. lugdunensis differs from other coagulase negative staphylococci with its rapid and destructive course and caused a higher mortality. Detailed microbiology identification, echocardiography evaluation and early surgery may improve outcome.

P059

FRONTAL MASS: A CHALLENGING DIAGNOSIS WITH AN UNEXPECTED CAUSE

G. Januário,* M. Costa Alves,* A. Correia,† and F. Rodrigues,* *Unidade de Infecciologia; and †Serviço de Neurocirurgia, Hospital Pediátrico de Coimbra, Coimbra, Portugal.

Background and Aims: Capnocytophaga spp. are gram-negative bacteria, normal constituents of the oral flora in humans and in some animals, which can be responsible for systemic infections, most frequently in immunocompromised patients.

Methods: The authors describe a case of an unusual Capnocytophaga infection in an immunocompetent child.

Results: A previously healthy 12-year-old boy was admitted to the Emergency Service with a 5-day history of frontal headache and fever. Amoxicillin-clavulanate was prescribed for a suspected sinusitis and moxifloxacin was added later because of persistent headache. He presented 1 month later with fever, left retro-ocular pain and a frontal mass. The CT scan showed a frontal abscess (44,7 × 41 mm) with extra-axial endocranial and extracranial component, with underlying destruction of bone tissue. Surgical drainage was performed and Capnocytophaga spp. was isolated in the purulent content. He was treated with amoxicillin-clavulanate with a good outcome. The detailed clinical history revealed a dog bite some days before the first clinical symptoms and a visible scar was still present in his dorsal region. It was not possible to confirm that this species was from the canine species. Dental examination was normal. An immunodeficiency was excluded. One year later he is still clinically well.

Conclusions: This is an unusual infection, with a rare clinical manifestation, that could be related to the dog bite. Capnocytophaga canimorsus is one of the most common agents of infection after dog bite. The microbiological identification of these bacteria facilitates appropriate antimicrobial therapy but it is somewhat difficult and a clinical guidance is important.

P060

ATYPICAL PRESENTATION OF TUBERCULOSIS IN A 15-YEAR-OLD GIRL: A CASE REPORT

E. Kapravelou, S. Vaessen, B. Florkin, V. Pasquasy, C. Lerusse, J.-M. Senterre, and M. Trippaerts, Citadelle Hospital, Liège, Belgium.

Introduction: Active tuberculosis primarily involves the lungs. Peritoneal tuberculosis is a rare presentation of tuberculosis particularly in children. Because of the diversity of the demonstrations, the diagnosis is often delayed and the complications and mortality increase.

Case Report: We report the case of a 15-year-old girl with past medical history of asthma, who presented to the Emergency Department with low fever, respiratory distress and increased abdominal diameter. Examination revealed an hypoventilation of the left lung and an abdominal distension with an ascitic wave. The chest radiograph and the CT scan of the thorax showed a pleural effusion and an ascite partitioned. We first suspected a tumoral process. This diagnosis was not confirmed by laboratory exams. The partitioned ascite directed us towards a tuberculosis. The tuberculosis skin test and the first polymerase chain reaction (PCR) for the Mycobacterium of Tuberculosis were negative. The interferon gamma release assays and the next PCRs in the pleural and abdominal fluid confirmed the diagnosis of Tuberculosis. Anti-tubercular therapy was initiated.

Conclusion: This case underlines the diversity of presentation of tuberculosis. The partitioned ascite is an essential element of orientation. Also a negative tuberculosis skin test does not exclude the diagnosis. The interferon gamma release assays can be a good alternative to the tuberculosis skin test when this one is negative and there is however a strong clinical suspicion. In case of doubt, not hesitate to repeat the laboratory exams like the PCR.

P061

BACTERIAL AND VIRAL INFECTIONS INDUCE ALTERATIONS IN ZINC PLASMA CONCENTRATIONS

T. Karakonstantakis,* A. Sergounioti,* P. Moraitis,† K. Theodoridou,* I. Papassotiriou,* and M. Theodoridou,† *Department of Clinical Biochemistry, “Aghia Sophia” Children's Hospital; and †First Department of Pediatrics, Athens University Medical School, Athens, Greece.

Abstract: We studied the correlation of zinc with procalcitonin (a highly specific marker for the diagnosis of bacterial infections) plasma concentrations and also evaluated the alterations of Zn concentrations in children with infections. 151 children were included in the study: 73 children with bacterial infections (Group A) and 78 children with viral infections (Group B). Serial blood samples were taken from almost 1/3 of patients of each group. Blood samples were collected the morning of day 1(on admission), day 4 (after admission), and after recovery. PCT concentration was determined by chemiluninescence, while Zn concentration was measured with AAS. The main results of the study showed that: a) patients with viral and bacterial infections had significantly lower Zn concentrations on admission (P < 0.03 and P < 0.0003, respectively) b) patients with bacterial infections had significantly lower Zn concentrations than those with viral infections (P < 0.03), while no such correlation was calculated in the day 4 (after admission) and after recovery (P > 0.73 and P > 0.15, respectively) c) PCT and Zn levels correlated significantly in patients with bacterial infections (P < 0.00001, r = −0.518) and d) no such correlation observed in children with viral infections. The lower zinc levels observed in patients with bacterial infections may be due to the action of IL-1, which released by granulocytes and mediates a redistribution of body zinc during the acute phase response. The latter results in increased hepatic zinc sequestration and urinary excretion of zinc. Zinc may also be utilized from the immune system in order to develop an optimal host defense.

P062

MICROORGANISMS ISOLATED FROM BLOOD CULTURES OF CHILDREN AND THEIR ANTIMICROBIAL SUSCEPTIBILITIES AT A KOREAN HOSPITAL (2007–2008)

H.-S. Kim, J.-S. Kim, W. Song, and K.-M. Lee, Laboratory Medicine, Hallym University Medical College, Anyang, South Korea.

Background and Aim: Analysis of blood culture results and antibiotic susceptibilities provides valuable information for the empirical treatment. The aim of the study was to identify the frequent causative microorganisms in bacteremia of children and their antibiotic susceptibilities at a Korean Hospital.

Methods: The blood culture results of 9,789 children less than 10 years old were analyzed. Bactec 9240 blood culture systems and Bactec Peds Plus F bottles were used. Identification of organism and antimicrobial susceptibilities were determined by Microscan LabPro system.

Results: Among the 9,789 blood cultures, 594 (6.1%) were positive. Among the isolates, 98.0% were aerobic and facultative anaerobes and 2.0% were fungi. Coagulase-negative staphylococci (CNS) were frequently isolated (68.2%, 405/594)). Excluding CNS, Staphylococcus aureus was isolated most frequently, followed by viridans streptococci, Enterococcus spp., Escherichia coli. 52.8% of S. aures isolates were methicillin-resistant S. aures (MRSA). All isolates of Enterococcus faecalis and Enterococcus faecium were vancomycin-susceptible. 33.3% of E. coli isolates were cefotaxime-resistant.

Conclusion: S. aureus is the most common etiologic agents of bacteremia in children. MRSA is frequently isolated. Gram negative bacteremia is relatively uncommon in children.

P063

EDUCATION AS KEY FACTOR IN INVASIVE BACTERIAL INFECTION OUTCOME-OUR EXPERIENCE WITH “RED FLAG” SYSTEM IN LOWER SILESIA, POLAND

E. Kuchar, L. Szenborn, and A. Jalowska, Pediatrics and Infectious Diseases, Medical University of Wroclaw, Wroclaw, Poland.

Background and Aims: Invasive bacterial disease (IBD) is a life-threating condition. Recognizing early symptoms could shorten the time to hospital admission which is critical for outcome. We focused on educational activities in hope to rise awareness and attain better outcomes.

Methods: “Red flags” are concept which is used to identify potentially serious pathology by recognizing key symptoms originally used in low back pain. We adapted this system to IBD focusing on hemorrhagic rash, lethargy, drowsiness, nausea, vomiting, cold hands and feet and prolonged capillary refill.

Results: About 100 doctors were trained during lectures, 3000 posters were distributed and a campaign in media (TV, Internet) had been carried on for 2 months. In the following 2007 year we hospitalized 60 children referred as IBD confirming the diagnosis in 28 (11 purulent meningitis, 7 sepsis and 10 mixed infection). 23/28 children were pretreated with antibiotics, 4/28 were referred to ICU and there was no fatal outcome. It is worth noting that two parents in their two children and one of the patients, a boy aged 12 y diagnosed sepsis himself. The etiology was identified in 14/28 cases (N.menigitidis: 9/14, S.pneumoniae: 2/14, H.influenzae 2/14, S.aureus 1). The main red flag symptom was hemorrhagic rash observed in 14/28 children (8/9 N.meningitidis, 1/2 S.pneumoniae, 1/1 S.aureus and 4/14 unknown etiology).

Conclusions: Education of parents & doctors seems to be the best way of reducing mortality in children with IBD. Haemorrhagic rash with fever is the main symptom raising suspicion of IBD.

P064

ETIOLOGY OF BACTERIAL INFECTIOUS DISEASES IN PRE-TERM NEWBORN INFANTS

E. Lekic,* and D. Dakic,† *Institute for Children Disease, Center of Neonatology Podgorica, †Institute for Children Disease, Center of Neonatology, Klinical Center Republic of Montenegro, Podgorica, Montenegro.

Introduction: Maternal, environmental, and host factors determine which infant exposed to a potentially pathogenic organism will develop serious or other potentially invasive infections, causing significant mortality and long-term morbidity in neonates, especially for premature infants, higher in infants with very low birth weight.

Aim/Material: The purpose in this retrospective study was to identifications the bacterial microorganisms caused neonatal infectious diseases in pre-term newborns hospitalized in the Center of Neonatology, during the period of 2002, 2003 and 2004. We used clinical, microbiological, laboratory and radiology methods.

Results: 682 pre-term newborns (PTNB) were treated at the Center of Neonatology in Podgorica during the period 2002–2004. In 98 PTNB were proven infections (14,3%). Most frequent infectious diseases were: omphalitis (36,7%), sepsis (30,6%),pneumonia (15,3%), cutaneus infections (12,2%), diarrhea (2,0%), conjunctivitis (2,0%) and urinary tract infection (1,0%).

Dominant pathogens in all infections diseases were Staphylococcus spp. and Klebsiella pneumoniae. The bacterial agents responsible for sepsis and/or meningitis were: Staphylococcus aureus (26,6%), Coagulase-Negative Staphylococcus (20,0%),Klebsiella pneumoniae (20,0%), Serratia marscensens (13,3%), then Streptococcus alfa haemolyticus group A, Acinetobacter spp. and Pseudomonas spp. (3,3%).

Conclusions: There are significant regional differences in pathogens of neonatal infections. It is important to identifications the bacterial microorganismsims in our region, analysis of longitudinal trends assist in the formulations of strategies to treat and prevent neonatal serious infections.

P065

GROUP A STREPTOCOCCAL MENINGITIS IN 5-YEAR-OLD BOY: A CASE REPORT

I. L'Erario,* M. Busetti,† and F. Marchetti,* *Departement of Pediatrics, Institute of Child Health, IRCCS Burlo Garofolo, †UCO Hygiene and Preventive Medicine, University of Trieste, IRCCS Burlo Garofolo, Trieste, Italy.

Abstract: Streptococcus pyogenes (SP) is an agent rarely associated to meningitis and corresponds to 0.2–1% of the cases, usually as a contiguous infection site, such as otitis, sinusitis and mastoiditis.

A previously healthy 5-year-old child presented to our service with fever, vomiting, ear ache and headache starter four day before. During initial examination, the patient appeared to be in a toxic condition and his neck was stiff. The patient was submitted to a lumbar puncture and the cerebrospinal fluid (CSF) was indicative of bacterial meningitis and therapy with ceftriaxone and dexamethasone was immediately instituted. Laboratory investigation revealed a white blood cell count of 23,200 leukocytes/μL with 22.100 neutrophils, ESR 109 mM, CSF with 2,400 cells/mm3 (60% neutrophils), protein of 56,6 mg/dL, glucose of 25 mg/dL, positive Gram stain and negative latex test. Blood culture was negative and CSF culture identified SP and the strain was sensitive to penicillin.

The clinical presentation of SP meningitis is not different from the other bacterial meningitis. SP has to be considered as a cause of bacterial meningitis in childhood: approximately 50% of cases reported during the neonatal period. In older children meningitis due to SP seems to be associated sometimes with a focus of infection in the middle ear. The antibiotic of choice for the treatment of SPM is penicillin and there have been no reports of resistance of this agent to this drug.

Our purpose is to emphasize that this agent is also a cause of meningitis in healthy children.

P066

UNUSUAL CLINICAL PRESENTATION OF A PATIENT WITH BARTONELLA HENSELAE INFECTION

M. Luminos, G. Jugulete, R. Mantescu, R. Matei, M. Vasile, A. Draganescu, and A. Visan, Pediatric, Institute of Infectious Diseases Matei Bals, Bucharest, Romania.

Background and Aims: Cat scratch disease is a loco-regional infectious disease, produced by Bartonella spp (henselae, claridgeaiae, quintana), usually with a benign evolution and complete recovery.

Methods: The authors present a clinical case of acute encephalitis, produced by Bartonella henselae, in an immunocompetent patient, with complete recovery and no neurological sequelae after etiologic and supportive treatment.

The diagnostic was established: clinical symptoms (fever, headache, seizures, vomiting and lethargy), laboratory findings and epidemiological diagnostic (a bite on right hand). Also, the diagnostic was completed with serologic test in cat that was positive.

Results: The patient was a girl, 8 ages old, was admission in our intensive care unit for: fever, headache, seizures, vomiting, lethargy and coma. Also, on the right hand, the child has a wound produced by cat. Serological diagnostic on the cat was positive for Bartonella Henselae. CRF was normal on lumbar puncture. IRM cerebral was normal. EEG show focal abnormalities, such as spike and slow sharp-wave patterns. The treatment was and etiologic (ciprofloxacin), pathogenic (dexamethazone) and symptomatic. The evolution was favorable with complete recuperation.

Conclusions: The presentation wanted to point out the possibility of this particular rare etiology in a clinical setting of acute encephalitis, especially in a patient with a positive history of animal exposure (the most probable etiology including rabies, cat scratch disease, choriolymphocytic meningitis).

P067

A FATAL CASE OF INFECTIVE ENDOCARDITIS CAUSED BY COMMUNITY-ASSOCIATED METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS ST 72 IN KOREA

S.H. Ma,* S.H. Oh,† K.T. Jung,‡ and Y.S. Lee,‡ *Dept. of Pediatrics, Fatima Hospital, Changwon; †Dept. of Pediatrics, Hanyang Medical University; and ‡Division of Antimicrobial Resistance, Korea National Institute of Health, Seoul, South Korea.

Background: Community-associated methicillin-resistant Staphylococcusaureus.

(CA-MRSA) has now emerged on five continents over the last decade. CA-MRSA is usually associated with young healthy individuals in the community, who have no risk factors for acquisition of HA-MRSA. CA-MRSA is primarily associated with skin and soft tissue infections however, there have been severe cases of CA-MRSA infection associated with septic shock, bacteraemia and necrotizing pneumonia.

More recently, infective endocarditis (IE) due to the involvement of CA-MRSA has been described.

Case: We report a fatal case of infective endocarditis caused by a non-US 300, Panton-Valentine leukocidin toxin- negative CA-MRSA clone without risk factors associated with HA-MRSA. This is a serious case of CA-MRSA infectin caused by a sequence type 72 clone, which is one of the common CA-MRSA clones in Korea where serious infections have been rare.

The patient was died by worsening cerebral hemorrhage with thrombocytopenia due to infective endocarditis.

P068

COMMUNITY-ACQUIRED METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (CA-MRSA) IN THE LAST DECADE IN A PAEDIATRIC HOSPITAL

B. Maia Vale, M. C. Alves, A. Cordeiro, L. Januário, and F. Rodrigues, Hospital Pediátrico Coimbra, Coimbra, Portugal.

Background and Aims: CAMRSA infections are a common and serious problem in some countries. Local and national surveillance is needed.

Methods: Retrospective review of all cases admitted to our Emergency Service (ES), between 1998 and 2008 (11 years), with a clinically relevant infection and S. aureus positive culture, obtained within 48 hours of admission. Isolates from sputum were excluded.

Results: CA S. aureus infection was diagnosed in 343 cases. MRSA was found in 17 cases (5%) with no increase over the years; 53% were male, the median age was 1,5 years and 58,8% were hospitalized. Diagnoses were: skin/soft tissue infection (11), urinary tract infection (3), sepsis (2) and osteomyelitis (1). Five children had traditional risk factors: indwelling catheter (3), recent hospitalisations/surgery (2), previous antibiotic use (2) and immunodeficiency (1). All received medical treatment (b-lactam in 7) and surgical drainage was performed in 6. The outcome was good in all. Resistances were: 56% to macrolides, 50% to aminoglycosides, 12,5% to cotrimoxazole and 5,5% to clindamycin. All were susceptible to vancomycin. Isolates were not typed.

Conclusion: The increased incidence of CA-MRSA referred in many countries was not found in our institution over the last 11 years. Some MRSA may still be healthcare associated making the number of community associated MRSA lower. Skin/soft tissue infections were the most frequently found and some children who received inactive antimicrobial therapy had outcomes similar to those who were treated with antimicriobial agents to which the organism was susceptible.

P069

MENINGOCOCCAL PURPURA FULMINANS: HYPOCALCEMIA A RISK PROGNOSTIC FACTOR

E. Mallet,* F. Dumas,† T. Blanc,‡ A.-M. Devaux,‡ and P. Ensel,‡ *Paediatrics; †Pediatrics, CIC INSERM 204, Rouen University Hospital; and ‡Pediatric Intensive Care Unit, Rouen University Hospital, Rouen, France.

Abstract: Despite progress in patient management, purpura fulminans remains a severe disease, and risk prognostic factors have been described by many authors. Our group has extensively researched hypocalcemia because cardiovascular consequences demonstrated in animal modes, point to immunoreactive hypocalcitoninema (E. Mallet, Lancet 1983) which was later found to be procalcitonin.

Aim: We attempted to access hypocalcemia as a prognostic factor and were prompted to conduct a retrospective local series (25 year period) on purpura fulminans, prior to current hyperendemia.

Main Results: 75 cases were collected (44 boys and 31 girls) aged from 1 month to 15 years. Most cases occurred between 6 months and 4 years (53 children ie 70% less than 4 years) with a peak between 1 and 2 years (18 children ie 25%), bacteria was identified 50 times out of 75, with 39 meningococcus B, 10 C, 6 unidentified. 18 deaths occurred and 11 severe sequelae (2 cutaneous, 2 neurological, 1 renal; 1 combination neurological and renal). Hypocalcemia occurred in 53% of cases (<2.2 mM/l) with rates falling to 1.56 mM/l. Multivariate analysis using logistic regression showed 4 variables very significantly involved in our series regarding lethal issue: well known as the presence on DIVC P 4.10−2, rapid evolution of purpura and kaliemia P 3.10−3, and the new factor hypocalcemia (calcemia or adjusted calcemia) P 3.10−2.

Conclusions: This hypocalcemia, previously reported by one author (Baines) may be added to the prognostic risk factors for purpura fulminans. Nevertheless etiology and consequences warrant further research.

P070

STAPHYLOCOCCAL SCALDED-SKIN SYNDROME IN A 2-YEAR OLD CHILD

I. Mammas, M. Koussouri, E. Mantziou, and N. Myriokefalitakis, 1st Paediatric Department, ‘Penteli’ Children's Hospital, Athens, Greece.

Background and Aims: Staphylococcal scalded-skin syndrome (SSSS) is a toxin-mediated condition occurring in neonates and young children, which is characterized by blistering and superficial desquamation of the skin. SSSS is caused by two staphylococcal exfoliative toxins (ETA and ETB) produced by Staphylococcus aureus, which split the granular cell layer of the skin. It is usually diagnosed by its characteristic exfoliating rash, however diagnostic dilemmas can cause delay in the treatment of children with SSSS. Early diagnosis and treatment with parenterally administered beta-lactamase resistant penicillins are important to prevent life threatening complications of SSSS.

Methods: In this report we present a case of suspected child abuse, later diagnosed as SSSS.

Results: A 2-year old girl was referred to hospital with perioral erythematous rash. She had coryzal symptoms with rhinitis and malaise. On examination three small round ulcerations on her sternum resembling cigarette burns were noted and hospitalization was decided. On the 2nd day of her admission, perioral exfoliation and new bullous lesions on her trunk, nose and right arm were observed. The bullae were tender with positive Nikolsky sign and they could rupture easily revealing a moist erythematous base. No mouth or anal mucosa was involved. Infection control measures were implemented instantly including isolation of the infected child. The desquamation ceased 3 days after the initiation of antibiotic therapy and the skin lesions resolved within 10 days.

Conclusions: This case reflects the importance of clinical observation during hospitalization in the early diagnosis of SSSS, so appropriate treatment can be initiated.

P071

BACTEREMIC VS NON-BACTEREMIC PNEUMONIA IN CHILDREN

E. Mel,* G. Livni,* Z. Samra,†‡ and S. Ashkenazi,*‡ *Pediatric A, Schneider's Childrens Medical Center Israel, †Clinical Microbiology, Rabin Medical Center, Petah Tikva; and ‡Felsenstein Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background and Aims: In order to enhance current knowledge of community-acquired bacteremic pneumonia in children, its characteristics were elucidated and compared to non-bacteremic pneumonia.

Materials and Methods: A 7-year (2000–2006) retrospective evaluation of the clinical and laboratory features of all children hospitalized with bacteremic pneumonia in a tertiary pediatric center. These were matched to 27 children hospitalized for pneumonia without bacteremia.

Results: Of 6653 children hospitalized with pneumonia, 57 (0.8%) had proven bacteremia. The causative bacteria were: S. pnuemoniae – 44 (77%), non-typable H. influenzae – 6 (10.5%), S. aureus – 3 (5.3%), Streptococcus group A – 2 (3.5%), Psuedomonas Spp and Klebsiella pneumoniae – 1 (1.8%) each. In the 5 cases of aspiration pneumonia, the causes of bacteremia were S. pneumoniae (2), H. influenzae (2) and S. aureus (1). The median age was 2 years with a male predominance. There was no mortality. As compared to children with non-bacteremic pneumonia, bacteremic children required hospitalization in pediatric intensive unit more often, had a longer hospitalization, higher white blood cell count and higher C-reactive protein, and higher rates of hyponatremia and hypoalbuminemia.

Conclusions: Children with bacteremic pneumonia present a more severe clinical course, and higher rates of laboratory abnormalities as compared to children with non-bacteremic pneumonia.

P072

THE RISK OF SERIOUS NOSOCOMIAL INFECTION BY STAPHYLOCOCCUS

S. Micheal, Hospital Infection Control, The Org. of Teaching Hospitals, Inestetute, Alexandria, Egypt.

Objectives: A study was done at Damanhour Teaching Hospital (1300 Bed) to evaluate handwash practice among medical staff using staph. Aureus presence or absence as a serious measure for infection control.

Patients and Methods: 56 of hospital physicians and nurses from Haemodialysis unit and from Heamatemesis unit were subjecteal to a questionaire about hand washing and Infection control also tests for the presence of staph. aureus in their hand flora swabs culture directly after handwashing before and after patients contact.

Conclusion & Recommendation: The study showed knowledge about the mode of viral B & C hepatitis transmission between physicians 70% while nurses 21%. The percentage of vaccinated staff against HBV infection was very bad 36% of physicians & 47% nurses. Usage of gloves & masks and goggles during contract with patients was very low, this was explained by pressure of work Bad system of medical waste disposal (needles. Syrings & Scaples …) was discovered in the questionaire.

There was a very high rate of positive staphylococcus Aureus hands swabs cultures from hands of physicians & nurses (50% in Heamodialysis unit & 75% in Haematemesis unit. Which have alarm about the high risk of severe nosocomial infections development in the future.

Educational programs along with training courses on infection control and proper handwashing already have been started in the hospital by the author.

P073

THE OUTCOME OF BACTERIAL MENINGITIS IN CHILDREN

S. Namani, Clinic of Infectious Diseases, UHCK, Prishtine, American Samoa.

Background: Bacterial meningitis (BM) is an emergent disease which even if early treated has a high mortality rate and neurologic complications (NC).

Patients and Method: Over a period of six years we have analyzed the outcome of BM in 277 children treated in Hospital of Infectious Diseases in Prishtina.

Results: From 277 children with BM, NC occurred in 21,7% of cases while from 63 adults NC occured in17,5% of cases (P > 0,005). The overall mortality rate was much higher in adults (M = 19%) comparing with children (M = 5,4%) (P > 0,001). The outcome of BM was the worsest for the youngest group-ages (the highiest mortality rate in neonates and the highiest rate of NC in children in first year of life) (P < 0.001). We didn't find significant difference in frequency of NC and mortality rate occording to gender and between children who came from rural places (NC = 22,4%, M = 5,6%) and children from urban places (NC = 20,7%, M = 5,2%) (P > 0,005). The outcome of BM in children was unfavorable for cases admitted after 3 days of illness (P < 0,001), for cases previously hospitalized (NC = 25,3%, M = 11,5%) and treated with antibiotics (NC = 26%, M = 10%), in cases with primary focus (NC = 24,7%, M = 5,7%), in cases caused by pathogen agents resistant to antibiotics(NC = 50%, M = 16,7%), in unconfirmed cases(M = 7,8%) and in hospital acquired infection(M = 15%). Factors that mostly influenced the worst outcome of BM in children were: presentation of severe clinical forms on admission (NC = 26,9%, M = 16,1%), alteration of mental state (NC = 31,2, M = 10,6%), presentation of neurologic deficit on admission (NC = 52,3%, M = 18,2%), presentation of seizures before admission (NC = 68,7%, M = 14,6%) and after admission (NC = 75,6%, M = 24,4%), presentation of purulent thick CSF (thick pus in 40% of death cases).

P074

OCCULT BACTEREMIA—A 3 YEAR REVIEW ON THE ADMISSIONS OF CHILDREN WITH FEVER WITHOUT FOCUS CONSIDERED AT RISK

A. Nicolau, R. Morais, S. Lima, and P. Flores, Pediatria, Hospital S. Francisco Xavier, Lisbon, Portugal.

Background and Aims: Currently, occult bacteremia (OB) has become a rare event and with better outcome due to vaccination against its most frequent and lethal agents. In Portugal, vaccination against Group b H. influenzae and Group C Meningococcus has become universal since 1996 and 2006 respectively. Heptavalent-Conjugated Pneumococcal Vaccine (PCV7) has been available since 2001 for private purchase only, still there’s a coverage of over 60%.

We aimed to identify the OB rate in children admitted to our hospital with fever without focus for being considered at high risk due to age or clinical appearance, and attempt to characterize the group in terms of its clinical and laboratorial profile.

Methods: A retrospective review of clinical files of children admitted with fever without focus for up to 7 days and 0–5 years old from 2005 to 2007.

Results: We found 53 cases. There was documented bacteremia in 6 of them (11,5%). 4 had incomplete vaccination (<3 months old). One had complete PCV7. All had symptoms for less than a day. 5 were considered ill appearing. Laboratory values, in the group, had no significant changes. Group B Streptococcus (GBS) was isolated in 2/4 below 3 months old. In those 3–36 months old (2), the agents were Pneumococcus and Meningococcus. 2 had meningitis (GBS and Meningococcus).

Conclusions: Clinical appearance and duration of fever were the only predictors of OB. GBS was an important agent up to 3 months old. In those 3–36 months, the agents encountered were those described in the literature.

P075

PNEUMONIA IN CHILDREN OVER THAN 3 YR.-ETIOLOGY, ANTIBIOTIC SENSITIVENESS, TREATMENT AND DRUGS HYPERSENSITIVITY REACTIONS

L. Nikolova, Dep. for Acute Respiratory Diseases in Children, Institute for Respiratory Diseases in Children-Kozle, Skopje, FYR Macedonia.

Abstract: The aim of this study was to analyze etiology, antibiotic sensitiveness and treatment of pneumonia in children over 3 years old, as well as drugs hypersensitivity reactions.

Material and Method: In the period 2006–2008 yr. 750 children at the age 3–16 yr. were treated in our Department for acute respiratory diseases with pneumonia. Diagnosis were made by means of clinical picture, some biological parameters, chest x-ray findings and microbiological investigations.

Results: Before hospitaliziation 91% of the patients were treated with antibiotics. 89% of them have had anamnestic data for cough, 67%–fever and 9%–drugs hypersensitivity reactions. Chest x-ray showed consolidations in 51%. Etiologic agents were investigated in 85% of the patients and a positive identification was made in 32% of them. The most commonly isolated bacteria Streptococcus pneumoniae- 48%, Haempohilus influenzae- 34%, and Moraxella catarrhalis -9%. Analyze of antibiotic sensitiveness confirmed that S. penumoniae was sensitive on Penicillin–91% and Ampicillin–86%. H. influenzae was sensitive on Penicillin–72% and Ampicillin 76%. M.catarrhalis was sensitive on Penicillin–69% and Ampicillin–84%. Isolated bacterial agents showed sensitivity on Amoxycillin- clavon acid in above 96% and Cephalosporines(III generations) in above 99%. The treatment consisted of antibiotics, parenteral hydration and respiratory physiotherapy. Cephalosporins applied as initial treatment in 51%, ampicillin in 30% and macrolides in 15%. Drugs hypersensitvity reactions confirmed in 4.0%. (ampicillin-2%, cephalosporins and macrolides-1%).

Conclusion: Pneumonia constitute a major health problem in our country and very often there are diagnostic and therapeutic problem (particulary if the children have drugs hypersensitivity reactions).

P076

BACTERIAL MENINGAISIS INFECTION IN KENYA

G. Nyabade, Counseling, Go Fishnet Youth Project, Kisumu, Kenya.

Objective: Kenyan village children are casualties to bacterial meningaitis. Early diagnosis and appropriate antibiotic treatment are perhaps the most important initiatives towards eradication of this great pendamic and its management in Kenyas rural villages. Though published datas suggest that fewer than half of the cases of childhood meningitis are identified at first assessment in hospitals in this region. The objective of this study indicates and brings to awareness that bacterial meningaitis kills many children from poor and desperate Kenyan villages without access to hospitals or clinics.

Methods: Nyando Sub District Hospital, serving 300 000 people in a rural, malaria-pendemic area of the Western Kenyan, was studied. A Kenya Medical Research Institute research center is located at Kisian near Kisumu city. All pediatric admissions aged 60 days between June 2001 and July 2002 were eligible.

Results: A total of 91 (2.0%) of 4582 admissions had meningitis, including 77 (4.0%) of 1929 of those who met the IMCI referral criteria for meningitis at admission. Independent indicators of the presence of meningitis were a bulging fontanel, neck stiffness, cyanosis, impaired consciousness, partial seizures, and seizures outside the febrile convulsions age range.

Conclusions: The presence of 1 of a bulging fontanel, neck stiffness, cyanosis, impaired consciousness, partial seizures, and seizures outside the febrile convulsions age range is a clear indication for lumbar puncture and/or presumptive treatment.

Keywords: Meningitis, Kenya, sub-Saharan, rural.

P077

INVASIVE E.COLI SEPTICAEMIA COMPLICATED BY ACUTE HEPATIC FAILURE AND HAEMOLYTIC UREMIC SYNDROME IN A FOURTEEN YEAR OLD MALE

E.U. Onyekwelu, Paediatrics, Royal Victoria Teaching Hospital, Banjul, The Gambia.

Background/Purpose: Some cases of E.coli septicaemia in neonates,infants and younger children are complicated by HUS. This complication is uncommon in adolescents from developing countries, except those in septic shock, mortality and multiple organ failures are usually higher in this age group. The pathogenesis of AHF in E.coli septicaemia is from dysfunction following hepatitis, kupffer cell hyperplasia which causes poor biliary excretion/free radical scavenging role/hepato-renal syndrome. Gram negative endotoxaemia sustains the vicious cycle of DIC, complement activation/kinin liberation/ renovascular spasms, anoxia, leaky capillaries/hypotension associated with HUS. A case where a good outcome was achieved by a timely intervention is described.

Case/Intervention: A fourteen year old child was admitted with a six days history of fever, vomiting dysentery, abdominal pains, oliguria and epistaxis. He was icteric, acutely ill looking, lethargic, pale and febrile. He had no features of chronic liver or renal dysfunction. He had no significant lymphadenopathy. He had a significant hepatomegaly without other visceromegaly. His urinalysis was significant for bilirubinuria, proteinuria,haemoglobinuria and erythrocyturia. He was severly anaemic at 4.4 g/dl, leucocytotic at 14.1 × 10 6, thrombocytotic at 50 × 10 9, hyperlactinaemic at 12 mmol/l. He had a significantly deranged hepatic and renal function indexes. He had no Hepatitis B antigaenaemia or malaria parasitaemia. Hepatomegaly/nephromegaly were demonstrated at USS. The blood/urine/stool cultures were positive for O157 H E.coli. Timely intervention with renal replacement therapy, antimicrobial therapy and transfusion lead to rapid complete laboratory/clinical recovery.

Conclusion/Importance: ARF in HUS following septicaemia in older children has a high mortality rate, experimental models showing renal injury well before deranged biochemistry, cystatin an earlier indicator of ARF will identify cases which will benefit from prophylactic interventions with fenoldapam a nephroprotector thereby precluding invasive interventions and progression to chronic renal failure/transplantation and sudden death.

P078

MASSIVE COMPOSITE ASCITES DUE TO CRYPTOGENIC CIRRHOSIS AND OCCULT MYCOBACTERIUM TUBERCULOSIS INFECTION IN A 13 YEAR OLD GIRL

E. Onyekwelu, Paediatrics, Royal Victoria Teaching Hospital, Banjul, The Gambia.

Background & Purpose: In most cases of ascites, basic evaluation is usually adequate for achieving a diagnosis, however this may not be applicable in cases of composite and diverse aetiologies. In such cases a methodological diagnostic approach will be rewarding. Infective causes should always be considered in children living between the Tropics of cancer and capricorn. A case where a diagnosis was achieved with this technique is described.

Case & Intervention: A 13 year old girl came to the ED with a 5 months history of fever, a 3 months history of abdominal swelling, respiratory difficulty and yellow eyes. Her history was significant for occasional coughs, ingestion of raw cow's milk, herbs, but not for TB contact, transfusion or any individual /familial ill health. She was pale, mildly icteric with pedal oedema. She was afebrile, acyanosed, had no clubbing or adenopathy. She had a massive ascites,cirrhosis, portal hypertension, normal ovaries at USS. CT revealed loculated, encysted, septated ascitic fluid. The serum albumin& liver enzymes values were normal. Her SAAG was < 1.1 and her ascitic fluid was positive for MTB. Intervention: Anti-TB drugs, diuretics, multivitamins and follow up.

Conclusion & Importance: The aetio-pathogenesis of ascites in cirrhosis has been reviewed. Portal hypertension definable by a hepatofugal flow at USS has been implicated. The diagnosis of Paediatric TB has always been debatable and ambigous. A high index of suspicion in the appropriate clinical setting and and the application of well selected investigations was invaluable in achieving a timely diagnosis. The use of methodological approach in the study of complex cases is highlighted.

P079

A METHODOLOGICAL STUDY OF CASES OF CLINICAL TETANUS AND THE IMPACT OF MODERATED SEDATION AND BETA BLOCKAGE ON THEIR OUTCOME

E. Onyekwelu, Paediatrics, Royal Victoria Teaching Hospital, Banjul, The Gambia.

Background/Purpose: The management of paediatric clinical tetanus is critical, given its high mortality rates at 20–58%. Application of a sedative, anxiolytic, muscle relaxant, anticonvulsant and nursing care is imperative. However, overenthusiastic sedation leads to respiratory depression/death whereas inadequate sedation contributes to ventricular arrhythmias due to spasms of cardiac muscles, and sympathetic dysautonaemia which could lead to hypertension/ tachycardia/ hypotension. Therefore, sequential moderated sedation/ beta blockade will be a logical management strategy; a series where this regimen was used to achieve an utmost outcome is described A prospective review of cases of clinical tetanus managed in the ED/ PICU from September 1999 to September 2008 is described.

Cases/Interventions: 47 cases, 31 males, 16 females aged below 15 years. The mean duration of hospitalization was 7.1 days. The immunization status was indeterminate in most cases. Lower limbs injuries 64.85%, unhygienic circumcisions 21.73%, ear piercing/ infections/ scarifications/ tattooing 13.42%. The 3.86% mortality figure was associated with late presentations/ bad prognostic factors. Interventions: Diazepam/ chlorpromazine or phenobarbitone, Tetanus Immunoglobulin/ toxoid, antibiotics, vitamin A/ standard nursing care. Interestingly most severe cases needing aggressive interventions were not lost. Surviving the first 96 hours was usually followed by a complete recovery without sequelae.

Conclusion/Importance: Good intensive care during the early periods of hospitalization reduced mortality significantly. Survivors have no sequalae; intensive care had a good cost benefit ratio. In comparison, a relatively moderated sequential sedation strategy applied in these series improved the mortality figures considerably. The role of reimmunisation of children to maintain protective antibody levels/adequate care of accidental, incidental/coincidental wounds is re-emphasized.

P080

THE APPLICATION OF ULTRASONIC ECHOGRAPHIC AND ROENTEGENOGRAPHIC FEATURES IN THE DIAGNOSIS OF PAEDIATRIC PULMONARY AND EXTRAPULMONARY TUBERCULOSIS AND ITS COMPLICATIONS

E.U. Onyekwelu, Royal Victoria Teaching Hospital, Banjul, The Gambia.

Background/Importance: Paediatric TB implying cases below the age of 5 is common and of public health importance by providing evidence of ongoing transmission. Anecdotal evidence intimates that these group are not infectious because they lack cavitary lesions,however recent investigations casted doubts on this hypothesis. Even with the novel diagnostic aids, the distinction of active Paediatric TB from Latent TB still remains challenging in most settings, being based mainly on opinions/results of chest x-rays interpreted in a standardized way by referenced ID Paediatricians/Roentgenologists in appropriate clinical settings.

The Spectra of Radiologic features associated with possible/ probable/definite PaediatricTB is itemised.

Clinical/Imaging Details: USS/CXRs of 29 children below 5 were reviewed,22 males, 17 females. Imaging was undertaken, evaluated, interpreted/ reported in a standardized manner by Roentgenologist/ Paediatrician, contact history 11, abdominal tumefaction 9, hepatomegaly 7, splenomegaly 9, lymphadenopathy 7, Icterus with deranged LFTS 3 TST positivity 5.

Radiologic Features: pPrihilar opacities 21. Right apical opacities 5, Miliary mottling 3, liquefying consolidations 3, bilateral patchy infiltrates 8, Hydrocephalus 1, left lobar consolidation 2, Unilateral para pneumonic effusions 3. mediastinal widening 17,atelectasis 1, hydropneumothorax 1, On AbdominalUSS, peri-hepatic, mesenteric lymphadenopathy 4, Transthoracic USS complemented X-rays for the demonstration of aerodynamically/haemodynamically/rheologically significant pleural effusions and for the elucidation of the pleural fluid micro anatomical environment, consistency, loculations septations / encystments which directed approach at diagnostic/therapeutic thoracocentesis. There were no cavitory lesions.

Conclusion/Importance: Although the diagnosis of Paediatric TB remains ambiguous, enigmatic and debatable especially in resource restricted settings, a methodologic approach to its investigation by well referenced teams could rapidly achieve a diagnosis /management by clarifying indeterminate and enigmatic cases.

P081

PURPURA AND ABDOMINAL ADENOPHATY BY BARTONELLA HENSELAE INFECTION

E. Palumbo, L. Gori, G. Boscarelli, C. Biondi, S. Giacoma, M. Branchi, and G. Pellegrini, Department of Pediatric, Hospital of Sondrio, Sondrio, Italy.

Abstract: We present two atypical cases of infection by Bartonella Henselae.

1) A seven year old child presented with an extensive purpura over his limbs and trunk, a spleen palpable 2 cm below the costal margin and cervical lymphoadenopaty. Laboratory test revealed a leukocyte count of 7.9 × 109 per liter, with 0.28 neutrophilis, 0.67 lymphocytes. The haemoglobin level was normal and platelet count was 6 × 109 per liter. PT, aPTT, RSV, RCP were normal. Chest roentgenogram and abdominal ultrasound examination were unremarkable, while neck ultrasound examination evidenced a diffuse cervical lymphoadenopaty with reactive characteristics. Treatment with intravenous gamma-globulin 1 g/Kg/die was prolonged for two days. After 48 hours the platelet count was 69 × 109 per liter and on day seven the count was 222 × 109 per liter with a total regression of purpura IgG antibodies to Bartonella henselae was performed using an indirect immunofluorescence assay and resulted positive (1: 2348, >128). Treatment with clarithromycin (15 mg/Kg/die) was prolonged for 14 days, obtained the regression of lymphadenopaty.

2) A fifteen year old child presented with a five days history of fever and abdominal pain, without superficial lymphoadenopaty. She presented a spleen palpable 1 cm below the costal margin. Laboratory test revealed a leukocyte count of 11.9 × 109 per liter, 0.25 neutrophilis, 0.64 lymphocytes. RCP was 303 IU/L (<5). Abdominal ultrasound examination evidenced a diffuse lymphoadenopaty with reactive characteristics and two ipoecogen lesions in the spleen. IgG antibodies to Bartonella henselae resulted positive (1:4600). Clarithromycin-therapy (15 mg/Kg/die) was prolonged for 21 days, obtained the normalization of ultrasound examination.

P082

STAPHYLOCOCCUS AUREUS NASAL CARRIAGE AND VITAMIN D RECEPTOR POLYMORPHISMS IN INDIVIDUALS WITH TYPE 1 DIABETES

C. Panierakis,* G. Goulielmos,† D. Mamoulakis,* S. Maraki,‡ E. Papavasiliou,§ and E. Galanakis,* *Department of Paediatrics, †Laboratory of Internal Medicine; ‡Laboratory of Microbiology; and §Department of Endocrinology, University of Crete, Heraklion, Greece.

Background: Polymorphisms in the vitamin D receptor (VDR) gene have been associated with susceptibility to several infections. The purpose of this study was to investigate whether polymorphisms in the VDR gene may influence nasal carriage of Staphylococcus aureus in individuals with T1D.

Methods: VDR polymorphisms FokI F>f, BsmI B>b, ApaI A > a, and TaqI T > t were determined and nasal swab was obtained to detect colonization of S aureus in 93 T1D patients. A repeat nasal swab was obtained in 76/93 individuals for estimation of persistent S aureus carriage.

Results: S aureus nasal colonization was observed in 31% and persistent carriage in 25%. TaqI T allele was related to S aureus colonization more than TaqI t (37.0% vs 20.9%; P 0.016; OR 2.22, 95% CI 1.11 to 4.46) as was to persistent S aureus carriage (29.3% vs 17.0%; P 0.068; OR 2.02, 95% CI 0.88 to 4.68). ApaI a allele was related to S aureus colonization more than A (38.5% vs 27.2%; P 0.081; OR 1.67, 95% CI 0.88–3.16). No differences were observed for BsmI and FokI genotypes.

Conclusion: VDR polymorphisms may be associated with nasal carriage of S aureus in individuals with T1D.

P083

STAPHYLOCOCCUS AUREUS COLONIZATION IN CHILDREN AFFECTED BY ATOPIC DERMATITIS

C. Pascolini, B. Capitanio, G. Prignano, M.T. Gallo, L. Cilli, A. De Santis, F. Anastasia, M. Vespaziani, V. Bordignon, E. Greco, and F. Ensoli, IFO-IRCCS San Gallicano, Roma, Italy.

Background and Aims: Atopic dermatitis is a chronic inflammatory skin disease associated with colonization of the skin with Staphylococcus aureus known to produce toxins with superantigen activity. In this study we determined the prevalence of S. aureus and MRSA in the lesional and nonlesional skin, and in the anterior vestibule of the nose in children with atopic dermatitis. We also examined the relationship between S. aureus skin lesion and nasal colonization, the production of toxins and the presence of nasal colonization in patient's cohabitants.

Methods: Nasal and skin (lesional and nonlesional) swabs cultures for bacterial isolation were obtained from 94 children affected by atopic dermatitis. Nasal swabs were taken from 15 patients’ cohabitants. S. aureus strains were tested for detecting the toxins SEA, SEB, SEC, SED, EXT and TSST-1.

Results: In the lesional skin we found 36% prevalence of S.aureus, in the same group of patients the nasal colonization was 94,4%. The presence of MRSA was 7% in the lesional skin and 3% in the nose. 65% of S. aureus strains isolated from patients releases toxins. We observed that all positive patients to S. aureus had at least one positive cohabitant and that the presence and the kind of toxins in strains isolated coincide to 100%.

Conclusion: This data focus the importance of the nasal carriage as risk factor for the development of skin lesions in atopic dermatitis patients and indicates that in the current diagnostic practice is appropriate to include the research of S. aureus in the patient's cohabitants.

P084

DIAGNOSTIC MARKERS FOR IDENTIFYING SEPSIS IN PATIENTS WITH SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS)

J. Pavare, I. Grope, and D. Gardovska, Chair of Pediatrics, Riga Stradins University, Riga, Latvia.

Background and Aims: Sepsis caused by infection remains a major cause of mortality and morbidity among children. According to available evidence the measurements of combinations of biochemical markers offer the best prospects for early diagnosis of sepsis. The aim of this study was investigate the value of measuring changes in C reactive protein (CRP), procalcitonin (PCT), interleukin 6 (IL6) and lipopolysaccharide-binding protein (LBP) for the early diagnosis of sepsis in SIRS patients.

Methods: Children with SIRS (n = 52) treated in the Children's Clinical University Hospital were enrolled in prospective study. At time 0 and at the 24th and 48th hours of the study inflammatory markers were evaluated.

Results: Sepsis was recognized in 21% of the SIRS patients. The difference in PCT levels between the sepsis and SIRS patients was statistically significant (P < 0.05). In SIRS patients at time 0 the mean IL6 level was 51.3 ± 137.2 pg/ml and the mean LBP level was 29.21 ± 36.2 μg/ml, which was significantly less than mean values of IL6 and LBP for sepsis patients (accordingly 476.68 ± 955.1 pg/ml and 46.15 ± 27.4 μg/m). The mean level of CRP at time 0 was 136.7 ± 89.7 μg/ml in sepsis patients which significantly different (P < 0.05) from the mean level in the SIRS patients (58.8 ± 56.8 μg/ml).

Conclusions: The levels of CRP, PCT, IL 6, LBP differed significantly in SIRS and sepsis patients. Those inflammatory indicators could be used to identify sepsis patients and particular attention should be paid to SIRS patients with elevated levels of above-mentioned inflammatory indicators.

P085

INTERACTIONS BETWEEN STREPTOCOCCUS PNEUMONIAE AND MORAXELLA CATARRHALIS IN AN IN VITRO MODEL OF NASAL COLONISATION

L. Peto,* D.J. Hil,* N.J. Griffiths,* and A. Finn; * Department of Cellular and Molecular Medicine, University of Bristol, School of Medical Sciences, Bristol, UK; and †Institute of Child Life and Health, Department of Clinical Sciences at South Bristol, University of Bristol, Bristol, UK.

Background and Aims: Both Streptococcus pneumoniae and Moraxella catarrhalis have the ability to elaborate a range of pathologies from their common niche in the nasopharynx. Synergistic or antagonistic interplay between these bacteria has the potential to influence both colonisation and pathogenesis. This study aims to investigate the effect of pneumococcal components on the subsequent adhesion of M. catarrhalis using an in vitro model of nasal co-colonisation.

Methods: Detroit 562 cells were incubated with filtered culture supernatant from encapsulated pneumococci (D39) (or culture medium as a control) for 24 hours. Two different M. catarrhalis strains, MX2 (high adherence) or A2 (low adherence) were subsequently added to the cells for 1 hour. Non-adherent bacteria were removed by washing and adherent bacteria labeled for immunofluorescence microscopy using appropriate antibodies. Samples were blinded and bacterial adherence quantified by counting.

Results: Prior pneumococcal stimulus increased subsequent adhesion of the MX2 M. catarrhalis by 2.55 times compared with controls (P < 0.001), but did not significantly affect adhesion with the A2 strain.

Conclusions: Prior incubation with pneumococcal proteins increased adherence of M. catarrhalis to pharyngeal cells via a mechanism that is currently unknown, but may act via adhesins expressed by MX2 and not by A2. This synergistic interaction may explain the increased co-occurrence of these organisms that has been reported in some epidemiological studies of acute otitis media. Future experiments will explore the role of specific pneumococcal antigens and validate the findings using primary respiratory epithelial cells in culture.

P086

STREPTOCOCCUS VIRIDANS INVASIVE INFECTIONS IN A PEDIATRIC POPULATION

J. Pierart,* P. Smeesters,*† A. Lossius,‡ Y. Miendje,§ P. Lepage,* and A. Vergison,* *Pediatric Infectious Disease Department; †Bacterial Genetics and Physiology Laboratory; ‡Université Libre de Bruxelles; and §Microbiology Department, Brugmann University Hospital, Brussel, Belgium.

Background and Aims: Streptococcus viridans (SV) is a heterogeneous group of facultative anaerobic a hemolytic streptococci found as a normal mouth commensal. SV growing in blood cultures are often considered as contaminants. However this pathogen may rarely cause invasive infection in non immunocompromised paediatric patients.

Methods: Retrospective review of cases of SV recovered from January 2006 to January 2009. Cases were identified by laboratory records, retrieving all SV isolated from a normally sterile site from children aged 0 to 17 years, admitted in our 170-bed paediatric teaching hospital. Contamination was defined as a single positive sample in a child which had otherwise not been treated for SV infection. SV cultured in blood from patients with malignant disease and in peritoneal fluid collected during appendicectomy were excluded.

Results: 115 children were identified. For 105, culture was contaminated. 3 patients presented non complicated abscesses (1 subcutaneous, 1 retropharyngeal and 1 retrotonsillar). 7 children previously healthy or with mild co-morbidities had a severe invasive infection: 1 endocarditis, 1 osteomyelitis (two focus), 1 mediastinitis, 1 catheter related septicaemia and 3 surgically treated empyema. Antibiotic resistances were noted in 3 cases. Some SV strains were sent for speciation by 16S rRNA sequencing, 3 were already identified as S. anginosus.

Conclusions: SV invasive infections in our pediatric population are rare and can occur in healthy children. Identification of SV with conventional microbiology tests is difficult and molecular technique can be used to identify species. Finally, antibiotic resistances observed should lead to improve the use of antibiotics.

P087

EXTRACRANIAL FRONTOORBITAL ABSCESS WITH SYSTEMIC INVOLVEMENT ASSOCIATED WITH BARTONELLA HENSELAE INFECTION

A.I. Piqueras,* M. Otero,* B. Orive,† L. Fernandez,* D. Pérez-Tamarit,* and F. Asensi,* *Unit of Infectious Diseases, Hospital Infantil La Fe, Valencia; and †Hospital Txagorritxu, Vitoria, Spain.

Abstract: Systemic infections caused by Bartonella henselae are very rare and most of cases are found in immunocompromised patients. We report a case of a 11/2-year-old girl admitted to the hospital with a supraciliar mass. Two months earlier she presented fever of unknown origin (FUO) for two weeks receiving various antibiotics without clinical improvement. An interciliar abscess appeared which was drained surgically. Afterwards, another mass in the right frontal supraciliar area developed. On arrival, physical exam showed a fluctuant, not painful supraciliar mass (4 cm), with enhanced osseous rim. No swelling of lymph nodes noted. Close contact with cats was denied. She was afebrile and blood tests, including CRP were normal. Serology for Leishmania, Borrelia, Coxiella, B. quintana and Rickettsia were negative. The mass was drained of purulent fluid. Cultures for aerobic, anaerobic and mycobacterias were negative. Immunodeficiency was excluded (lymphocyte subpopulations analysis and granulocyte function test were normal). Malignancy was excluded. Cranial CT scan showed a cystic lesion of the extracranial soft tissue in the right frontoorbital area with irregularity and thickness of the underlying parietal bone and hyperechoic areas surrounded by a thin rim highly echogenic. Chest X-ray showed areas of calcification in mediastinum. Abdominal ultrasound showed multiple echogenic areas in spleen, pancreas and liver. Anti B. henselae antibodies was detected (IgG titre 1:256 in IFA). The diagnosis of B. henselae abscess with systemic involvement was made. The girl was treated successfully with clarithromycin for 8 weeks. B. henselae infection should be considered in the initial evaluation of FUO.

P088

INFECTIOUS INCIDENCE IN CHILD BURNS

M.C. Popoiu,* E.S. Boia,* R. Ilie,† A. Popoiu,* C. Ilie,* and O. Marginean,* *Pediatric, University of Medicine and Pharmacy ‘Victor Babes’ Timisoara; and †Pathology, Emergency Children Hospital, Timisoara, Romania.

Background: Burnt wounds present high risk of infection. Despite significant advances in the treatment, sepsis remains the major cause of the morbidity.

Aims: We intend to establish the infectious incidence in burnt wounds, locally treated with Silversufadiazine and conventional antibiotherapy.

Methods: We evaluated 35 children–22 male and 13 female–admitted in ICU Department of Pediatric Surgery, between 2005 and 2008. We studied the thickness of lesions and the bacteriological status affecting the burnt wounds.

Results: To an amount of 30 patients (85,7%), the lesions were partial thickness. For the others, we obtained the following bacteriological datas:v 4 patients with Gram +; v 11 patients with Gram–(3 with Pseudomonas Aeruginosa);v 3 patients had Gram + and Gram -; v to 6 patients we discovered fungal infection;v sepsis was encountered in 10 patients; septic shock appeared in 8 patients. Mortality was 5, 43% (2 patients).

Conclusions: Even with correct local therapy, infectious incidence in pediatric burns remains important. Pseudomonas Aeruginosa represent nosocomial infection (8,57%). Burn lesions requires supplementary surgical measures in order to limit the damage produced by bacteria and fungus.

P089

USE OF SEROSURVEYS TO REFLECT EPIDEMIOLOGICAL CYCLES OF BORDETELLA PERTUSSIS INFECTION

M. Riffelmann, and C.H. Wirsing von Koenig, Institut fuer Hygiene und Labormedizin, HELIOS Klinikum Krefeld, Krefeld, Germany.

Background: Large serosurveys in the EU (ESEN) and in the US (NHANES) have established reliable data about the overall distribution of anti-pertussis toxin (PT) antibodies in the population. We tried to detect, whether small serosurveys would detect epidemiological cycles in the circulation of B.pertussis that occur every 3–4 years.

Methods: Adult plasma and blood donors aged between 18 and 60 years were screened for IgG-anti-PT by a standardized ELISA method using the CBER/FDA reference serum. A value of ≥100 EU/ml was regarded as indicative for a recent contact to B.pertussis antigens. Nasopharyngeal swabs received from children (<16 years) with suspected pertussis from a similar catchment area were tested for Bordetella-DNA by real-time PCR amplyfing the IS 481 of B.pertussis and the IS 1001 for B.parapertussis.

Results: In 2002, 600 donors were screened and 4 had an IgG-PT of ≥100 EU/ml (0.7%), and a total of 306 swabs were tested from which 12 were positive for Bordetella-DNA (3.9%). In 2003, a total of 1,500 plasma donors were tested and 6 of them had an IgG-PT of ≥100 EU/ml (0.4%). In the same year 330 swabs yielded 15 positive results (4.5%). In 2005, a total of 2,000 plasma donors were tested and 70 of them had an IgG-PT of ≥100 EU/ml (3.5%). In that year, from a total of 470 swabs 161 were positive for Bordetella-DNA (34.2%), indicating an epidemiological cycle.

P090

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS ISOLATES IN A TERTIARY SPANISH CHILDREN’S HOSPITAL: CLINICAL AND MICROBIOLOGIC EVALUATION

M. Santos-Sebastián, F. Gonzalez-Martinez, M.L. Navarro-Gomez, J. Huerta-Aragoneses, M. Fontecha-Garcia, C. McCoig, J. Saavedra-Lozano, E. Cercenado, and T. Hernandez-Sampelayo, Hospital Gregorio Marañon, Madrid, Spain.

Background and Aims: Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as an important cause of infection among healthy children in many areas of the world in recent years, but this tendency has not been confirmed in Spain. The aim of this study was to evaluate the incidence and resistance pattern of MRSA.

Methods: We reviewed charts of children with an MRSA isolate between 2005 and 2008. Clinical and microbiological parameters were analyzed and compared between community-acquired (CA-MRSA) and hospital-acquired MRSA.

Results: MRSA was isolated from 34 patients. Seventeen (50%) were CA-MRSA: 10 skin and soft-tissue infection (58,8%), 6 ear exudates and 1 from a complicated sinusitis and meningitis. Hospital-acquired MRSA was isolated from respiratory tract (7 cases), spinal fluid (3 cases), wound exudate (2 cases) and other locations (5 cases). We did not find an increased number of isolates of CA-MRSA during the study period (10 in 2005–2006 vs 7 in 2007–2008). One CA-MRSA and 7 hospital-acquired MRSA were resistant to macrolides (7% vs 41%; P = 0,02), and 7 CA-MRSA and 15 hospital-acquired MRSA to fluoroquinolones (41% vs 88%; P = 0,005). Five CA-MRSA were resistant to clindamycin (29,4%) without change in recent years. Only one isolate was resistant to cotrimoxazole. All MRSA isolates were susceptible to vancomycin and rifampin.

Conclusions: In our study we have not found an increased incidence of CA-MRSA in the last years. CA-MRSA was significantly more susceptible to macrolides and fluoroquinolones than hospital-acquired-MRSA. According to our findings cotrimoxazole may be the best option for the treatment of CA-MRSA infections.

P091

THREE CHILDREN OF A FAMILY WITH TUBERCULOUS LYMPHADENITIS

B. Sharifi-Mood,* R. Alavi-Naini,* M. Metanat,* M. Khalili,† and M.-R. Sharifi,‡ *Research Center for Infectious Diseases & Tropical Medicine; †Research Center of Pediatric Infectious Diseases; and ‡Departement of Radiology, Zahedan University of Medical Sciences, Zahedan, Iran.

Abstract: Tuberculosis is a major problem health in the Southeast of Iran. This area is near by Afghanistan and the incidence of TB is high. The clinical presentation of TB disease is very different and we observe very rare cases of diseases in this region. But, tuberculous lymphadenitis of the neck is common in Zahedan (a city in Southeasetrn Iran).

Hereby, We report three cases of TB lymphadentitis in a family (two brothers and one sister). What was surprising in our patients was that three cases of a family were symptomatic in one time. They had 3, 5 and 8 years old.

All cases referred to our hospital because of fever, weight loss, and multiple lymph nodes in their necks. Duration of symptoms was about 2 months. Diagnosis was performed by histopathological examination and they treated with antituberculous drugs according to national guideline.

P092

FAILURE RATE OF TREATMENT AMONG SMOKER CHILDREN WITH NEW CASE PULMONARY TUBERCULOSIS, ZAHEDAN, SOUTHEASTERN IRAN

B. Sharifi-Mood,* M. Khalili,† R. Alavi-Naini,* M. Metanat,* and M. Parsi,‡ *Research Center for Infectious Diseases and Tropical Medicine; †Pediatric Diseases, Zahedan University of Medical Sciences; and ‡Zahedan TB Center, Zahedan, Iran.

Introduction/Aim: Smoking damages the lung’s defence mechanism against infections including tuberculosis(TB) and the other infections. Association between smoking, tuberculosis disease and complications have been reported among adults patients, but there are a few reports on the influence of smoking on pulmonary diseases in children. The aim of this study was to evaluate the effect of smoking on the treatment of TB among children with pulmonary TB.

Materials and Methods: From May 2005 to November 2007, we evaluated all TB patients < 18 years in Zahedan Tuberculosis Center (Southeastern Iran). Nobody was immunosuppressed, or drug resistant.

Results: Thirty nine tuberculous patients, including 15 cases who were smokers, evaluated. Except 3 cases, the others had an age range between 15–18 years. All smokers were male. Smokers had a longer duration of clinical symptoms including chronic cough than non-smokers. Smoker had a delay in sputum smear conversion time. Among non-smokers one patients had failure (4%), but in smokers failure rate was 18%.

Conclusion: Based on the results from this study, smoking is associated with a delay in the response to treatment and an increasesd failure rate among children with PTB.

Keywords: Failure rate, Children, Pulmonary TB, Cigarette smoking, Treatment.

P093

SPECTRUM OF CLINICAL MANIFESTATIONS OF BRUCELLOSIS IN CHILDREN AND ADOLESCENTS IN THE SOUTHEAST OF IRAN

B. Sharifi-Mood, and M. Metanat, Research Center for Infectious Diseases & Tropical Medicine, Zahedan University of Medical Sciences, Zahedan, Iran.

Background/Aim: Brucellosis is an ancient infectious disease and has a worldwide distribution. It has a different clinical manifestations and can cause chronic debilitating illness with extensive morbidity and sometimes, it can be fatal. Familiarity with this re-emerging zoonosis is essential for physicians to recognize it. In this study, we present different clinical features of the disease in children and adolescents in Southeatern Iran.

Material and Method: During two years, from 2005 to 2007, we evaluated the patients with brucellosis who referred to our hospital and had an age less than 18 years. Diagnosis was made by serologic tests including wright and 2ME. A titer more than 1:160 in two tests was diagnostic.

Results: Among 59 cases who referred to our clinics, 17 cases were between 7–18 years. Almost, disease in adults had not a specific feature and the symptoms were fever, constitutional symptoms or bone pain. But, disease had a more specific feature in children. A 17-old-year boy had osteomyelitis (L2-L4) with cold abscess. An 11-year-old girl had pancytopenia and other girl patient who was 15 years old, presented with seizure and with more evaluations during hospitalization, the diagnosis of brucella meningitis confirmed. Another boy patient had septic artheritis and the diseae was confirmed by culture in the last patient.

Conclusion: Our study showed that brucellosis in children has more specific clinical manifestations than adults.

Keywords: Brucellosis, clinical manifestations, children.

P094

GROUP A STREPTOCOCCUS NECROTIZING FASCIITIS IN INFANT WITH A SECONDARY CASE OF NECROSIS IN CAREGIVER

T. Slaouti,* F. Sablier,† P.-A. Drèze,‡ P.-E. El Fouly,§ D. Allemeersch,† L. Van Melderen,‡ and P. Smeesters,‡¶ *Paediatric; †Microbiology, Clinique de l'Europe; ‡Bactérial Génétics and Physiology Laboratory, Université Libre de Bruxelles, §Plastic Surgery; Clinique de l'Europe; and ¶Paediatric Infectious Diseases, Université Libre de Bruxelles, Brussels, Belgium.

Background: Necrotizing fasciitis (NF) is a soft tissue infection usually caused by Group A Streptococcus (GAS). The last 2 decades have brought an increase of invasive GAS infections, including NF. GAS streptodornases are exotoxins playing a central role in GAS spreading in connective tissues.

Methods: NF diagnosis was based on consensus definition (J. Ped, 2007; 151; 79–84). Bacterial identification and antibiogram were performed using Vitek2. GAS emm-typing, MLST and PCR detection and sequencing of 14 GAS exotoxins were carried out using standard protocols.

Results: A 7 months-old girl presented a cellulitis of the arm complicating a varicella. Despite of early treatment by clindamycin and penicillin, she evolved towards a decompensated shock justifying intensive care therapy. Simultaneously, NF appeared rapidly and aggressive surgical debridement was decided. During the surgery, the nurse pricked one's finger with contaminated sharp. Despite of immediate disinfection, she presented 24 hours later a cellulitis with necrosis of the finger. Multisensitive emm-type 5.44 GAS strains were isolated from wound samples of both the child and the nurse, indicating that the strains most likely belong to the same GAS clone (MLST under progress). Moreover, the virulence factor genes were identical in the 2 isolates. Only one superantigen-encoding gene (speC) was found but a rather high number of streptodornase-encoding genes (spd1, spd3, spd4 and sdn) was detected.

Conclusions: The high number of streptodornase-encoding genes in this GAS isolate might account for its high virulence which explain most likely the rapid evolution towards necrosis in the two different hosts.

P095

EVALUATION OF CLINICAL FINDINGS AND TREATMENT OF CHILDHOOD BRUCELLOSIS IN IRAN

G. Soleimani, Pediatrics, Research Center for Children and Adolescents Health Zahedan University of Medical Sciences, Zahedan, Iran.

Abstract: Retrospectively we evaluated the records of 45 children with brucellosis; 31 males (68.8%) and 11 females (24.4%). only 16.3% (8/42) of the patients were < 5 years. 24% (12/42) were older the 5 years but ≤10 years and 59.7% (22/42) were older than 10 years but ≤15 years. Twenty eight of the children were living in rural areas and the remaining living in urban areas. Ingestion of unpasteurized milk was reported in 24 (53.3%) children animal contact in 15 (33.3%), while 19 (42.2%) children appeared to have no history of exposure to either. There was the most common symptom 32 children presented with high fever reaching 39.5°c,4 of there with chills intermittent and night fever was observed in 10 children respectively. sweating in (76.4%) and artheralgia or arthritis involved mianly the knee and hips was observed in 30 (83%) children. Sacroileitis was seen in 2 children (4.8%). Antibiotic treatment lasted for 28 days on average. There were no complications or relapses, except one, and the final outcomes were excellent.

P096

LUNG ABCESS IN CHILDHOOD: RETROSPECTIVE ANALYSIS OF 32 CASES

A. Somer,* A. Erkin Cakmak,* B. Caliskan,* O. Uzunhan,* F. Gun,† N. Salman,* N. Gurler,‡ T. Salman,† and A. Celik,† *Pediatric Infectious Diseases; †Pediatric Surgery; and ‡Microbiology and Clinical Microbiology, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey.

Background and Aims: Lung abscess is defined as localized necrotizing inflammation of lung parenchyma that rarely occurs in childhood. Staphylococcus aureus is the most common isolated microorganism. This study aimed to review the clinical and laboratory findings, and prognosis of children with lung abscess.

Methods: We reviewed the medical records of 32 children (22 males and 10 females) hospitalized with a diagnosis of lung abscess between 1986 and 2008. The information was obtained regarding age, gender, presenting symptoms, underlying conditions, microbiological data and treatment modalities.

Results: Eight of the 32 patients had primary lung abscess, while 24 had secondary lung abscess due to comorbidities. Fever and cough were the most common presenting symptoms. Five of 32 patients had neuromotor retardation. Immune deficiency was diagnosed in three cases. Thoracocentesis or percutaneous drainage was performed to twenty-five of 32 children and the most common pathogen isolated from the abscess was S.aureus (21.8%). All patients were initially treated with antibiotics, and twenty-seven of 32 were treated with multiple antibiotics. Cephazoline, vancomycin or teicoplanin were the first choice of treatment due to their Gram positive coverage and in case of persisting fever meropenem, imipenem or aminoglycosides was added to therapy due to their Gram negative spectrum.

Conclusion: In children with pneumonia, persisting fever or auscultation findings must alert the physician about accompanying or developing lung abscess. Antibiotics having Gram positive coverage must be the first choice of treatment due to the most common organism isolated, S.aureus.

P097

IINVASIVE MENINGOCOCCAL DISEASE (IMD) IN COSTA RICAN (CR) CHILDREN (CH)

A. Soriano-Fallas,* K. Camacho-Badilla,* M.L. Herrera,* M. Hernández-de Mezerville,* M.L. Avila-Agüero,† and R. Ulloa-Gutierrez,* *Hospital Nacional de Niños de Costa Rica, San Jose, †Ministerio de Salud de Costa Rica, San José, Costa Rica.

Background and Aims: Meningococcus is the second leading cause of bacterial meningitis in CR ch. Reports about IMD in Latin American (LA) ch are scarce and the real burden is unknown. Our objective was to describe the epidemiology and microbiology of IMD in ch admitted to the only paediatric tertiary referral and teaching hospital (H) of CR.

Methods: Retrospective chart review of ch aged <14 yrs with a laboratory-confirmed IMD episode, period Nov 15, 2000 to Nov 5, 2006.

Results: 31 patients (pts) were identified, of which 6 had an incomplete chart and were excluded. 12/25 (48%) pts were boys. Mean age was 2.9 yrs (range 12 days to 13.8 years); overall, 80% were <5 yrs of age. The most common clinical presentations were meningitis in 84% pts and meningococcemia in 16% pts. The most common symptoms were: fever, 100%; decreased consciousness, 84%; neck rigidity, 64%; and purpuric/petechial rash, 64%. Only 1 isolate was penicillin-resistant and none were cefotaxime-resistant. Serogroup distribution was as follows: B, 61.5%; A, 15%; W-135, 15% and C, 7.6%. 28% pts were admitted to the PICU. Complications included secondary seizures in 24%, septic shock in 20%, and amputations in 4% (1 pt) No deaths occurred.

Conclusions: Compared to other countries, the mortality rate of IMD in CR ch is low. Most cases wouldn't have been prevented with the current vaccines available in CR.

P098

LESSONS LEARNT FROM A FATAL TUBERCULOSIS CASE

A. Sulik,* D. Rozkiewicz,* E. Oldak,* M. Talalaj,† and P. Konopinski,† *Department of Pediatric Infectious Diseases, Medical University of Bialystok; and †Pediatric Intensive Care Unit, University Children's Hospital, Bialystok, Poland.

Background and Aims: In industrialized countries it is believed that generalized tuberculosis (TB) in children is rare due to universal vaccine availability and rather low incidence rate in adults. However, in the past few years a dramatic reemergence of TB all over Europe has been noticed. One possible reason could be increased rate of TB among immigrant populations. A child who represents nearly natural history of miliary TB is being presented.

Methods: A case report.

Results: A one-year-old boy, born in Poland, vaccinated at birth against TB disease and living in a refugee camp was admitted to the Pediatric Intensive Care Unit (PICU) due to dyspnea, tachycardia and opisthotonus. History revealed that the child had previously been hospitalized for pneumonia (at the age of 4 months) and generalized lymphadenopathy (at the age of 10 and 12 months). Each time hospitalization was interrupted by his parents who declined diagnostics and requested early discharge. A formal statement in their own native language was filed with medical records. At admission to PICU child's vital signs were abnormal. Chest X-ray revealed miliary tuberculosis, cerebrospinal fluid examination showed lymphocytic pleocytosis (87 cells) when intra-cranial tuberculomas were visualized on MRI. Tuberculin skin test stayed negative. TB diagnosis was confirmed by gastric culture. The child died on 22nd day of hospitalization despite proper anti-tuberculosis treatment from miliary tuberculosis with CNS involvement. Thorough investigation revealed contact with fresh adult TB case in a refugee camp.

Conclusions: Neither negative TST nor vaccination history should exclude TB from differential diagnosis.

P099

SUILYSIN PREVENTS INVASION AND TRANSLOCATION OF STREPTOCOCCUS SUIS ACROSS THE BLOOD-CEREBROSPINAL FLUID BARRIER IN VITRO

T. Tenenbaum,* T. Papandreou,* D. Gellrich,† A. Seibt,† R. Adam,* H.-J. Galla,‡ C. Schwerk,* and H. Schroten,* *Department of Pediatrics, University Hospital Mannheim, Mannheim; †Department of Pediatrics, Heinrich-Heine University, Düsseldorf; and ‡Department of Biochemistry, Westfälische Wilhelms-University, Mannheim, Germany.

Background and Aims: Previous experimental studies in a standard Transwell culture system have shown Streptococcus suis ability to compromise barrier function of porcine choroid plexus epithelial cells (PCPEC). The development of an ‘inverted’ Transwell filter system of PCPEC enables us with this model to investigate bacterial invasion and translocation from the physiologically relevant basolateral (blood) to the apical (cerobrospinal fluid) side. Previously we could show specific invasion and translocation of S. suis across the PCPEC exclusively from the basolateral side. During this process, bacterial viability and the presence of a capsule as well as cytoskeletal regulation of PCPEC seemed to play an important role.

Methods: Now, we analyzed the effects of the thiol-activated hemolysin suilysin on S. suis invasion and translocation rate across PCPEC and its influence on PCPEC barrier function.

Results: Cell viability and barrier function were not significantly affected after infection of suilysin mutants and the S. suis wildtype. Interestingly, we observed a lower invasion and translocation rate in three different suilysin deficient mutants compared to the S. suis wild-type. In contrast previous published results show that suilysin promotes invasion into the endothelial cells.

Conclusions: Thus, possibly regulated by the presence of a suilysin, S. suis induces signals in PCPEC that prevent cellular uptake during the bacterial transcellular translocation process. Further experiments have to clarify the mechanisms for our observations. Still, our data underline the relevance of the blood-cerebrospinal fluid barrier as a gate for bacterial entry into the central nervous system.

P100

GRANULOMATOUS CERVICOFACIAL LYMPHADENITIS–NOT THAT MANY?

K.C. Thoon,* K.T.E. Chang,† C.Y. Chong,* and N.W.S. Tee,† *Paediatric Medicine; and †KKH Laboratory, KK Women's and Children's Hospital, Singapore, Singapore.

Introduction: Granulomatous cervicofacial lymphadenitis (GCL) is not uncommon in children. We sought to determine their epidemiologic profile and identify features that aid management.

Methods: We retrospectively analyzed epidemiologic, clinical, laboratory, imaging and histopathological data for patients who had lymph node biopsies performed between 1998 and 2006, from the cervicofacial region that showed granulomatous lymphadenitis.

Results: We identified 60 children with GCL, noting a rising incidence from 2003 (>75% cases occurred after 2003). Mean age was 67 months, mean symptom duration before presentation was 7 weeks. Most had single (73%) and unilateral (97%) lymphadenopathy, without features suggestive of acute bacterial lymphadenitis. Forty-two percent of children had Tuberculin Skin Test (TST) reading of 310 mm. There were 10 (19%) positive node cultures, including 7 isolates of Non-Tuberculous Mycobacteria (NTM; 4 Haemophilum, 2 Fortuitum, 1 not identified), 2 isolates of M.Tuberculosis (TB), and 1 of M. Bovis (BCG strain). Subgroup analysis suggested that patients with NTM GCL (compared to TB GCL) were younger (56 months vs. 99 months) and had lymphadenopathy in the parotid/ pre-auricular or submandibular regions, but did not reach significance. Younger age predicted recurrence after any initial treatment (mean 42 months of age vs. 73 months, P = 0.05), while initial complete excision of affected nodes predicted no recurrence (8% recurrence vs. 43%, P = 0.03).

Conclusions: The incidence of GCL appears to be rising. While microbiological yield is low, most were due to NTM; our isolates were predominantly M. haemophilum. Initial complete excision of affected nodes (if possible) remains the best mode of treatment.

P101

SUBTLE NEUROLOGICAL AND FUNCTIONAL PROBLEMS IN SCHOOL AGE SURVIVORS OF BACTERIAL MENINGITIS

G. Vartzelis,* V. Vasilopoulou,* C. Chatzichristodoulou,† and M. Theodoridou,* *“Agia Sofia”, University Hospital, Athens; and †Medical School of Thessalia, Larissa, Greece.

Background and Aims: Bacterial meningitis is a serious infection with high morbidity and a significant risk for neurological sequelae. Additionally to major disabilities, meningitis survivors could develop subtle problems in many functional areas, including motor and sensory performance, dexterity, competence and behavior. The aim of this study was to assess the presence of such problems in children and teenagers with a history of bacterial meningitis.

Methods: Thirty children and teenagers with a history of bacterial meningitis were compared to 30 healthy controls for neurological soft signs (NSS), dexterity, competence and behavior problems. For the assessment of the NSS, the protocol of Shafer and colleagues was used. Dexterity was assessed with the Grooved Pegboard Test and competence and behavior problems were tested with the Child Behavior Checklist (CBCL).

Results: Meningitis survivors performed worst than controls only in one out six NNS tested. In that item (motor speed), subjects needed more time to complete the timed tasks of the examination (P = 0.019). There was no significant difference in performance on the Grooved Pegboard Test and the items assessed with the CBCL.

Conclusions: Children and teenagers with a history of bacterial meningitis showed no significant differences when compared to healthy controls with respect to the presence of NSS, dexterity, competence and behavior problems.

P102

A COMPARISON OF REAL-TIME PCR AND CONVENTIONAL CULTURE-BASED METHODS FOR THE DIRECT DETECTION OF GROUP B STREPTOCOCCI FROM CLINICAL SPECIMENS

A. Vickers,* A. De Zoysa,* A. Bedford Russell,† P.T. Heath,‡ E. Galiza,‡ I. Storey,† L. Hicks,* and A. Efstratiou,* *Respiratory and Systemic Infections, Health Protection Agency Centre for Infections, London; †Neonatal Unit, Heartland's Hospital, Heart of England NHS Trust, Birmingham; and ‡Division of Child Health, St George's Hospital, University of London, London, UK.

Background and Aims: Group B streptococci (GBS) are the principal cause of sepsis and meningitis in neonates. Development of a rapid and sensitive method to detect GBS from clinical specimens may improve healthcare for expectant women and newborns and allow appropriate antibiotic prophylaxis/therapy to be implemented. The objective of this prospective study was to evaluate the utility of a non-culture based method for GBS diagnosis. This molecular detection method involves real-time amplification of a novel target gene, the GBS-specific cylB gene, using Roche's fluorescence resonance energy transfer LightCycler PCR system.

Methods: To compare the sensitivity of cylB PCR and conventional culture-based methods for GBS detection, a collection of 100 clinical specimens (ear swabs) were analysed. The specimens were obtained from newborns undergoing sepsis screening on the neonatal units of two UK hospitals. Swabs were examined for GBS by LightCycler PCR amplification of cylB and by culture on GBS selective media (Granada agar).

Results: A total of 100 ear swabs were analysed. PCR and culture-based methods were positive for 7 specimens and negative for 84 ear specimens. Only one ear swab was negative for GBS by PCR, but positive by culture. GBS were detected in an additional 8 ear swabs by PCR, but not by culture.

Conclusions: PCR amplification of cylB enabled detection of GBS in 8 specimens from which GBS could not be detected by culture. The superior sensitivity and reduced time-to-result of this molecular assay makes it an attractive option for GBS detection, particularly in the urgent intrapartum setting.

P103

PREDOMINANCE OF NON-TYPEABLE HAEMOPHILUS INFLUENZAE IN THE NASOPHARYNX AND MIDDLE EAR OF CHILDREN WITH RECURRENT ACUTE OTITIS MEDIA

S. Wiertsema,* J. Bowman,† G. Chidlow,† D. Murphy,‡ H. Coates,§ and P. Richmond,¶ *School of Paediatrics and Child Health, University of Western Australia; †Division of Microbiology & Infectious Diseases, PathWest Laboratory Medicine, Perth; ‡Pneumococcal Reference Laboratory, Queensland Health Forensic and Scientific Services, Coopers Plains; §Department of Otorhinolaryngology, Princess Margaret Hospital for Children; and ¶Vaccine Trials Group, Telethon Institute for Child Health Research, Perth, Australia.

Introduction: Streptococcus pneumoniae (Pnc), non-typeable Haemophilus influenzae (ntHi) and Moraxella catharralis (Mc) are traditionally the main pathogens associated with recurrent acute otitis media (rAOM). The aim of this study was to investigate carriage patterns and the presence of bacteria in the middle ear of children with rAOM.

Methods: Nasopharyngeal (NP) swabs and middle ear effusions (MEE) of children with rAOM were cultured for Pnc, ntHi, Mc using conventional culture methods. In addition, samples will be analysed using pathogen specific PCR. Pneumococcal serotyping was performed by the Queensland Pneumococcal Reference Laboratory. NP samples are also being collected from healthy age-matched controls.

Results: Bacterial culture results in children with rAOM (n = 109) showed that ntHi was the most frequently carried pathogen in the nasopharynx (60.8%), followed by Mc (51.7%) and Pnc (35.0%). Of the 42 Pnc isolates cultured from NPS, only 4 (9.1%) were PCV-7 serotypes whereas 19 (43.2%) were vaccine related types, predominantly 19A (n = 12) and 6A (n = 5). The remainder 21 (47.7%) were non vaccine types with 11A (n = 6) and 15C (n = 3) the most common serotypes. 131 MEE samples have been cultured in which ntHi was found in 17 (13%), Mc in 10 (7.6%) and Pnc in 4 (3.1%) samples.

Conclusions: Introduction of PCV-7 has reduced the prevalence of Pnc in children with rAOM, however an increase in ntHi and Mc is observed. New vaccines for rAOM may need to include additional bacterial antigens. Furthermore, surveillance of bacterial NP carriage and MEE isolates may help inform vaccine policy.

For the Gromit Study Research Team, Vaccine Trials Group, Telethon Institute for Child Health Research, Perth, Australia

P104

DETECTION OF ANTIBIOTICS RESISTANCE PATTERNS IN ISOLATED STRAINS FROM VARIOUS BACTERIAL INFECTIONS IN CHILDREN IN HAMADAN, WEST OF IRAN

R. Yousefi Mshouf,* F. Eghbalian,† and M. Koshki,‡ *Microbiology; †Pediatrics; and ‡Hamedan Medical Science University, Hamadan, Iran.

Background and Objective: Antibiotics resistance of pathogens is one of the main problems for pediatric infections in the third world countries. Therefore, the aim of study was the evaluation of frequency of bacterial infections in children and detection of antibiotics resistance patterns of bacteria in Hamadan, during 2002 to 2007.

Methods: This is a cross-sectional study that performed on 6391 children under 14 years of age who admitted at pediatric wards from 2002 to 2007. All children which were diagnosed with meningitis, septicemia, pneumonia, gastroenteritis, and urinary tract infections (UTI) were evaluated. Disk agar diffusion method was used to determine the isolated bacterial resistance to 12 antimicrobial agents. Data were analyzed using spss system.

Results: From 6391 samples, 27.7% were positive culture. 65.4% of isolated bacteria were gram negative and 34.6% (613) were gram positive. The most common infections were: urinary infections (36.8%), gastroenteritis (34.9%), sepsis (17%), pneumonia (9.2%), and meningitis (2.1%). Isolated bacteria were: E. coli (36.3%), Staphylococcus aureus (18.2%), Staphylococcus epidermidis (13.3%), Klebsiella spp., (10%), Enterobacter spp., (6%), Shigella spp., (3.9%), Pseudomonas auroginosa (2.8%). The most effective antibiotics on both gram positive and gram negative isolates were ceftriaxone, imipenem, nitrofurantoin, cefepime, kanamycin and gentamicin. Most strains were resistant against cephalexin, ampicillin, erythromycin and co-trimoxazole.

Conclusions: This study showed that the most common bacterial infections were gastroenteritis, UTI and sepsis. E.coli and Kelebsiella spp., were the most common gram negative bacteria and Staphylococcus aureus was the most common gram positive one, which were resistant to the wide spectrum antibiotics.

P105

SEROLOGICAL RESPONSE IN CHILDREN WITH GROUP A STREPTOCOCCAL PHARYNGITIS IN THE UNIVERSITY HOSPITAL IN LATVIA

D. Zavadska,*† I. Grope,*† and D. Gardovska,*† *Department of Peadiatrics, Riga Stradins University; and †Children’s Clinical University Hospital, Riga, Latvia.

Abstract: Antibody tests have no value at the time of diagnosing acute GAS sore throat; however, they are crucial in providing evidence for antecedent streptococcal infection in terms of rheumatic fever prevention.

Objectives: To detect the serological response in children having GAS acute pharyngitis with episode of sore throat in Children's Clinical University Hospital in Latvia.

Methods: With the support of WHO a total of 340 patients between 2–12 years of age with complaints of sore throat were screened at the emergency setting of the University hospital. Throat swabs were obtained for GAS culture, rapid Biostar Strep A OIA MAX GAS antigen detection tests (RADT) were done and serological response was measured by having at least double elevation in antistreptolysin O (ASO) and/or antiDNase B titres in pair seras. According to all three above-mentioned criteria episode of acute GAS pharyngitis was defined.

Results: From 340 children having complaints of sore throat, 94 (27.6%) had positive RADT and 75 (22%) of the latter-positive GAS culture. Serological response was detected to 36 (48%) children who met acute GAS pharyngitis criteria, from which 22 (61%) had both tests elevated twice or more, 9 (25%) individuals had elevated only ASO titres and 5 (14%) had only antiDnaseB titres.

Conclusions: Serological testing indicates that half (52%) of those having positive RADT and GAS culture, are GAS carriers with sore throat of unknown origin. To verify serological response it is desirable to perform both of the serological tests, in order to reveal acute GAS pharyngitis.

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BONE, JOINT AND SOFT TISSUE INFECTIONS

P106

GRADENIGO’S SYNDROME COMPLICATED BY S. PNEUMONIAE MENINGITIS

M.C. Alves,* G. Januário,* A.R. Monteiro,† and F. Rodrigues,* *Infectious Diseases Unit; and †Otorrinolaryngology Service, Hospital Pediátrico de Coimbra, Coimbra, Portugal.

Background and Aims: Gradenigo’s syndrome, the association of acute otitis media (AOM), headache/facial unilateral pain and sixth nerve paralysis, is a rare presentation of petrositis and a very rare complication of AOM.

Methods: We describe a case of Gradenigo’s syndrome complicated by Streptococcus pneumoniae meningitis.

Results: A 8-year-old girl, with recurrent AOM, was admitted to the Emergency Service (ES) with a 2-months history of intermittent fever and unilateral headache. At the beginning of the symptoms an AOM was diagnosed. A month later a sixth nerve palsy was observed. A computerized tomography (CT) was performed and showed osteitis of the right petrous apex, suggesting petrositis or a tumoral lesion and mastoiditis. Two days later, she was admitted to the ES with meningeal signs, severe headache, vomiting and fever. A lumbar puncture was performed and meningitis was confirmed. She was started on ceftriaxone and vancomycin. S. pneumoniae, serotype 3, susceptible to penicillin was isolated. Because of a suspected allergic reaction, with severe pruritus, antibiotics were changed and treatment was completed with levofoxacin. During treatment a magnetic ressonance imaging was performed showing an improvement. The outcome was good. A year later she has a normal physical examination and the CT shows resolution of the infection.

Conclusions: Life-threatening complications of AOM, although rare, still occur, as it happened with our case. In the presence of unilateral pain and sixth nerve palsy, Gradenigo’s syndrome should be evocated and treatment should not be delayed in order to avoid other complications. Conservative medical treatment without surgery was successful.

P107

SEPTIC ARTHRITIS (SA) IN COSTA RICAN CHILDREN (CH)

P. Bolaños-Azofeifa, M. Alvarado-Salazar, M. Hernández-de Mezerville, K. Camacho-Badilla, A. Soriano-Fallas, and R. Ulloa-Gutierrez, Hospital Nacional de Niños de Costa Rica, San Jose, Costa Rica.

Background and Aims: Publications about SA in Latin American ch are scarce, and this is one of the largest series in the Americas. Our main objective was to describe the epidemiology and microbiology of SA in ch hospitalized at the only paediatric tertiary referral and teaching hospital of Costa Rica.

Methods: Retrospective chart review of patients (pts) aged <13 yrs with a hospital discharge diagnosis of SA, from January 1, 2003 to December 31, 2007.

Results: 110 pts were included, 64% were male. Age distribution was the following: newborns, 8% pts; 1–24 months, 25%; 2–5 yrs, 22%; and >5 yrs, 45%. The most common symptoms were: fever, 88 (80%) pts; pain, 100 (91%) pts; and functional limitation, 97 (88%) pts. The main affected joints were: hip (48%), knee (42%), ankle (3.6%), and elbow (3.6%). The 3 most common agents were: S. aureus, 33 (30%) pts (half were MRSA); S.agalactiae, 2 (1.8%) pts; and K.pneumoniae, 2 (1.8%) pts. Cultures were sterile in 64 (58%) pts. Arthrocentesis and arthrotomy were performed in 85% and 64% of pts, respectively. Complications and sequelae occurred in 13.6% and 9%, respectively. No deaths occurred.

Conclusions: Empirical initial antibiotic therapy for Costa Rican ch with SA should include drugs effective against MRSA. The high rate of sterile cultures in our series prompts urgent improvement in detection procedures for establishing the etiologic role of Kingella kingae.

P108

OSTEOMYELITIS: EPIDEMIOLOGY, CLINICAL MANIFESTATIONS AND MANAGEMENT

M. Bueno Barriocanal, M. Ruiz Jiménez, J.T. Ramos Amador, V. Soto Insuga, and E. Criado Vega, Paediatrics Service, University Hospital of Getafe, Madrid, Spain.

Background: The aim of this study was to describe the epidemiology, clinical and laboratory data and management of ostemyelitis in our hospital.

Methods: All patients younger than 15 years admitted in our center with osteomyelitis between 2000 and 2008 were retrospectively reviewed.

Results: Forty eight patients were identified (52% female), with median age of 2 years (range 6–150 months). Main onset manifestations were pain (96%), functional impairment (89%) and fever (75%). Mean time since onset until admission was 6,5 days ± 6,6. Femur (25%), tibia (25%), tarsus (20%) and pelvis (14%) were the most affected bones. Leukocytosis (>13.000/mm3) was found in 52% cases and elevated PCR (>30 mg/L) in 50%. Procalcitonin was elevated (0,5–2 ng/ml) in two out of seven patients. Blood cultures were positive in 21%, goup A streptococcus was the bacteria most frequently isolated (13%). Gammagraphic bone scan, performed with mean time since onset of 8,2 days ± 6,8, was diagnostic in all cases. Patients received antibiotic treatment, initially i.v. (mean time 10,2 days ± 3,4), later switched orally (17,4 days ± 6,6). Surgical treatment was required in 3 cases. Only one patient had chronic osteomyelitis criteria, the rest of them had a favourable outcome.

Conclusions: Ostemyelitis is often difficult to diagnose due to absence of specific clinical and laboratory findings and the young age at presentation. Although X- rays are useful, gammagraphic bone scan was the best imaging test for diagnosis in our series. Early diagnosis and treatment are essential to avoid chronic osteomyelitis and skeletal disabilities.

P109

MULTIDRUG-RESISTANT SKELETAL TUBERCULOSIS: REPORT OF TWO CASES

T. del Rosal, F. Baquero-Artigao, M.J. Garcia-Miguel, and F. del Castillo, La Paz Children Hospital, Madrid, Spain.

Background and Aims: The increasing emergence of drug-resistant strains is a serious problem in the management of tuberculosis. Few cases have been reported of multidrug-resistant skeletal tuberculosis in children.

Methods: Two cases of multidrug-resistant skeletal tuberculosis diagnosed at Hospital La Paz (Spain) are described.

Results: Case 1: A 4-year-old immigrant Chinese girl presented with a 6-month history of a fluctuant mass at her right ankle. MRI revealed cortical tibio-talar irregularities and synovial hypertrophy. An open synovial biopsy was performed, which showed tubercular granulomas. Tuberculin skin test was positive. PCR for M. tuberculosis in biopsy sample and synovial fluid were positive. Multidrug-resistant M. tuberculosis was isolated from synovial biopsy and gastric aspirates. Case-contact evaluation revealed tuberculosis in a grandfather in China. Treatment with five drugs led to complete healing of tibio-talar erosions.

Case 2: A 4-year-old girl presented with a 4-month history of progressive kyphosis. MRI showed dorsal spondilytis and paravertebral abscess. Tuberculin skin test was positive. She underwent surgery and abscess material culture yielded multidrug-resistant M. tuberculosis. Case contact study was negative, but further questioning of the family revealed a household contact with a young immigrant from Morocco who had died from tuberculosis. Both strains were identical by RFLP analysis. Currently she is being treated with good evolution.

Conclusions: Skeletal tuberculosis is an emergent disease that requires a high index of suspicion for diagnosis. Rapid identification of multidrug-resistant strains is necessary for an adequate management of cases. Case contact studies should be conducted whenever a case of tuberculosis is identified.

P110

RIB TUBERCULOSIS IN A CHILD: CLINICAL, RADIOLOGICAL, HISTOPATHOLOGICAL FINDINGS AND UTILITY OF THE QUANTIFERON-TB GOLD TEST FOR DIAGNOSIS

E.C. Dinleyici,* H. Ilhan,† Z.A. Yargic,* E. Dundar,‡ C. Calisir,§ and A.K. Kocak,* *Department of Pediatrics; †Department of Pediatric Surgery; ‡Department of Pathology; and §Department of Radiology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey.

Introduction: Skeletal tuberculosis (TB) accounts for 1–5% of all TB and involvement of the rib is extremely uncommon. Clinical and radiological features of bone TB may resemble other conditions such as infections and bone tumors.

Case Report: A 3.5 year-old boy was referred to our clinic with the local swelling at the right side of the pectoral region during last 9 months. On physical examination, he had pectus excavatum, and there was slightly tender palpable mass measuring 5 × 5 cm on left chest wall. BCG scar was present. He had no history of fever, weight loss, trauma and family history for chronic conditions including tuberculosis. He was initially considered as to have Ewing sarcoma with ultrasonography. Computerized thorax tomography revealed mild destructive lesions of the rib and hypodense lesion measuring 8 × 5 × 6 cm. There was no evidence of pulmonary TB with radiological findings, and early gastric aspirates were negative for AFB on three occasions. Histopathological examination of incisional biopsy showed granulomatous inflammation. Ziehl-Nielsen-stained smears for AFB were negative. PPD produced 20-mm induration at 48 hours. The QuantiFERON-TB Gold test was positive. He had been treated with isoniazid, rifampicin, pyrazinamide. Mass lesion completely disappeared after first month, and there was no recurrence after finishing 9-month-therapy.

Conclusion: Diagnosis of extra-pulmonary TB is difficult and high index of suspicion is required in children. The QuantiFERON-TB Gold test may hold promise for use when conventional workup including microbiological tests is not diagnostic when tuberculosis is suspected.

P111

OSTEOMYELITIS IN CHILDREN-A PORTUGUESE HOSPITAL STUDY

M. Duarte Ferreira,* T. Marques,† C. Gouveia,† and M.J. Brito,† *Hospital Fernando Fonseca; and †Paediatrics, Hospital Fernando Fonseca, Lisbon, Portugal.

Background: Despite diagnostic and therapeutic advances, osteomyelitis continues to cause significant disease burden, presenting a challenge to physicians.

Objectives: Review the experience and outcome of osteomyelitis in children from a suburban area outside Lisbon.

Methods: Retrospective study of children with osteomyelitis, between July 1996 and December 2008. Osteomyelitis was classified as acute (AO) or chronic (CO), if symptoms were present for less or more than two weeks before diagnosis. Demographic, clinical, laboratory, imagiologic, therapeutic data and outcome were analysed.

Results: Total of 47 children, 34 (72%) with AO and 13 (28%) with CO. Median age was 6,9 ± 4,6 years and 26(55%) had risk factors: sickle-cell disease (10), preceding fracture (5), immunodeficiency (2), paraplegia (2), varicella (2) and others (5). The mean duration of symptoms was 9 ± 16 and 146 ± 143 days in AO and CO, respectively. The most affected bones were the femur (25%) and tibia (25%). Etiologic diagnosis was made in 25(53%) cases, by blood culture (47,6%), pus aspiration (80%) or both (25%). Staphylococcus aureus (56%) and Salmonella (16%) were the predominant organisms. Skeletal scintigraphy confirmed diagnosis in 64% cases. The median duration of parental therapy was 29,5 days and surgical procedure was performed in 16(34%) patients. Complications included: abscess (14), fistula (4) and chronic osteomyelitis (3). Children with AO had higher leukocyte count (16930 vs 9277; P = 0,007) and serum C-reactive protein (11,15 vs 4,18; P = 0,048). None of the patients who switched to oral therapy within 2 weeks was rehospitalized.

Comments: Despite the longer duration of symptoms prior to diagnosis, the overall outcome was similar to that reported by others.

P112

SALMONELLA OSTEOARTICULAR INFECTION IN CHILDREN WITH SICKLE CELL DISEASE

S. Dugue,* M. Benkerrou,† P. Mariani-Kurkdjian,‡ G. Ithier,§ F. Fitoussi,¶ P. Armoogrum,∥ A. Bourrillon,* F. Missud,§ L. Holvoet,§ A. Baruchel,† A. Faye,* C. Alberti,** E. Bingen,†† G.F. Penneçot,‡‡ and M. Lorrot,* *General Pediatric Unit; †Pediatric Hematology and Sickle Cell Disease Unit, Hôpital Robert Debré, Assistance Publique Hôpitaux de Paris et UFR Denis Diderot, Paris 7; ‡Microbiology Unit; §Pediatric Hematology and Sickle Cell Disease Unit; ¶Pediatric Orthopaedics Unit, Hôpital Robert Debré, Assistance Publique Hôpitaux de Paris; ∥Public Health, Hôpital Robert Debré AP-HP; **Public Health, Hôpital Robert Debré AP-HP et UFR Denis Diderot, Paris 7; ††Microbiology Unit; and ‡‡Pediatric Orthopaedics Unit, Hôpital Robert Debré, Assistance Publique Hôpitaux de Paris et UFR Denis Diderot, Paris 7, Paris, France.

Background and Aims: Salmonella osteoarticular infection is a severe condition in children with sickle cell disease (SCD).

Methods: Retrospective analysis of patients hospitalized in our institution between 1997 and 2008. Salmonella was isolated from the blood, pus or articular aspirates.

Results: 12 cases were analyzed. The median age was 3 years (SD ± 5.7, range 15 months to 14 years) and 67% of children were under 5 years. Before admission, gastro-enteritis symptoms were present in 66% of cases and vaso-occlusive crisis in 83%. Median duration of symptoms was 3 days (SD ± 8.8, range 0 to 31 days). The predominant presenting symptom was pain in 92% of cases, 33.3% of the patients have multifocal infection and 70% involved bones of the arm. The initial CRP was greater than 30 mg/L in 75% (median: 51 mg/L, SD ± 30.4,). 50% of the 20 osteoarticular samples isolated Salmonella spp despite the initiation of the antibiotherapy (from 1 to 25 days). Initial ultrasound was the most contributing exam pathological in 80% of cases. Parenteral antibiotics associating a third generation cephalosporin and ciprofloxacin were given in all cases during a long period (mean: 17 days; range 8 to 26 days). Ten patients (83.3%) undergone surgical therapy. Control of infection was difficult: 50% of the patients needed more than one operation for subsequent arthritis, osteomyelitis or sub periostal abscess.

Conclusions: Salmonella osteoarticular infections remain a therapeutic challenge in children with SCD: dissemination of the infection occurs frequently despite medico-chirurgical treatment.

P113

PEDIATRIC OSTEO-ARTICULAR INFECTIONS CAUSED BY STREPTOCOCCUS PNEUMONIAE

C. Lemaitre,* C. Doit,† A. Ferroni,‡ H. Vu-Thien,§ J. Raymond,¶ C. Pernet,∥ Y. Lefevre,** A. Faye,* C. Glorion,†† P. Mary,‡‡ J.-P. Damsin,‡‡ R. Seringe,§§ E. Bingen,¶¶ C. Alberti,∥ G.-F. Penneçot,** and M. Lorrot,* *General Pediatric Unit, Hôpital Robert Debré APHP; †Microbiology Unit, Hôpital Robert Debré APHP, UFR Denis Diderot, Paris 7; ‡Microbiology Unit, Hôpital Necker Enfants Malades APHP; §Microbiology Unit, Hôpital Armand Trousseau APHP; ¶Microbiology Unit, Hôpital Saint Vincent de Paul APHP, University Paris 5; ∥Public Health; **Pediatric Orthopaedics Unit, Hôpital Robert Debré AP-HP, UFR Denis Diderot, Paris 7; ††Pediatric Orthopaedics Unit, Hôpital Necker Enfants Malades APHP, University Paris 5; ‡‡Pediatric Orthopaedics Unit, Hôpital Armand Trousseau APHP; §§Pediatric Orthopaedics Unit, Hôpital Saint Vincent de Paul APHP; and ¶¶Microbiology Unit, Robert Debré AP-HP, UFR Denis Diderot, Paris 7, Paris, France.

Background and Aims: Pediatric pneumococcal osteo-articular infections (OAI) are uncommon (5–10% of pediatric OAI). The objective of this study was to describe their clinical and microbiologic characteristics.

Methods: Data were retrospectively collected from children aged <16 years, who were hospitalized for pneumococcal OAI between 1997 and 2007 in 4 pediatric hospitals in Paris.

Results: A total of 42 children were included: 30 arthritis, 8 osteomyelitis and 4 osteomyelitis with arthritis. The mean age of the 42 infected children was 12 months (range 3 months to 14 years) and 74% of the patients were <2 years. Six of 39 children (15%) were immunized with 7-valent pneumococcal conjugate vaccine (PCV7).

Twenty-three of 42 strains (55%) were intermediate or resistant to penicillin. Fifteen of 42 serotypes (36%) were available: two serotypes 1, one 6A, one 6B, one 9, three 14, one 15B and six 19A (40%). Five of 6 serotypes 19A were intermediate or resistant to penicillin. Vaccine strains were isolated in 3 not vaccinated children and in a child who received only one vaccine injection. The 19A serotype was the only strain isolated in the 3 children with complete vaccination. The evolution was favorable for all children but 5 children required one secondary surgical revision (3 arthritis, 1 abscess, 1 peritonitis).

Conclusion: The epidemiology of pediatric pneumococcal OAI is changing with the widespread of the PCV7. In this study, the most common serotype was 19A. Children >2 years of age are also affected.

P114

CONSENSUS FOR OSTEOARTICULAR INFECTIONS’ DIAGNOSTIC CRITERIA IN CHILDREN, USING A DELPHI METHOD

A. Mitha,* F. Dubos,*† M. Boulyana,* V. Hue,* and A. Martinot*‡, *Paediatric Emergency Unit and Infectious Diseases, Lille University Hospital, Lille; †U149, INSERM, Paris; and ‡Faculty of Medicine, Lille-2 University, Lille, France.

Purpose: There are many diagnostic criteria for osteoarticular infections in the literature, without consensus. This study aimed to determine consensual definition criteria for arthritis, osteomyelitis, and any osteoarticular infections in children, using a Delphi method.

Methods: A group of 12 French-speaking experts (paediatric infectious diseases physicians and paediatric orthopaedic surgeons) were contacted for participating to an e-mail Delphi process in the year 2008. Diagnosis criteria identified in a systematic PubMed research were proposed to the Delphi participants for consensus for an epidemiological definition (definite diagnosis) and for a clinical definition (probable diagnosis). Five definition criteria for arthritis, eight for osteomyelitis and five for any osteoarticular infection were included in a 3-rounds process. Exclusion of the worst definitions was performed in the first round. A classification of the remaining definitions was performed in the second round. A selection of the best definition within the two most accurate was performed in the third round. An a priori consensus threshold of at least 70% was required for each round.

Results: Eleven experts (from Switzerland [n = 1], Belgium [n = 5] and France [n = 5]) participated. A consensus was obtained for an epidemiological definition of arthritis, osteomyelitis, and any osteoarticular infection. A consensus was also obtained for a clinical definition of any osteoarticular infection. However, no consensus was found for a clinical definition of arthritis and osteomyelitis, for which two definitions have been retained.

Conclusion: This Delphi process has provided consensual definitions for osteoarticular infections that could be used for either epidemiological or clinical next studies.

P115

OSTEOMYELITIS IN CHILDREN: COMPARATIVE STUDY BETWEEN GROUP A BETA-HEMOLYTIC STREPTOCOCCUS (GABHS), METHICILLIN-SUSCEPTIBLE (MSSA) AND METHICILLIN-RESISTANT (MRSA) STAPHYLOCOCCUS AUREUS

M.F.B. Pereira, C. Finelli, S. Carmo Neidenbach, M.J. Mimica, F.J. Almeida, and E.N. Berezin, Pediatrics, Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil.

Background and Aims: Acute hematogenous osteomyelitis (AHO) is caused by Staphylococcus aureus in most cases. GABHS usually is next in frequency.The objective of this study was to compare the clinical manifestations, laboratory findings and outcomes of children with AHO caused by GABHS, methicillin-susceptible and methicillin-resistant Staphylococcus aureus.

Methods: Medical records from children admitted at Santa Casa de São Paulo Hospital with a diagnosis of AHO between February 2007 and December 2008 were reviewed. Diagnosis of AHO was based on clinical and imaging criteria. Antimicrobial susceptibilities were determined by disk diffusion tests.

Results: A total of 21 patients with AHO were included during the 23 months study period. S. aureus was the etiologic agent in 10 (47%) cases being 3 of these MRSA. GABHS was identified in 5 (23,8%) patients. Polymicrobial infection occurred in two cases. Patients with MSSA and MRSA AHO had a mean duration of fever of three days whereas patients with GABHS had a mean of two days of fever. On admission, mean white blood cell (WBC) count was 16986/mm3, 18842/mm3 and 21283/mm3 and mean erythrocyte sedimentation rate (ESR) was 87.3 mm/h, 67.8 mm/h and 117 mm/h in patients with GABHS, MSSA and MRSA AHO, respectively. The median total duration of antibiotic therapy was 18.0, 24.0 and 44.0 days for GABHS, MSSA and MRSA AHO, respectively.

Conclusions: MRSA AHO was associated with a higher WBC count and ESR than MSSA and GABHS AHO. Moreover, patients with MRSA OHA needed longer antibiotic therapy than those with MSSA and GABHS AHO.

P116

CHRONIC RECURRENT MULTIFOCAL OSTEOMYELITIS (CRMO) DUE TO COXIELLA BURNETTI INFECTION- IS THERE A ROLE FOR INTERFERON (INF)- γ THERAPY?

E. Peromingo, D. Falcon, M. Camacho, O. Neth, and I. Obando, Pediatric Infectious Diseases and Immunology, Hospital Universitario Virgen del Rocio, Sevilla, Spain.

Abstract: Q fever is a zoonosis caused by Coxiella burnetti, an obligate intracellular bacteria. It is rare in children and osteoarticular involvement in chronic Q fever has only been described in six children (1). There is uncertainty regarding the optimal treatment and monitoring of these patients.

We present a 3-year-old girl with a 12-months history of painful swelling of her wrist, followed by a pseudo-paralysis of her arm, a chronic abscess of the chest wall and finally back pain. MRI of the spine revealed destructive vertebral lesion at T10 level with extradural extension and X-rays showed additional bone destructive lesions in the humerus and femur. Histopathology of the humerus biopsy was normal; blood and biopsy cultures remained negative. Flucloxacillin was given with good clinical response; however a new lesion developed in the navicular bone 3 months after stopping antibiotic treatment. At this point, the diagnosis of Q fever was established serologically (anti-phase I IgG titer: 1/32000) and by PCR from bone biopsy. Antimicrobial therapy with rifampicin and ciprofloxacin was started; immunology studies including the Interleukin-12 and INF-γ/INF-γ receptor pathway were normal. Two years later the disease has not been satisfactory controlled and therapy with INF-γ (12.5 mcg/m2 s.c. 3-times weekly) was initiated to enhance killing of C. burnetti through monocytes/macrophages; so far no new lesions have occurred.

C. burnetti infection should be considered in paediatric patients with chronic recurrent multifocal osteomyelitis. Optimal therapy remains to be established and may consist of prolonged antibiotic therapy and adjuvant immunotherapy.

1. Nourse, CID 2004.

P117

SEPTIC ARTHRITIS: A 5 YEAR RETROSPECTIVE STUDY

G. Queirós, F. Marques, C. Gouveia, and M. Brito, Unit of Infectious Diseases, Department of Paediatrics, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.

Background: Septic arthritis (SA) is a disabling and potentially life-threatening condition requiring prompt diagnosis and treatment.

Aims: Comparing results after the implementation of management guideline in our department in January 2007 and compliment evaluation.

Materials and Methods: Retrospective study of children with SA, admitted between January 2003 and June 2008. Demographic, clinical, laboratory, imagiologic, therapeutic data and outcome were analysed.

Results: 56 patients, with median age of 23 months (max 15 years; min 17 days). Risk factors were present in 19,6% (congenital heart disease and trauma) and co-morbidities in 16,1% (varicella, meningococcal sepsis, pneumonia, piomyositis, bursitis and Kawasaki disease). Microbiological diagnosis was achieved in 32,1%, by blood culture (11%), pus aspiration (5.4%) or both (16%). Staphylococcus aureus was the predominant organism (17,9%).After guideline introduction we verified: a slight increase in laboratory data (WBC 90,5 vs 100%, P = 0,5; CRP 88 vs 100%, P = 0,3; ESR 40,5 vs 64,3%, P = 0,1); synovial fluid analysis (0 vs 21,4%, P = 0,01), imaging (US 88 vs 92%, P = 0,6; bone cintigraphy 19 vs 35,7%, P = 0,25) and microbiologic studies (pus aspiration cultures 59 vs 78,6%, P = 0,3). There was no significant change in therapeutic arthrocentesis (83,3–85,7%, P = 1). Antibiotic use according to the guideline was 71% and the duration was accomplished in 64%. There was no significant reduction on median in-hospital stay (14 ± 13,2 vs 13,5 ± 8,7 days, P = 0,5) and in 50% the follow-up was insufficient.

Conclusion: Our audit identified deficiencies in standards of care of SA, despite a management improvement after guideline implementation.

P118

OSTEOARTICULAR INFECTIONS IN BELGIAN CHILDREN: A SURVEY OF CLINICAL, BIOLOGICAL, RADIOLOGICAL AND MICROBIOLOGICAL DATA

Q. Rasmont, D. Van Der Linden, J.-C. Yombi, and P.-L. Docquier, UCL Cliniques Universitaires Saint-Luc, Brussels, Belgium.

Abstract: The aim of this study is to report the most frequent pathogens which were found to be responsible for osteo-articular infections in infants and children in Belgium, and to propose an appropriate empirical antibiotic therapy to apply before identification of the responsible pathogen. Clinical presentation, imaging and blood biology are also reviewed and analysed.

Fifty-six cases of osteo-articular infections (acute/subacute osteomyelitis, osteo-arthritis, septic arthritis, spondylodiscitis, sacro-iliitis) treated between 2001 and 2007 were retrospectively reviewed, focusing on clinical, biological, microbiological and radiological data. Septic arthritis, acute osteomyelitis, septic osteo-arthritis and sacro-iliitis often have a loud clinical (fever, pain, inflammatory signs) and biological presentation. Subacute osteomyelitis and spondylodiscitis are almost asymptomatic, but for functional impairment. The responsible pathogen was isolated in 38% of the cases. The most frequent pathogen was Staphylococcus Aureus, followed by Pneumococcus, Streptococcus A and B, Kingella Kingae, and Haemophilus. None of them had resistance to usual antibiotics..

Functional impairment is the only constant symptom of osteo-articular infections. Other clinical and biological symptoms may be absent, making the diagnosis often difficult. We recommend oxacillin (>5 years) or a combination of oxacillin with cefotaxime (<5 years) in the empirical treatment of osteo-articular infection, and a total of 4 weeks of treatment.

P119

SALMONELLA PARATYPHI B SKULL OSTEOMYELITIS AND SICKLE CELL DISEASE

S. Rooze,* C. Delaet,† A. Klein,‡ A. Ferster,‡ and P. Lepage,§ *Pediatric; †Pediatric Nutrition and Metabolic Disease; ‡Pediatric Hemato Oncology; and §Pediatric Infectious Disease, HUDERF, Bruxelles, Belgium.

Abstract: We report the case of a 17 year-old teenager with an uncommon site of chronic osteomyelitis..

She had been followed up for severe sickle cell disease (SCD). She was hospitalized for an acute febrile illness. Her physical examination was unremarkable. Her laboratory findings were normal, without elevated inflammatory markers. Blood culture results revealed an occult bacteremia due to Salmonella paratyphi B. She was first treated by 48 hours of IV ceftriaxone, followed by 8 days of oral ciprofloxacin. Her clinical evolution remained satisfactory and she was discharged after 6 days. She was rehospitalized 3 months later for severe headache. A 2 cm local tumefaction of the skull close to the right parietal bone was noticed. New laboratory exams were again normal. MRI demonstrated parietal osteomyelitis with severe lesions of the right parietal bone spreading to the soft tissue and complicated by extradural abscess. Percutaneous aspiration of this collection was positive for Salmonella paratyphi B. The collection aspirated twice and the bone abscess was first treated by oral ciprofloxacin. The clinical and diagnostic imaging response was very poor during the first weeks of antibiotic treatment. Surgery was performed after 2 months of oral therapy to drain the collection and incise the necrotic bone. Oral ciprofloxacin was given during 6 months and a good clinical and radiological outcome was obtained.

Osteomyelitis of the skull is a rare disease, even in immunocompromised patients such as SCD subjects. This infection is frequently complicated by extradural abscess. Treatment must include surgery and antibiotic therapy.

P120

SEPTIC ARTHRITIS AND OSTEOMYELITIS IN CHILDREN: A REVIEW OF CASES FROM 1997–2006, OXFORD, ENGLAND

C.M. Snowden,* D.F. Kelly,* I.A. Mohammed,* T. Theologis,† A. Wainwright,† and A.J. Pollard,* *Department of Paediatrics, University of Oxford; and †Nuffield Orthopaedic Centre, Oxford, UK.

Background: Osteomyelitis (OM) and septic arthritis (SA) are serious bacterial infections with potential long-term morbidity. There is a paucity of evidence upon which to base treatment recommendations. We reviewed management of all cases of SA and OM in children aged <10 years at the John Radcliffe and Nuffield Orthopaedic Hospitals, Oxford during 1997–2006.

Methods: Cases of SA and OM were identified through clinical discharge coding and subsequent chart review.

Results: Forty six cases of OM (30 < 5 years of age) and 56 cases of SA (45 < 5 years of age) were identified. Duration of presenting symptoms for OM was 1–42 days (median = 5.5) and for SA 1–14 days (median = 1). Positive bacterial cultures were obtained for OM in 11/35 (31.4%) with surgical samples and for SA in 25/52 (48%) with joint aspirates. Of 36 positive cultures the most frequent organisms were Staphylococcus aureus (10), Group A streptococcus (9) and Streptococcus pneumoniae (3). Empiric treatment with beta-lactam antibiotics was used in 93% of cases, median total treatment duration of 44 days for OM and 29 days for SA. Of 86.9% OM patients with a recorded outcome, complete recovery occurred in 95%. Outcome for patients with septic arthritis was recorded in 73% of patients treated, with complete recovery in 93.2%.

Conclusion: For OM and SA the causative organism was identified in under half the cases with microbiological specimens. Despite variable practice with respect to antibiotic choice, route and duration of treatment, most patients achieved complete recovery.

P121

HIP AND KNEE PAIN IN A CHILD WITH BACTEREMIC PNEUMOCOCCAL PNEUMONIA AND EMPYEMA

A. Vuckovic,* D. Biarent,† M. Bellemans,‡ and P. Lepage,§ *Pediatrics; †Pediatric Intensive Care Unit; ‡Department of Pediatric Orthopedics; and §Department of Pediatric Infectious Diseases, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium.

Background: Streptococcus pneumoniae is a leading cause of pediatric invasive infections including bacteremia, meningitis and pneumonia. However arthritis is a scarcer manifestation of pneumococcal disease.

Clinical Case: A 3-year old girl -healthy and properly vaccinated- presented with fever and dyspnea. Laboratory and radiographic data indicated an acute inflammatory syndrome with pulmonary consolidation and pleurisy. Empiric IV cefotaxime was started. After 2 days, computed tomography identified a loculated empyema requiring surgical drainage. Blood cultures isolated a penicillin-susceptible pneumococcus (serotype 1); the antimicrobial regimen was therefore switched to IV penicillin. Meanwhile the girl developed pain and reduced mobility of the left leg. Ultrasonography showed small effusions of hip and knee joints. Scintigraphy excluded other bone involvement. Pneumococcal arthritis was confirmed by PCR analysis of the joint fluid. Protracted fever lasted for 2 weeks, but serial blood cultures remained negative. CRP level and leukocytosis remained high for 3 weeks. The chest drain was retrieved after 5 days. Antibiotics were administrated during 6 weeks with a parenteral-oral sequence. Despite pulmonary recovering, residual joint dysfunction persisted after 1 month.

Conclusion: We report an unusual manifestation of pneumococcal disease, including complicated pneumonia, bacteremia and polyarticular arthritis. Septic arthritis might be underestimated since the diagnosis of joint infection is mostly performed by culture and direct fluid examination. PCR is a sensitive method to distinguish septic from reactive arthritis without requiring viable pathogens. In presence of invasive infections, molecular diagnosis may be helpful in case of negative culture results or prior antibiotic use.

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CONGENITAL INFECTIONS

P122

FETAL VARICELLA EMBRYOPATY: CASE REPORT

D. Albu,*† C. Albu,*‡ E. Severin,* A. Toma,§ and M. Dumitrescu,¶ *Genetics, University of Medicine and Pharmacy; †Obstetrics-Gynecology; Genetics; ‡Alco San Clinic Bucharest; §Neonatology, ’Panait Sarbu’ Hospital; and ¶University of Medicine and Pharmacy, Bucharest, Romania.

Background: Fetal Varicella Embryopaty is a rare disorder in which affected infants have multiple congenital abnormalities due to the mother’s infection with varicella zoster virus early during pregnancy.

Objectives: To detect the prenatal ultrasound findings associated with Fetal Varicella Embryopaty and to specifythe most appropriate safety method of Fetal Varicella Embryopaty prenatal diagnosis.

Patient Selection: A 21-year-old female,exposed accidentally to varicella zoster virus during the first weeks of pregnancy, was referred at 20 weeks’ gestation for aselective ultrasonography for detection of fetal abnormalities.

Methods: Ultrasonography at 16 weeks of pregnancy; selectiveultrasonography for detection of fetal abnormalities, triple test and amniocentesis.

Results: Ultrasound examination revealed a single fetus with an abnormal fetal development: microcefaly, microphthalmia and cataracts, bilateral clubbed feet, abnormally positioned handsand polyhydramnios. Fetal chromosomal analysis showed normal male karyotype: 46,XY. After an extensive counseling the parentsdecided to terminate the pregnancy. The pathology exam confirmed all the malformations.

Conclusions: The necessity of ultrasound examination for the prenatal detection of fetal abnormalities to all pregnancies and especially for the risk categories.

P123

LONG-TERM FOLLOW-UP OF TOXOPLASMA GONDII CONGENITAL INFECTION: STUDY OF 11 MOTHER/CHILD PAIRS IN A SINGLE CENTER

C. Alejandre,* M. Espiau,* P. Soler-Palacín,* N. Martín,† A. Martín,* and C. Figueras,* *Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron Hospital; and †Pediatric Ophtalmology Unit, Vall d’Hebron Hospital, Barcelona, Spain.

Background and Aims: The clinical pattern of congenital Toxoplasma gondii (Tg) infection ranges from asymptomatic to severe manifestations. The risk of late complications has been extensively described. Aim: to evaluate long-term outcome of vertically transmitted Tg infection.

Methods: Retrospective study (January 1997–December 2007) of all children in which Tg infection was microbiologically confirmed during pregnancy or in the first year of life.

Case Definition: positive IgM and/or IgA, persistence of positive IgG beyond 12 months of age or positive PCR in amniotic fluid or blood. Yearly ophthalmological and clinical follow-up was performed in all cases.

Results: Eleven children were included. Median age: 9 years (2–22). Vertical infection was dated in the third trimester in 6/11 cases (undetermined in 5). Amniocentesis was performed in 2/11 cases, with positive PCR to Tg in both. In the resting 9 cases diagnosis was established by serological methods. Spyramicin was given to 7/11 mothers, and 8/11 children received treatment with pyrimethamine-sulphadiazine and folinic acid for one year. 4/11 newborns were clinically asymptomatic and 7/11 symptomatic. Sequelae were detected in both groups (2/4 and 6/7): chorioretinitis (7), severe neurological sequelae (3,1 died) and partial hearing loss (1). Late onset and reactivation of chorioretinitis were detected at a median age of 3,5 years (4 cases).

Conclusions: The risk of late onset complications (mainly chorioretinitis) even in asymptomatic Tg infected newborns confirms the importance of a long-term ophtalmological follow-up. Significant efforts should be done to standardize the management of Tg infection during pregnancy.

P124

CONGENITAL ANOMALIES AMONG NEONATES BORN TO WOMEN WITH ACTIVE CYTOMEGALOVIRUS INFECTIONS

H. Ali, Microbiology & Immunology, Dean, Technical & Health Institute-Zakho, Zakho, Iraq.

Background and Aims: Cytomegalovirus (CMV) can cross the placenta and cause fetal infections. This study was sought to follow-up a number of pregnant women with serological evidence of active CMV infection until delivery to determine the incidence and types of symptomatic congenital CMV infections among the neonates.

Methods: Sixty women with and 50 women without serological evidence of active CMV infection were enrolled in this study. Infection was diagnosed by utilizing specific ELISA kits to detect the specific CMV-IgM and IgG isotypes in serum of the participant women and CMV-IgM marker in cord blood samples obtained from the neonates after delivery.

Results: Specific CMV-IgM isotype was detected in cord blood samples of 6 (10%) overtly sick infants (with different congenital anomalies) born to mothers with serological evidence of active CMV infection. Central nervous system abnormalities were detected in all six cases (2 with microcephaly and 4 with hydrocephaly).

Conclusions: Congenital CMV infection should be suspected in infants born with congenital abnormalities, especially those of the central nervous system. Moreover, the detection of more cases of hydrocephalus in this region is worthwhile and notable.

P125

PERINATAL TRANSMISSION OF HEPATITIS C VIRUS-HOSPITAL SANTO ANDRÉ, LEIRIA-PORTUGAL 2002–2006

S. Bacalhau, C. Timóteo, and J. Agro, Serviço de Pediatria, Hospital Santo André, Leiria, Portugal.

Background: The vertical transmission of hepatitis C virus (HCV) is the main route of infection in children, occurring in rare cases (0–10%). Current recommendations for HCV screening include anti-HCV testing at age >18 months to reduce false positives and false negatives.

Aims: To characterize the population of children born to HCV-positive mothers in Hospital Santo André. To identify risk factors for perinatal HCV transmission and improve approach to HCV screening in our department.

Methods: Retrospective descriptive study of children born to HCV-positive mothers between January 2002 and December 2006. New anti-HCV testing were performed in cases that didn't meet recommendations for HCV screening.

Results: We included 59 children born to HCV-positive mothers in a total of 12 985 births, corresponding to a prevalence of 0.45%. We identified a child with HCV infection without any risk factor for perinatal transmission. Of the children with negative anti-HCV at age 18 months, half had done anti-HCV prior to age 9 months, all positive. Children discharged because of negative anti-HCV at age 9 months were called in a 2nd phase of the study, for new anti-HCV at age >18 months, beeing all negative.

Conclusions: The perinatal HCV transmission rate was 2.9%. There were no identified risk factor for perinatal transmission in the single case of HCV infection. Regarding anti-HCV at age 9 months, there was a high rate of false positives but no false negative. This study has enabled the detection and correction of mistakes in our approach to HCV screening.

P126

CONGENITAL TUBERCULOSIS: REPORT OF TWO CASES

T. del Rosal,* F. Baquero-Artigao,* M.J. Garcia-Miguel,* G. Muñoz,† E. Valverde,† and F. del Castillo,* *Pediatric Infectious Diseases Unit; and †Neonatal Intensive Care Unit, La Paz Children Hospital, Madrid, Spain.

Background and Aims: Congenital tuberculosis is a rare disease, fatal when untreated and with non specific signs and symptoms.

Methods: Two cases of congenital tuberculosis diagnosed at Hospital La Paz (Spain) in the last year are described. Both children were born in Madrid but their mothers came from Morocco.

Results: Case 1: A 3-month-old boy presented with cough from the first month of life. Chest radiograph showed hilar adenopathy and tuberculin skin test was positive. After 12 days of treatment, the patient's condition worsened developing respiratory distress and cyanosis. CT scan and bronchoscopy revealed left main bronchus compression. Gastric aspirate culture was positive for M. tuberculosis. The mother suffered from primary sterility due to tubal obstruction and pregnancy was achieved by in vitro fertilization.

Case 2: An 8-day-old preterm neonate presented with fever and respiratory distress. He received broad-spectrum antibiotics with no improvement. Chest radiograph showed miliary pattern. Tuberculin skin test was negative. Bronchial washings yielded acid-fast-bacilli (AFB) on smear microscopy and M. tuberculosis by polymerase chain reaction (PCR) and by culture.Both children were successfully treated with antitubercular drugs and corticosteroids.Both mothers had normal chest radiograph and negative sputum AFB smear and culture. Tuberculin skin test was positive in case 1 1 and negative in case 2. Endometrial biopsies demonstrated tubercular granulomas and PCRs were positive for M. tuberculosis.

Conclusions: Congenital tuberculosis can mimic many perinatal diseases making the diagnosis difficult. It is important to consider it, particularly if the mother is at risk for tuberculosis, or suffers from tubal sterility.

P127

THE CORRELATION BETWEEN ASYMPTOMATIC CONGENITAL CYTOMEGALOVIRUS (CMV) INFECTION AT BIRTH AND LATER OUTCOMES IN CHILDREN

K. Gogberashvili, and N. Mahjavidze, Pediatrics, Tbilisi State Medical University, Tbilisi, Georgia.

Abstract: The correlation between asymptomatic congenital CMV infection at birth and later physical and developmental outcomes of children remain unclear.

Objectives: This study was undertaken to ascertain whether children with congenital cytomegalovirus (CMV) infection at birth, but without neurologic symptoms, differed in somatic, neurologic, developmental, or intellectual status from matched control children at 4–6 years of life.

Study Design: Retrospective cohort study. 32 of all the 44 children with asymptomatic congenital CMV infection at birth were investigated at age of 5–6 years for surveying physical growth and intellectual developments. The neurologic status was assessed with the Stott test and intellectual development with the Wechsler Intelligence Scale for Children.

Results: no significant differences were noted between the asymptomatic congenital CMV infection children and the controls in average weight, height and head circumference (both P > 0.05). However, the intellectual development was disproportion in asymptomatic congenital infected children. Compared with the control group, both global development quotient (DQ) and full-scale intelligence quotient (IQ) scores of asymptomatically infected children were worse (t = 2.19, P = 0.031; t = 2.48, P = 0.015), especially on language DQ scores (t = 3.25, P = 0.002) and verbal IQ scores (t = 3.88, P = 0.001), as the incidence rates of mental retardation (DQ/IQ < 70), (P > 0.05).

Conclusions: Although asymptomatic congenital CMV infection did not have significant influence on the later physical development, it is obviously an important factor correlating with long-time intellectual and cognitive outcomes, especially on the development of language. It is necessary to survey CMV congenital infection and monitor the early intellectual development of children with asymptomatic congenital CMV infection.

P128

GANCICLOVIR TREATMENT OF CONGENITAL CYTOMEGALOVIRUS DISEASE IN TERM AND PRETERM NEWBORNS

M. Golkowska, A. Dobrzanska, J. Czech-Kowalska, and D. Gruszfeld, Neonatology Department, The Children's Memorial Health Institute, Warszawa, Poland.

Background and Aims: Ganciclovir (GCV) is used in the treatment of serious congenital cytomegalovirus disease in the newborns. The treatment needs to be started early after birth and be extended to obtain adequate therapeutic effect.

A total of 57 newborns with a history congenital CMV disease, hospitalized at the Neonatology Department between January 2002 and December 2006, treated with GCV, were analyzed.The aim of this study was to estimate the safety of ganciclovir therapy in term and preterm newborns.

Methods: The individual doses of GCV were used and its blood levels were analyzed with HPLC method.In the study group there were 47 (82,46%) term newborns and 10 (17,54%) premature babies (≈37 weeks).

Results: In the study group the mean body weight in the start up point of GCV therapy was 3188,60 g ± 747,65 g (1400–4865 g). The treatment was started in the 14th (5–35) day of life. The mean duration of therapy was 21 (13–44) days. The mean daily dose of GCV was 12,28 ± 4,82 mg/kg/day. In 36 (63,16%) newborns the doses were increased to obtain appropriate therapeutic levels of the drug in the blood.

The following side effects were noted both in term and preterm newborns during the GCV treatment: neutropenia in 19 (33,33%), anemia in 30 (52,63%), elevated aminotransferase levels in 8(14,04%).No thrombocytopenia was observed. Renal function during and after treatment was normal.

Conclusions: GCV is well tolerated in newborns with congenital cytomegalovirus infection, both mature and premature,if its serum concentration monitoring and its individual doses are used.

P129

SINGLE CENTRE EXPERIENCE WITH CONGENITAL TOXOPLASMOSIS: ANALYSIS OF PATIENTS MANAGED IN OUR DEPARTMENT (WROCLAW, POLAND) IN LAST 8 YEARS

E. Kuchar, L. Szenborn, Z. Szymanska-Toczek, J. Jasonek, and K. Zyzak, Pediatrics and Infectious Diseases, Medical University of Wroclaw, Wroclaw, Poland.

Background and Aims: Congenital Toxoplasmosis may involve the retina and brain with long-life sequelae. Signs and symptoms are similar to other congenital infections and the disease is often diagnosed late. The aim of the study was to sum up single centre experience with management of toxoplasmosis and analysis of patients (age, sex, manifestations, mode of diagnosis) treated in our department in last 8 years.

Methods: Descriptive retrospective study; 13 children with congenital toxoplasmosis attending the Department of Pediatrics Infectious Diseases in Wroclaw, Poland between 2000 and 2007 were enrolled.

Results: 33 children suspected of congenital Toxoplasma gondii infection were referred to our department (about 0,4–0,5% of all admissions) in analyzed period. The diagnosis was confirmed in 13 children (8 girls and 5 boys) aged 5 days-3 years (median 3 months), Toxoplasmosis was responsible for 0,1–0,3% of all admissions per year. Disease was diagnosed with serological tests in all patients but two: in one the diagnosis was made by PCR and in the other during autopsy. The most frequent manifestation were: intracranial calcifications, dilatation of ventricles and retinochoroiditis observed in 6/13, 6/13 and 5/13 patients respectively. 12/13 children were treated with pirymethamine/sulpha with 100% survival but sequelae were found in 10/12 children in follow up ranging from 1 to 8 years.

Conclusion: Though congenital toxoplasmosis is rarely responsible for hospitalizations in children, it results in sequellae in the vast majority of children and should be considered in any child with unexplained abnormalities of eye or CNS.

P130

MONITORING THE HIGHS AND LOWS OF CONGENITAL CMV

S. Luck,* M. Sharland,† C. Atkinson,* and P. Griffiths,* *Centre for Virology, UCL Medical School; and †Paediatric Infectious Diseases, St George's Hospital, London, UK.

Background: During treatment for congenital CMV (cCMV) clinicians may monitor viraemia but there is currently no information to support its superiority to viruria. No published studies to our knowledge report on viral load (VL) in saliva or the relationship between VL in different body fluids.

Aims: To observe and compare changes in VL in different body compartments during treatment for cCMV.

Methods: VL of samples of blood, urine and saliva was measured using CMV PCR as part of a prospective study. VL data for blood and urine were also available from a national treatment registry, set-up with ESPID funding, and from clinical samples received in our laboratory.

Results: A total of 207 samples (83 blood; 86 urine; 38 saliva) were obtained at a mean of 9 time points from 12 babies treated for cCMV. 10/12 babies were viraemic at birth. Mean VL from specimens within 7 days of commencing treatment was 3.2 ± 0.94, 7.1 ±1.1 and 7.4 ±1.0 in blood, urine and saliva respectively. Urine and saliva VL followed a similar declining trend that was distinct from that seen for blood. Complete viral suppression was uncommon during a 42 day course of treatment.

Discussion: Despite a lower baseline, full suppression of viraemia during treatment was rare. Preliminary results show that saliva may be a useful tool for monitoring viral response to treatment. The relevance of viral suppression in each of these body compartments and how they relate to VL in the central nervous system are yet to be determined.

P131

MOTHER-TO-CHILD TRANSMISSION OF CYTOMEGALOVIRUS IN CHILDREN OF HIV-POSITIVE MOTHERS

A. Mania, K. Mazur-Melewska, M. Figlerowicz, A. Kowala-Piaskowska, and W. Sluzewski, Department of Infectious Diseases and Child Neurology, University of Medical Sciences, Poznan, Poland.

Abstract: Infections with cytomegalovirus (CMV) remain significant clinical problem especially concerning immunodeficient patients. Children of HIV-positive mothers undergo panel of diagnostic test for possible vertical infections. The aim of the study was to analyse the rate of CMV-transmission in these children in addition to routine monitoring.

Forty newborns of HIV-positive women were enrolled in the study, 26 girls and 14 boys, gestational age 33–39 week (mean 36.8 ± 1.8 week), birth weight 2060–3820g (mean 2700 ± 366g). Children were tested for HIV, HCV, CMV in week 1, 4 and 16 after birth. In all children HIV viral culture with detection of p24 antigen and HIV-RNA was preformed. Children positive for anti-HCV antibodies were tested for the presence of HCV-RNA in the blood by RT-PCR. Patients with the presence anti-CMV antibodies were tested for the presence of CMV-DNA in blood and urine by quantitative PCR assay. History data, birth parameters and clinical findings were compared between CMV-positive and negative children.

No child from the study group was found to be HIV-positive. One HCV infection was detected. However CMV-DNA was found in the blood in 12 patients (30%) and in the urine in 30 children (75%). Children with CMV-DNA in the urine had lower birth weight (2607.6 ± 268.0 vs. 2996 ± 493.9; P = 0.03). In 2 children CMV-DNA was detected in the blood late the week 16 with significant peripheral lymphadenopathy.

CMV-infection is relatively common among children of HIV-positive women. Test should be therefore included into standard monitoring for early detection of possible symptomatic cases.

P132

SEROPREVALENCE FOR TOXOPLASMOSIS OF MATERNAL SEROLOGY FOR COLLECTION OF UMBILICAL CORD BLOOD IN BRAZIL

E. Migowski,*† B. Pugliese,* L. Serpa,* E. Loureiro-Vieira,* C.E. Czeresnia,‡ L.F. Alencar,§ B. Alencar,§ L. Evangelista,‡ C. Dale,¶ C. Castro,∥ I. Proença,† I. Tadeu,** N. Schymura,† and F. Leite,∥ *Federal University of Rio de Janeiro; †Institute Prevenir É Saúde, Rio de Janeiro; ‡Célula Mater, São Paulo; §Clínica Ginecológica Wunder & Alencar; ¶Clínica Médica Carlos Lowndes Dale; ∥Núcleo Integrado da Mulher, Rio de Janeiro; and **Cordvida Umbilical Cord Blood Bank, São Paulo, Brazil.

Background and Aims: Umbilical cord blood (UCB) is an important source of stem cells. In Brazil, although the storage do not requires maternal serological screening for Toxoplasma gondii, sometimes IgG and IgM anti-toxoplasma are done. We aimed to describe the percentage of TOXO (IgG and IgM) reactive samples in mothers who decided to store UCB in a private umbilical cord blood bank.

Methods: Descriptive, transversal and retrospective study of 1931 blood samples. Results of IgG and IgM anti-TOXO had been carried through.

Results: All 1931 samples analyzed were obtained from high socioeconomic class women collected by a private UCB bank. IgG negative 1359 (70,4%), IgG positive 571 (29,6%), inconclusive 1 (0,1%), IgM negative 1918 (99,3%), IgM positive 11 (0,6%), inconclusive 2 (0,1%).

Conclusions: The seroprevalence of anti-toxoplasma IgG in this group was 29.6%, lower than in general Brazilian pregnant women’s population, that varies from 32.4% to 77.1%, depending on the region. That can be explained by the higher socioeconomic conditions of the this group. The seronegative leads to the risk of the women infection during pregnancy. Only 0.6% had probably recent infection (demonstrated by the presence of IgM anti-toxoplasma), what places the newborns at risk of infection. The risk of transmission to the fetus on an acute infection is 20- 50%, and can cause hydrocephaly, corioretinitis, mental retardation, cerebral calcification and death.

P133

SEROPREVALENCE FOR CYTOMEGALOVIRUS OF MATERNAL SEROLOGY FOR COLLECTION OF UMBILICAL CORD BLOOD IN BRAZIL

E. Migowski,*† B. Pugliese,* L. Serpa,* E. Loureiro-Vieira,* C.E. Czeresnia,‡ L.F. Alencar,§ B. Alencar,§ L. Evangelista,¶ C. Dale,∥ C. Castro,** I. Proença,† I. Tadeu,†† N. Schymura,† and F. Leite,** *Federal University of Rio de Janeiro; †Instituto Prevenir É Saúde, Rio de Janeiro; ‡Célula Mater, São Paulo; §Clínica Ginecológica Wunder & Alencar; ¶Célula Mater; ∥Clínica Médica Carlos Lowndes Dale; **Núcleo Integrado da Mulher, Rio de Janeiro; and ††Cordvida Umbilical Cord Blood Bank, São Paulo, Brazil.

Background and Aims: Umbilical cord blood (UCB) is an important source of stem cells. In Brazil storage requires maternal serological screening, including IgG and IgM anti-cytomegalovirus (CMV). We aimed to describe the percentage of CMV (IgG and IgM) reactive samples in mothers who decided to store UCB in a private umbilical cord blood bank in Brazil.

Methods: Descriptive, transversal and retrospective study of 3779 blood samples, collected by a private UCB bank. Results of IgG and IgM anti-CMV had been carried through.

Results: All 3779 samples analyzed were obtained from high socioeconomic class women. IgG negative 1163 (30,8%), IgG positive 2578 (68,2%), inconclusive 38 (1,0%), IgM negative 3665 (96,9%), IgM positive 61 (6,1%), inconclusive 52 (1,4%), not available 1 (0,02%).

Conclusions: The seroprevalence of CMV infection in this group was 68.2%, lower than in general

Brazilian population (80%), which can be explained by the higher socioeconomic conditions of this group. However, 1.6% had probably recent infection or reactivation of the virus (demonstrated by the presence of IgM anti-CMV). Intrauterine CMV infection is the most common of all recognized intrauterine infections, occurring in an estimated 0.4%-2.3% of all live births, and it can have a variable outcome. Although studies on long-term follow-up are needed for a better understanding of the effectiveness of mass screening, identifying the women under risk of primary CMV infection may help to prevent congenital infection and to provide early treatment for the neonates affected.

P134

MATERNAL SEROLOGIC PROFILE FOR COLLECTION OF UMBILICAL CORD BLOOD IN BRAZIL

E. Migowski,*† B. Pugliese,* E. Loureiro,* C.E. Czeresnia,‡ L. Evangelista,‡ I. Tadeu,§ L.F. Alencar,¶ B. Alencar,¶ C. Dale,∥ N. Schymura,† F. Leite,** I. Proença,† and C. Castro,** *Federal University of Rio de Janeiro; †Institute Prevenir ú Saúde, Rio de Janeiro; ‡Célula Mater; §Cordvida Umbilical Cord Blood Bank, São Paulo; ¶Clínica Ginecológica Wunder & Alencar; ∥Clínica Médica Carlos Lowndes Dale; and **Núcleo Integrado da Mulher, Rio de Janeiro, Brazil.

Background and Aims: Umbilical cord blood (UCB) is an important source of stem cells. According to RDC- resolution #153/04 of ANVISA, in Brazil, storage requires maternal serological screening, obtained during the partum. We aimed to analyze and describe the serologic profile of mothers who decided to store UCB in a private cord blood bank.

Methods: Descriptive, transversal and retrospective study of 3780 blood samples collected by a private UCB bank. These serologies had been carried through: HBsAg, anti-HCV, Lues (VDRL and FTA-abs), HIV I/II, HTLVI/II.

Results: From 3780 samples, 21 (0.6%) were positive for HBsAg, and only 6 (0.2%) were positive to anti-HCV. For HIV, 2 (0,1%) were positive, confirmed by other exam. For HTLVI/II, from 3778 samples, 6 (0.2%) were positive. The same result was found for Lues, using the VDRL test, although only one (0.03%) was confirmed in the FTA-abs test.

Conclusions: All samples were obtained from high socioeconomic class women, who probably are concerned about diseases prevention, as they pay for a private cord blood bank. Therefore, the good results found in this study, probably does not represent the serologic profile for general population. Other researches among this topic must include other segments of the population, including mothers from different social levels. In this way, we can build effective strategies to prevent infectious disease in pregnant women and their children.

P135

CT/ECHOCARDIOGRAPHIC/TRANSCRANIAL TRANSFONTANELLE/ABDOMINAL ULTRASOUND FEATURES IN PAEDIATRIC NON SYNDROMIC ISOLATED CONGENITAL OPHTHALMOPATHIES, IMPLICATIONS FOR THE DETECTION OF A COVERT CONGENITAL RUBELLA SYNDROME

E. Onyekwelu, Paediatrics, Royal Victoria Teaching Hospital, Banjul, The Gambia.

Background/Purpose: In Congenital Rubella syndrome there are constellations of clinical features implicationg the Central nervous system, Cardiovascular system,Eyes and the heamato-lymphatic systems.Embryological, the optic vesicles/cups are derived from the fore brain, hence it will be plausible to infer that causalities will involve the two structures synchronously. Cardiovascular defects are commonly associated with other congenital structural anomalies with quality of life and mortality implications. A review where an interplay of imaging modalities was applied to explore causality factors related to congenital rubella syndrome in a case series of clinically congenital isolated opthalmopathies is described.

Imaging Details: The Computer assisted tomographic/ Echocardiographic/ Transcranial Transfontanelle Ultrasound features in 15 cases of congenital Ophthalmopathies presenting in infancy and childhood were reviewed.

Cases: Congenital developmental cataracts 2, familial, 5 non familial, 5 congenital glaucoma/buphthalmos, 3 nystatgmus.The High Resolution CT 2D/M mode Echo/Transcranial Transfontanelle Ultrasound were undertaken,evaluated,validated and interpreted in a standardized manner by the Radiologist/Cardiologist. The study concerned 9 females and 7 males all aged below one year.

Results: The features were piquantly unremarkable in all cases. This Potpourris of imaging modalities will be most relevant in settings where causality by Rubella is plausible but may be very clinically covert. The unyielding imaging features in these cases intimates that structural defects within the limits of these imaging modalities are unlikely to be related defects, it is possible that on progression to MRS/SPECT/ Electroretinogram/Visual Evoked Potentials more eloquent implicating or associated lesions could be deciphered which could direct genetic counseling, generate hypothesis and could also direct management and research.

P136

CONGENITAL SYPHILIS—A PREVENTABLE DISEASE STILL OCCURRING-REPORT OF FOUR CASES

I. Sampaio, G. Oliveira, and M. Albuquerque, Pediatrics, Hospital de Santa Maria, Lisbon, Portugal.

Introduction: Congenital syphilis is preventable by serological screening and correct treatment of pregnant women. However it is still a significant public health issue and increasing incidence has been reported in several European countries.

Procainic-penicilin is not currently available in our country and choosing to treat suspected cases implies admission for 10 days of IV-treatment.

Case Report: We report four cases fulfilling the CDC case definition of congenital syphilis, admitted to our unit in one-month period for IV-treatment with penicillin.

Two newborns had unsupervised gestations. One mother refused treatment while the others received adequate penicillin regimen. One mother was treated in the last month of pregnancy, and in one other case the partner refused treatment. Only in one child the non-treponemic titre was fourfold greater than maternal titre. In the other cases decision to treat was based on presence of symptoms, absence of expected decrease in maternal non-treponemic titre after treatment, and mother treated one month before delivery.

Two of the newborns were born prematurely and small for gestational age, one of them had severe disease with hepatosplenomegaly, ascitis, thrombocytopenia and conjugated hyperbilirrubinemia.

None of the children had alterations in the long bone X-ray and LCR examination was not conclusive.

Discussion: These four cases illustrate the clinical implications of a preventable disease. Current guidelines result in treating many non-infected children. Appropriate prenatal measures can not only avoid the consequences of dramatic symptomatic cases as well as prevent the long hospital stay needed to complete treatment of suspected cases.

P137

ANTENATAL DIAGNOSTIC PROBLEM OF CONGENITAL RUBELLA

I. Shah, and S. Bhatnagar, B.J.Wadia Hospital for Children, Mumbai, India.

Abstract: Rubella infection in the mother during pregnancy can lead to congenital rubella syndrome characterized by microcephaly, growth retardation, cataracts, patent ductus arteriosus, mental retardation and hepatosplenomegaly especially if rubella is acquired in the 1st trimester. With adequate prenatal screening tests and use of rubella vaccine, perinatal transmission of rubella has almost been abolished in developed countries. During pregnancy, several laboratory tests such as amniotic fluid analysis and fetal blood sampling for rubella polymerase chain reaction (PCR) or presence of rubella IgM have been used to diagnose fetal affection and then determine about continuation or medical termination of pregnancy.

Case Report: A 30 day old preterm neonate presented with jaundice and clay coloured stools since Day 7 of life. He was second of twins with birth weight of 800 grams and delivered at 7 months of gestation. Mother had fever with rash at 5 months of gestation and her TORCH titres at that time were positive for Rubella IgM. She underwent amniocentesis and amniotic fluid rubella PCR was negative following which she continued her pregnancy. Both babies were tested for Rubella IgM at birth and both had a positive Rubella IgM though urine for rubella PCR were negative. On presentation, the child had jaundice, Ascitis, hepatosplenomegaly, dilated abdominal veins. Other systemic examination was normal. Investigations showed thrombocytopenia, hyperbilirubinemia, elevated liver enzymes and peripheral pulmonary Stenosis suggestive of congenital rubella syndrome. Subsequently the child had decreasing jaundice and normalization of liver enzymes after 2 months.

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EMERGING AND RE-EMERGING INFECTIONS

P138

HUMAN METAPNEUMOVIRUS AND HUMAN CORONAVIRUS INFECTION AND PATHOGENICITY IN SAUDI CHILDREN HOSPITALIZED WITH ACUTE RESPIRATORY ILLNESS

S. Al Hajjar,* S. Al Thawadi,† A. Al Seraihi,‡ S. Al Muhsen,* and H. Imambaccus,† *Pediatrics; †Pathology and Laboratory Medicine; and ‡Pediatric Hematology Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.

Background and Aims: Human metapneumovirus (hMPV) and the Netherland human coronavirus (HCoV-NL63) have been isolated from children with respiratory tract infection. The prevalence of these viruses has not been reported from Saudi Arabia. We sought to determine whether hMPV and HCoV-NL63 are responsible for acute respiratory illness and determine clinical features and severity in hospitalized pediatric patient population.

Methods: Nasopharyngeal specimens from children less than 16 years old who were with acute respiratory diseases were tested for hMPV and HCoV-NL63 by reverse transcriptase-polymerase chain reaction. Samples were collected from July 2007 to November 2008.

Results: Both viruses were found among Saudi children with upper and lower respiratory tract diseases during the autumn and winter of 2007 and 2008, contributing to 141.1% of all viral diagnoses with individual incidences of 9.4% (hMPV) and 1.3% (HCoV-NL63) among 489 specimens. Initial symptoms included fever, cough, nasal congestion. Lower respiratory tract disease occurs in immunocompromised individuals and those with underlying conditions. Clinical finding of respiratory failure and culture negative shock have occurred in 7 children infected with hMPV and have of hematologic malignancies, mylofibrosis, Gaucher disease, and congenital immunodeficiency: 2 of the 7 patients died with acute respiratory failure. All children infected with HCoV-NL63 had underlying condition, one of the 4 patients developed respiratory failure.

Conclusion: hMTP and HCoV-NL63 are important cause of acute respiratory illness among hospitalized Saudi Children. hMPV infection in the lower respiratory tract is associated with morbidity and mortality in immunocompromised children. HCO-NL63 may cause severe lower respiratory disease in those with underlying condition.

P139

ESBL (EXTENDED SPECTRUM BETA LACTAMASE) INFECTIONS-AN EMERGING PROBLEM IN CHILDREN

M. Anderson,* and M. Khare,† *Derbyshire Children's Hospital; and †Dept. of Pathology, Derby City General Hospital, Derby, UK.

Background and Aims: There is an emergence of infections with ESBL-producing micro-organisms recently. They remain poorly characterised in children. We sought to characterise children in a teaching hospital from whom an ESBL-producing organism had been isolated.

Methods: We identified all children under sixteen years of age who had ESBL-producing organism isolated in the year 2007.The referral source was contacted for further information where possible. Clinical details and treatment were analysed to determine likelihood of infection or colonisation.

Results: Fifteen children were identified, aged three months to nine years. Thirteen isolates were obtained from urine, one each from a wound swab and a cough swab. Three isolates were obtained from hospitalised children, but only one of these needed treatment. This child presented with lymphadenitis and continued to be pyrexial and irritable despite treatment with cephalosporin. Subsequently ESBL producing organism was isolated from the urine and she responded to appropriate antibiotic. Data was available for nine out of twelve patients originating from the community. Of these, four had repeat specimens which didn't grow ESBL-producer again. Three were treated and two remained asymptomatic and well. Two asymptomatic children had recently visited the Indian subcontinent.

Conclusions: ESBL-producing organisms are increasingly isolated in children, but from our review appear frequently to be colonisers rather than pathogens. However, it is very important to be vigilant about the possibility of ESBL infection in children especially if they fail standard antibiotic therapy or they had recent visit to Indian subcontinent which has high reservoir of resistant organisms.

P140

TICK-BORNE LYMPHADENOPATHY, A RICKETTSIAL DISEASE IN CHILDREN. DESCRIPTION OF 34 CASES IN SPAIN

E. Antón,* T. Muñoz,† F.J. Travería,† M. Quesada,* I. Sanfeliu,‡ and F. Segura,* *Infectious Disease Department, Corporació Sanitària Parc Tauli. Department of Medicine (Universitat Autonoma de Barcelona); †Paediatric Department, Corporació Sanitària Parc Tauli.; ‡Laboratory of Microbiology, Corporació Sanitària Parc Tauli. UDIAT. Department of Medicine (Universitat Autonoma de Barcelona), Sabadell, Spain.

Background: A newly recognized rickettsial disease, named TIBOLA (tick-borne lymphadenopathy), was first identified twelve years ago. The aim of this study was to describe the epidemiological and clinical aspects of patients with TIBOLA diagnosed in children in Catalonia (North-eastern Spain).

Methods: The study included all patients <14 years treated in our hospital who presented characteristic clinical symptoms of TIBOLA (the presence of an inoculation lesion after a tick bite with regional lymphadenopathies). Inclusion period: 2000–2008. Serology tests: for Rickettsia conorii and R. slovaca. The presence of Rickettsia was assessed by PCR in blood, skin biopsy and ticks from patients.

Results: Thirty four patients fulfilled the inclusion criteria. Mean age: 7.2 years (2–13). 23 males. 26 cases appeared from October to April. 33 patients were tick bite on the scalp. A necrotic eschar was observed in 27 cases and was surrounded by a perilesional erythematous halo in 21. All patients had painful regional lymphadenopathies. Serology for R. conorii was positive in 4 cases. Serology for R. slovaca and PCR were negatives.The tick, identified as Dermacentor marginatus, was studied in six patients. Three out of them were positive for sequences compatible with R. slovoca as determined by DNA sequencing. 30 patients received antibiotic treatment. Progress was satisfactory in all cases.

Conclusion: TIBOLA is present in Catalonia. Although clinical and epidemiologic manifestations are very specific microbiologic confirmation is difficult.

Work supported by a FIS 060536 and by REIPI RD06/008.

We thank MM. Nogueras, I. Pons, S. Lario and J. Luelmo.

P141

SITUATION OF CRIMEAN-CONGO HAEMORRHAGIC FEVER IN IRANIAN CHILDREN IN 2008

S. Chinikar,* R. Mirahmadi,* A. Ghalyanchi-Langeroudi,* M. Moradi,* M. Markarian,* T. Jalali,* M. Rahpeyma,* S.M. Ghiasi,* M.M. Goya,† M.R. Shirzadi,† and M.M. Zeinali,† *Pasteur Institute of Iran; and †Ministry of Health, Center of Disease Control (CDC), Tehran, Iran.

Background and Aims: Crimean-Congo Haemorrhagic Fever (CCHF) disease is one of the most important infectious diseases in Iran. This viral zoonotic disease has a mortality rate around 50%, its agent is a virus of the genus Nairovirus and family Bunyaviridae. It is transmitted to humans by infected tick bite, handling of infected blood or tissues or nosocomially. CCHF has been reported from Africa, Eastern Europe, Asia and the Middle-East.

Methods: The laboratory of Arboviruses and Viral Haemorrhagic Fevers of the Pasteur Institute of Iran (National Reference Center) has collected Iranian CCHF probable children's sera (aged from 2 months to 14 years) in 2008. They were all checked by specific ELISA for detecting antibodies against CCHFV and by RT-PCR assay for detecting the genome of the virus.

Results: In 2008, the number of confirmed cases is 9 and 2 ended to death. Among the 9 confirmed cases, 5 were boys and 4 were girls. Two of confirmed cases had a history of contact with the blood or tissue of infected livestock.6 were of rural origin and 3 were of urban origin.

Conclusions: Our studies demonstrate that CCHF is one of the children infectious diseases in rural areas in Iran. These studies also show the fact that in rural areas children who had contact with blood and exudates of infected livestock (as CCHF is asymptomatic in livestock) are more at risk. So informing children and their parents about routes of transmission and prevention of this disease is really crucial.

P142

SCREENING OF CHAGAS DISEASE IN BOLIVIAN PREGNANTS AND FOLLOW UP OF THEIR CHILDREN IN A NON-ENDEMIC AREA

L. Gonzalez-Granado,* M.I. Gonzalez-Tomé,* P. Rojo Conejo,* I. Camaño,† E. Salto,‡ and M. Flores,§ *Pediatrics; †Obstetrics and Ginecology; ‡Microbiology, Hospital 12 Octubre/Universidad Complutense; and §Centro Nacional de Microbiología, ISCIII, Madrid, Spain.

Introduction: Spain is the first country in bolivian immigration all over the European Union. The aim is to determine the prevalence of Chagas Disease in bolivian pregnant to find cases of vertical transmission and its associated characteristics

Methods: Prospective, cross-sectional study. Percentage of immigrations: 20%. Group of study bolivian pregnants attended at tertiary hospital in the south of Madrid. As screening test a immunochromatographic one was used, and confirmed by ELISA/IFI when positive. Case was defined by positive serology with two different techniques. In the child: Mother infected and positive parasitologic assay or positive serology at the seventh month of life.

Results: 327 pregnant and their 328 children were studied. Median age 27 (range 15–44). Median gestational age: 39 wk (range 26–42). By regions, from Cochabamba were 63%. The 54% came from rural areas. The 5% has received blood donations in Bolivia. The 67% had seen triatomids at home. The 54% had lived in adobe houses. The 62% of them has been travelling to Spain since 2004. Almost 80% has never returned to their country. Any direct relative with Chagas Disease: 28,3%. Relatives infected and dead: 6,6%. Prevalence of Chagas Disease in the study population: 18%. The rate of vertical transmission was 2%. There is statistical difference between infected and non-infected pregnant and living in urban or rural area but not comparing apgar, weight or gestational age.

Conclussions: Screening of Chagas’Disease should be considered in bolivian pregnants due to the high rate of infected women in this population and the possibility of vertical transmission.

P143

DETECTION OF HUMAN RHINOVIRUS C IN CHILDREN WITH ACUTE LOWER RESPIRATORY TRACT INFECTIONS, SOUTH KOREA

T.H. Han,* J.-Y. Chung,† E.-S. Hwang,‡ and J.-W. Koo,† *Laboratory Medicine; †Pediatrics, Sanggyepaik Hospital, Inje University College of Medicine; and ‡Microbiology and Immunology, Seoul National College of Medicine, Seoul, South Korea.

Backgroud and Aims: Human rhinoviruses (HRV) are common causes of respiratory disease, but their molecular epidemiology has been poorly investigated. Recently, new HRV genotype, HRV-C, was identified, which clinical spectrum is still not clear. The purpose of this study was to investigate the molecular epidemiology of rhinovirus in children hospitalized with acute respiratory disease in Korea.

Methods: From the 148 HRV positive samples, a total of 54 samples which were negative for other respiratory viruses were included in the study for subsequent sequence analysis from January 2006 to December 2006. All specimens were tested for the presence of human respiratory syncytial virus (hRSV), influenza virus A, influenza B, parainfluenzavirus, and adenovirus using direct immunofluorescent assay, and for human metapneumovirus (HMPV) by RT-PCR. For genotyping of hRV, primer P1-1 were used as the forward primer and multiple primers were used for reverse primer; P3-1, P2-1, P2-2 and P2-3.

Results: Upon 5'-NCR gene analysis of HRV, 26 HRV strains were HRV-A, 11 were HRV-A2, 6 were GAC, and 2 were HRV-B. HRV-C was detected in 9 patients. The HRV-C positive patients had variable diseases including pneumonia, bronchiolitis, and asthma exacerbation. None of the HRV-C patients required admission to intensive care unit. HRV-C infection was at their peak in September.

Conclusion: HRV-C was detected in children hospitalized with LRTIs in Korea, which suggest the possible role of HRV-C in children. The standardization of diagnostic method for HRV-C is needed, becasue diverse strains of HRV are co-circulating including HRV-C and GAC.

P144

THE SEVERITY OF PERTUSSIS IN YOUNG INFANTS IN THE UNITED ARAB EMIRATES

M. Howidi, R. Nair, and J. Rajah, Pediatrics, Shaikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.

Background: Pertussis is one of the vaccine preventable diseases that can potentially be fatal. Despite the availability of a vaccine, the disease continues to pose a significant risk to infants. The case fatality varies but generally ranges between 2–3 percent in infants. Risk factors for death need to be identified and addressed before the disease progresses to death.

Objectives: To evaluate the clinical course of pertussis presented to Shaikh Khalifa Medical City (SKMC). To identify the risk factors for mortality in this group of children.

Methods: We conducted a retrospective case review of children <2 years admitted to SKMC with PCR proven pertussis over the period 2004 to 2008.

Results: Forty patients were admitted during this period. The mean age was 63.3 days. Mortality rate was 12.5% (5 deaths). The median length of stay was 6 days. Co-infection with other viruses occurred in 16% of the patients (RSV, Parainfluenza, and Influenza). Using step wise logistic regression analysis for mortality the only variate came out significant for death was absolute lymphocyte count (P = 0.008, OR 5.11, 95% CI 1.5-17.1). Prematurity, pneumonia, and age, as predictors were not found to be statistically significant.

Conclusion: Our mortality figure was higher than reported benchmarks. Amongst other postulates it remains possible that our PCR testing provided us with a more sensitive diagnostic tool in infants that may previously have been missed. Our small sample size possibly prohibited known predictors from being statistically significant.

P145

FIRST TIME INVESTIGATED CHOLERA OUTBREAK IN THE INDIAN STATE OF UTTARAKHAND 2007: THE DANGER OF DRINKING UNPROTECTED, UNTREATED SPRING WATER

P. Jain, Medical and Health, Government of Uttarakhand, Dehradun, India.

Background: Outbreak of Cholera and other water borne diseases is quiet common and continue to be public health problems in Indian. These outbreaks are rarely investigated. We received information about increased number of diarrhea cases with four deaths in a village of Uttarakhand state of India during July 2007. We investigate this outbreak to identify risk factors and propose recommendations.

Methods: A retrospective cohort study was conducted to identify risk factors used a questionnaire. We collected rectal swabs and water specimen for microbiological studies. We describe the outbreak in terms of time, place and person.

Results: We identified total 85 cases (Median age: 27 years) among 416 villagers (Attack rate 20%), starting 22nd June to 17th July 2007, cases peaked on 11th July. The age specific attack rate was highest among 50 years and older (30%). Case Fatality Rate was (CFR = 4.7%) and highest (24%). among 50 years and older age group. The attack rate was higher among those who using spring tank water than the other water source (21.8% vs. 3.1%, P < 0.001, relative risk: 7, 95% confidence interval [C.I.]: 2.8–17). The Attributable risk was 85% among those who using spring tank water. Laboratory isolated Vibrio Cholerae 01 Eltor Ogawa from one of the two rectal swabs and two out of three water samples showed fecal contamination.

Conclusion: An outbreak of Cholera was due to unprotected spring water supplied into community without any treatment including chlorination for drinking water was the source of outbreak.

P146

LYMPHATIC FILIARIASIS (LF) PRESENTING AS HYDROCOELE IN A CHILD FROM ENDEMIC AREA

T. Jamal Mohamed,* N.A. Nordin,† and K.A. Mohd Razali,* *Paediatric Infectious Diseases Unit; and †Institut Pediatric, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia.

Abstract: Lymphatic filiariasis is considered as one of most devastating disease under the Neglected Tropical Diseases by WHO. In Malaysia, there are still some areas in northern states and East Malaysia that are endemic for LF.

Disease associated with LF infections in children is poorly understood.We report here a case of asymptomatic microfilaremic boy who was found to have hydrocoele and lymphadenopathy during ultrasound.

This 6 years old boy was found to have positive Brugia rapid test during screening in his village in Gua Musang, Kelantan. He was otherwise well with no symptoms of recurrent fever, leg or genitals swelling. On examination, he was afebrile with mild pallor and noted to have right inguinal lymphadenopathy with no limb or scrotal oedema. There was no palpable lymphnode over axilla, epitrochlear, crural or popliteal region.

His hemoglobin was 10 g/dL and his white blood cells was 11 × 103/uL(EO-35%). His Brugia rapid test (Anti-filiarial Ig G antibody) was positive for Brugia Malayi. Night blood examination using nuclear pore technique detected 22 microfilaria/1 ml of blood. Ultrasound examination showed bilateral hydrocoele with right inguinal and left axillary lymphadenopathy. No filarial dance sign noted.

He was treated with DEC and albendazole and during follow up ultrasound showed resolution of hydrocoele and lymphadenopathy.

Unlike adults,lymphatic filariasis presents with non-pathognomonic syndromes as clinical presentations in children like fever, lymphadenopathy or arthropathy and high index of suspicion is needed to look for infected children during mass screening.

Acknowledgement to Filiariasis Division, Institute for Medical Research, Jalan Pahang, Kuala Lumpur.

P147

CHANGING CLINICAL MANIFESTATIONS OF DENGUE INFECTION IN NORTH INDIA

C. Kanta,* R. Kumar,* G. Agarwal,† J. Agarwal,† A. Jain,† and R. Nagar,† *Pediatrics; and †Microbiology, CSM Medical University, Lucknow, India.

Background & Aims: We have observed a changing clinical picture of dengue infection over the last 2 years and describe here clinical features observed in the last season in a teaching hospital in Northern India.

Methods: Children admitted to the CSM Medical University Hospital, Lucknow from August to December 2008 with suspeced dengue infection were enrolled and their clinical and laboratory findings charted. IgM capture ELISA was done in serum using commercial kits. Those testing positive for dengue IgM were considered ’probable’ dengue infection. WHO case definitions were used for Dengue Hemorrhagic Fever (DHF). Those with altered sensorium were classified as Dengue Encephalopathy (DE).

Results: Eighty children were dengue IgM positive. Mean age was 5.9 (±3.1) years, male: female ratio was 1.6:1 and 87.5% were from rural areas. History of seizures was present in 45%, altered sensorium in 51.2%, vomiting in 41.2%, hemorrhage in 38.8%, skin rash in 37.5% and jaundice in 2.5% cases. Edema was present in 47.5%, hepatomegaly in 62.5%, splenomegaly in 60%, meningeal signs in 8.7% cases and generalized increase in muscle tone in 13.7%. Investigations revealed low platelet count (<100,000/cu mm) in 60.3%, pleocytosis in cerebrospinal fluid in 17/38 (44.7%) and raised sGOT and sGPT in 76.9% and 66.7% respectively. DE and DHF were present in 53.7% and 22.5% cases respectively. Mean duration of fever was 14.9 ± 7.3 days. Mortality rate was 13.7%.

Conclusions: A significant proportion of children presented with little described features of encephalopathy, edema, splenomegaly and prolonged fever.

P148

CONGENITAL TUBERCULOSIS: A RARE FORM OF AN EMERGING DISEASE

F. Mouchet,* B. Verbruggen,† and V. Toppet,‡ *Pediatrics, CHU-SP; †Pediatrics, Clinique de l'Europe; and ‡Radiology, CHU-SP, Bruxelles, Belgium.

Abstract: Congenital tuberculosis (TB) is considered a rare entity and diagnosis is usually delayed due to the non-specific presentation.

A 62-day old girl was admitted with fever and broncho-pneumonia. She was delivered, vaginally, at 33 week's gestation to a HIV negative mother emigrated from Pakistan and living in Belgium for the last six years. The pregnancy was complicated by fever and preterm labour 3 days before the birth. The baby did well until day 60 when she developed fever, light cough and poor feeding. On Physical examination she seemed moderately ill with aural discharge, normal chest sounds and slight abdominal distension.

Laboratory evaluation revealed mild inflammatory syndrome, chest X-Ray showed bilateral reticulo-nodular opacities and narrowing of the left main bronchus. After an unsuccessful 2 days cure of broad-spectrum antibiotics, tuberculin skin test (TST) and three gastric aspirates were performed. TST demonstrated a 15 mm induration and positive acid-fast stain was detected on the gastric aspirate. Anti-tuberculosis treatment was initiated. Cultures grew M. tuberculosis resistant to nicotibine.

Mother's disease was prompted because of child′s disease and she was diagnosed with miliary and meningitis TB. An endometrial biopsy revealed inflammation with non necrotic granuloma.

Tuberculosis should be considered when diagnosing infants with aspecific symptoms of infection and/or pneumonia that are non-responsive to conventional antibiotics. Careful evaluation of the mother is required when analyzing illnesses in an infant. The incidence of neonatal TB might increase in industrialized countries as a result of immigration from countries with higher TB incidence among women of childbearing age.

P149

WHOOPING COUGH: RE-EMERGING INFECTION

D. Pinto,* I. Matos,* A. Bandeira,* L. Carreira,† C. Santos,‡ M. Guedes,* and G. Reis,* *Pediatrics; †Pediatric and Neonatal Intensive-Care Unit; and ‡Microbiology, Centro Hospitalar do Porto-Unidade Hospital Santo Antonio, Porto, Portugal.

Background and Aims: Whooping cough, a highly contagious disease caused by Bordetella pertussis, is re-emerging, despite the widespread use of vaccines during the last decade.

Our aim was to analyze the pediatric cases of confirmed pertussis infection, in the last year.

Methods: Retrospective review of medical records from children with positive Bordetella-specific polymerase chain reaction, at Centro Hospitalar do Porto, from January to December 2008. Data collection included the age of presentation, sex, pertussis immunization status, household contacts, presenting symptoms and signs, duration of hospital stay, clinical course, treatment and complications.

Results: Six children were identified, five were less than 6 months old (median 53 days) and one was14 years-old. Four children needed hospitalization, one of them in the intensive-care unit. Cough was present in all cases, paroxistic cough and cyanosis in 5 (83%). Two patients had apnea episodes: one, a preterm child, needed reanimation; the other, had also a Parainfluenza 2 bronchiolitis and developed central sleep apnea during the convalescence stage.

Three cases had possible sick contacts, which were adults in two of them.

Half of the children had not received any pertussis vaccine, and the older child received the 5 doses.

Conclusions: The 6 cases in only one year may suggest a significant resurgence of the infection, which can be fatal in early life. The clinical presentation can be atypical in the adolescence group, and the disease is often misdiagnosed. The authors agree with the need to review the immunization schedule to protect the vulnerable pre-immunisation group.

P150

PERTUSSIS COMPLICATED BY CENTRAL SLEEP APNEA—CASE REPORT

D. Pinto,* I. Matos,* L. Gomes,* J. Lopes,† H. Estêvão,‡ and G. Reis,* *Pediatrics; †Neurophysiology, Centro Hospitalar do Porto-Unidade Hospital Santo Antonio, Porto; and ‡Pediatrics, Centro Hospitalar de Coimbra, Coimbra, Portugal.

Background and Aims: Vaccination against pertussis has led to significant decline in morbidity and mortality, however this disease is far from controlled. Newborns and infants too young to be fully vaccinated are highly susceptible to infection and at risk of severe disease and death.

Methods: Case report.

Results: The authors present a clinical case of a 6-week-old female infant with Bordetella pertussis infection associated with Parainfluenza 2 bronchiolitis admitted in the intensive-care unit after a prolonged apnoeic episode reversible with stimulation. Following transfer to pediatric nursery, the paroxistic cough improved but, during sleep, she presented repeated apnoeic episodes with mild dessaturation. Many apnoeic episodes, mostly of central type, without paroxistic or epileptic activity, were recorded by electroencephalography (EEG). Polysomnographic study preformed 7 weeks after the beginning of symptoms revealed many episodes with periodic breathing, particularly on REM, with slight reduction of cardiac frequency. Two months after discharge she repeated the EEG which was normal.

Conclusions: This case suggests that, beside the fact that the periodic breathing could be normal in young infants, the transitory apnoeic and cyanotic episodes could be facilitated by pertussis. However, the underlying mechanisms responsible for this dangerous complication are still unknown.

P151

CO-INFECTION CCHF AND MALARIA

B. Sharifi-Mood, R. Alavi-Naini, and M. Metanat, Research Center for Infectious Diseases & Tropical Medicine, Zahedan University of Medical Sciences, Zahedan, Iran.

Abstract: Southeast of Iran is an endemic region for CCHF. In 1999, we faced with an outbreak of CCHF in Sistan and Baluchestan, where is near by Pakistan and Afghanistan.The most cases of Malaria in Iran are also reported from this area. Hereby, we report a 17-year- old woman who admitted to our hospital because of acute fever, headache, epistaxis, petechia and vaginal bleeding. The patient treated with ceftriaxone for probable diagnosis of Typhoid fever and Ribavirin for CCHF because she had a history of animal contact in a rural area during the last 5 days. Laboratory results showed pancytopenia. On 2 th day of hospitalization, blood test revealed the M. Falciparum and quinine (IV) started. Unfortunately, she died due to massive GI and vaginal bleeding in ICU. Three weeks later, we received a positive test (Rt-PCR and IgM-ELISA) for CCHF.We recommend every physician should be aware of co-infection Malaria and CCHF in endemic area.

Keyword: Co-infection CCHF and Malaria.

P152

KIDS PROPHYLAXIS POST-EXSPOSURE RABIES INFECTION IN BOSNIA AND HERZEGOVINA

L. Sporisevic,* A. Bajraktarevic,† and Z. Begic,‡ *Pediatrics Department, First Medical Aid; †Pediatrics Department, Public Health Institution of Canton Sarajevo; and ‡Pediatrics Department, Pediatrics Clinic Sarajevo, Sarajevo, Bosnia-Herzegovina.

Objective: Rabies virus in neurotrophic RNA virus that causes an acute encephalitis with atypical focal neurological signs and paralyses. Although rabies infections in childhood are rare, they can cause serious health problems. The recommendations for children given here are intended as a general guide but child has its specifics caracteristics.

Methods: Post-exposure prophylaxis (PEP) is any prophylactic treatment started immediately after exposure child to a rabies disease in Bosnia and Herzegovina. The treatment consists of repeated injections of rabies vaccine and immunoglobulin.

Results: Post-exposure treatment, which consists of local treatment of the wound, followed by vaccine therapy (with human rabies immunoglobulin) should be initiated immediately with contacts of categories II and III, but for category I (touching or feeding animals, licks on the skin), no treatment is required in ours cases in Bosnia. PEP is commonly used, and very effective, to prevent the outbreak of rabies after a bite by a rabid animal.

Discussion: Only the cell-derived vaccines that meet the WHO requirements regarding safety, potency and efficacy for this application may be considered for intradermal use.

Conclusions: It has been shown that purified equine rabies immunoglobulin products cause adverse reactions in 3% of vaccinees in Sarajevo, even when sensitivity tests are performed prior to their administration.

Keywords: Rabies, Post-exposure prophylaxis (PEP), Management, Children.

P153

WHOOPING COUGH: A RE-EMERGING DISEASE

M. Thalen, Chief Scientific Officer, SynCo Biopartners, Amsterdam Zuidoost, The Netherlands.

Abstract: Despite the high vaccination coverage in most of the Western world, the incidence of whooping cough has increased in all age groups during the last decades. The introduction of acellular vaccines nor the introduction of booster vaccinations in toddlers has changed this trend. Current vaccines are not well equipped to overcome the rising incidence of whooping cough for various reasons. Therefore, an improved whooping cough vaccine is needed.

The required characteristics of such an improved vaccine are that it

(1) allows all age groups to be vaccinated with B. pertussis circulating strain antigens,

(2) protects against whooping cough induced by B. parapertussis,

(3) enables infants to be vaccinated earlier,

(4) causes minimal adverse events after repeated vaccination, and

(5) protects longer than currently registered vaccines.

Consequently, vaccine compositions that can fulfill these requirements were examined, using time to market, costs and risks as constraints. The most likely candidates to succeed are oral or intranasal vaccines consisting of inactivated B. pertussis cells, since an oral vaccine has already shown proof of protection in a phase III study without adverse events, and an intra-nasal vaccine has shown proof of concept in a phase I study. Live attenuated vaccines are also promising, but may take longer to commercialize. At this point it is not clear if B. parapertussis cells should also be included in an improved whooping cough vaccine, and what the cost-benefit ratio would be.

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EPIDEMIOLOGY

P154

LACK OF MOTHER-TO-NEWBORN TRANSMISSION OF HEPATITIS C VIRUS IN IRAQI WOMEN: A PROSPECTIVE STUDY WITH HEPATITIS C VIRUS RNA TESTING

W. Al-Kubaisy, Faculty of Medicine, Community Medicine & Public Health, Al-Nahrain University, Baghdad, Iraq.

Background: What has been published about the risk of mother-to-infant transmission of hepatitis C virus (HCV), shows variation according to the population studied and the test used. Polymerase chain reaction (PCR) was used for the first time in Iraq in a prospective study.

Aims: To asses the risk of vertical transmission in an unselected population of Iraqi pregnant women.

Material & Methods: HCV antibodies (Abs) were sought with third generation enzyme immunoassay (EIA-3) in 3491 pregnant women. A positive reaction was then confirmed by a third-generation immunoblot assay (LiaTek-III). This last test was confirmed positive in 112 serum samples. we followed 26 babies of 25 anti-HCV positive mothers at first month of life. Eight of these children could be followed for six months postnataly.

Results: All the 26 neonates were positive for HCV Antibodies (with EIA-3 and Lia Tek-III) during the first month of life and it completely disappeared within the following six months. HCV RNA was consistently negative in 22 sera (14 infants at first months and 8 of repeated at 6 months later) regardless of the hepatitis C virus polymerase chain reaction status of their mothers (9 of whom were positive for HCV RNA).

Conclusion: The study showed the absence of vertical transmission of HCV from pregnant Iraqi women to their offspring.

Acknowledements:

A. D. Niazi, Professor. Dept. of community Medicine, AL-Nahrain Faculty of Medicine, Baghdad, Iraq.

K. Kubba, Professor. Dept. of Obstetrics and Gynecology, AL-Nahrain Faculty, Baghdad, Iraq.

P155

ANTIBIOTIC PRESCRIPTION AT DISCHARGE IN A FRENCH PEDIATRIC EMERGENCY DEPARTMENT IN 2008

F. Angoulvant,*† H. Bellanger,* B. Millet,* S. Bauer,‡ J.-C. Mercier,* R. Cohen,§ O. Bourdon,‡ and C. Alberti *Service d'Accueil des Urgences; †Unité d'úpidémiologie Clinique; ‡Pharmacie, AP-HP/ Hôpital Robert Debré, Paris; and §Laboratoire de Microbiologie, Hôpital Intercommunal de Créteil, Créteil, France

Background: Respiratory Tract Infection (RTI) is very common among children seen in a Paediatric Emergency Department (PED). Our aim was to evaluate the antibiotic prescription at discharge for RTI in our PED.

Methods: We studied the database of the 73 875 PED visits in 2008.

Results: During 2008, RTI accounted for 15410 (20,5%) of PED visits.

Conclusion: These results suggest a good appliance of national guidelines by physicians in our PED. The high number of AOM questions about the criteria used in our PED to identify properly AOM.

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P156

EPIDEMIOLOGICAL PROFILE OF BLOODY DIARRHEA AMONG CHILDREN LESS THAN TEN YEARS OF AGE IN BAGHDAD

A. Aqel, Department of Pathology, Microbiology & Forensic Medicine, Faculty of Medicine, Mu'tah University, Al-Karak, Jordan.

Background and Aims: Because of the high incidence of bloody diarrhea in Baghdad, we tried to study and to evaluate these cases. Our aims were to evaluate the prevalence of bloody diarrhea among children with diarrhea less than 10 years old, to identify the most commonly causative agents and to detect factors that may be associated.

Material & Method: A sample of 1500 children was collected. All children aging less than 10 years with diarrhea. Mother interviewing and clinical examination of each child was carried-out. Then general examination and cultured of stool was performed.

Result: The prevalence of bloody diarrhea was (28%) of the patients presented with diarrhea. The male to female ratio was 1.42:1, with no significant association. Children whose age ranged between (7–9 years) constituted significantly higher rate (66.6%), although (1–3 years) children are largest age group attendants 270 (30.6%).

Entamoeba Histolytica was the main causative agents for all age groups, with significant higher prevalence among age group (1–3 years), followed by Non-typhoid salmonella and Shigella.

Higher prevalence of bloody diarrhea was detected among those residing rural areas, children on exclusive bottle-feeding and children who use teats & have thumb sucking habit.

Their were highly significant between the clinical signs and bloody diarrhea like fever in (33.3%), vomiting in (29.7%), dehydration in (45.9%), tenesmus in (45.2%) and convulsion in (50%) of cases.

Conclusion: Parasitic infection as well as bacterial infection is serious public health problem among Iraqi children mostly related to environmental sanitation and personal hygienic conditions.

P157

CLIMATIC FACTORS ASSOCIATED WITH ROTAVIRUS INFECTIONS IN CHILDREN UNDER 5 YEARS OF AGE IN ENGLAND AND WALES

C. Atchison,* B. Lopman,*† C. Tam,* and S. Hajat,‡ *Infectious Diseases Epidemiology Unit, London School of Hygiene & Tropical Medicine; †Gastrointestinal, Emerging and Zoonotic Infections Department, Health Protection Agency; ‡Public and Environmental Health Research Unit, London School of Hygiene & Tropical Medicine, London, UK.

Background: Rotavirus is the most common cause of gastroenteritis in children under 5 years. In England and Wales, rotavirus incidence is highly seasonal; the peak in late winter/early spring suggests a role for meteorological factors in the epidemiology of the virus.

Methods: Poisson regression adapted for time-series data was used to investigate the short-term effects of mean weekly temperature, relative humidity and total rainfall on number of reported laboratory-confirmed rotavirus infections in children under 5 years between 1993 and 2008. Separate models were constructed for each of the 10 regions of England and Wales. We adjusted for long-term trends, seasonal patterns, other climate factors and public holidays. We estimated the percentage change in number of rotavirus reports per unit decrease in temperature, humidity and rainfall. Region-specific estimates were pooled across regions in a meta-regression to provide a combined estimate.

Results: There was strong evidence for a linear relationship between mean weekly temperature and reported rotavirus infections. The pooled estimate for England and Wales was a 16% (95% CI 9% to 24%) increase in number of reports per 1°C decrease in temperature above a threshold of 5°C. A 2% (95% CI 1% to 4%) rise in number of reports was observed per 10 mm drop in total weekly rainfall. There was no overall effect of relative humidity on number of rotavirus reports.

Conclusion: Climate variability can affect the incidence of rotavirus infections. An understanding of the links between climatic factors and rotavirus infections can help predict the demands on health services.

P158

GLOBAL CHANGES IN PNEUMOCOCCAL SEROTYPE EPIDEMIOLOGY-VACCINE EFFECT, ANTIBIOTIC USE EFFECT OR SECULAR TREND?

S. Black, Center for Global Health, Cincinnati Children's Hospital, Cincinnati, OH, USA.

Background: Since the introduction of PCV7 pneumococcal conjugate vaccine, increases in the prevalence of serotype 19A have been attributed to vaccine. However, similar changes have been seen for this serotype and other serotypes in countries not using vaccine. Furthermore, 19A increases have not been seen in all populations using vaccine.

Methods: Pneumococcal serotype epidemiology was reviewed in several countries.

Results: Epidemiologic surveillance in Spain over the 25 years before PCV7 reveals dramatic changes in the absolute and relative prevalence of various serotypes. Recent UK data demonstrates substantial increases in serotypes 1, 7F and 19A prior to PCV7. In Denmark, there has been a four-fold rise in serotype 1, but 19A accounts for only 1% of cases in children. In Korea, increases in serotype 19A predate PCV7 introduction. In the US, serotype 19A increases in the country overall occurred following PCV7. However, surveillance in the American Indian population, with extensive PCV7 use before and after licensure, reveals 19A disease incidence has decreased in this population. This contrasts with substantial increases in 19A disease in Native Americans in Alaska. Interestingly, macrolide use is uncommon in the American Indian population and common in the Alaskan Native, Korean, Spanish and UK populations.

Conclusions: Pneumococcal serotype epidemiology varies substantially over time and place. Antibiotic use patterns may have a stronger influence on emergence of new strains than vaccine. The focus of attention on one serotype, 19A, has hindered recognition of increases in incidence and morbidity due to other serotypes such as 1 and 7.

P159

THE OUTBREAK OF VIRAL HEPATITIS A IN THE CZECH REPUBLIC IN 2008: THE NEED FOR ACTIVE CONTROL OF CONTACTS

Z. Blechova,* M. Trojanek,* V. Nemecek,† M. Podojilova,‡ and V. Maresova,* *1st Department of Infectious Diseases, Bulovka University Hospital, Charles University in Prague, 2nd Medical Faculty; †National Health Institute; and ‡Department of Infectious Diseases, Bulovka University Hospital, Prague, Czech Republic.

Backgorund: The incidence of viral hepatitis A (VHA) decreased considerably in the Czech Republic in last years. In 2008 occurred the outbreak of VHA in Prague and Central Bohemian Region. Out of 1103 cases, 197 were diagnosed in children. The aim of our study was to evaluate the epidemiological and clinical characteristics of VHA cases.

Materials and Methods: We are presenting retrospective analysis of paediatric patients with VHA admitted to our department in 2008.

Results: 100 children (56 males and 44 females) with the median age of 8 years were enrolled to the study. The length of hospital stay was 6 days at average. Contact with the infection in family members was noted in 57 patients; 23 patients negotiated any contact with VHA. The most frequent symptoms were: icterus (in 48 cases), nausea (45), fever (44), emesis (36) and abdominal pain (32). Asymptomatic course was observed in 33 patients. Medians of AST and ALT levels were 10,58 μkat/l (ranging from 0,56 to 139) and 27,19 μkat/l (0,35 to 109,7) in symptomatic patients; 0,91 μkat/l (0,44 to 32,77) and 0,98 μkat/l (0,28 to 41,19) in asymptomatic patients. Medians of bilirubin levels were 59 μmol/l in symptomatic and 10 μmol/l in asymptomatic patients. The relapse of the disease occurred in 3 patients.

Conclusion: Active control of VHA contacts in our country proved to be important because the course of VHA was asymptomatic in one third of our cases. But in many patients without clinical symptoms the elevation of aminotransferases was detected.

P160

THE TREND OF BACTERIAL MENINGITIS IN ITALIAN CHILDREN AFTER THE INTRODUCTION OF THE VACCINES AGAINST MENINGITIS

M.G. Caporali,* P. D'Ancona,* P. Stefanelli,† M. Cerquetti,† T. Sofia,† S. Giannitelli,* and A. Pantosti,† *CNESPS; and †MIPI, Istituto Superiore di Sanità, Roma, Italy.

Background: In Italy, data on bacterial meningitis are available from the 1994. They derive from statutory notification of meningitis (since 1991 only for Neisseria meningitidis) and from the “national surveillance of bacterial meningitis” (since 1994) based on clinical notifications. Vaccines against N.meningitidis, Streptococcus pneumoniae, Haemophilus influenzae are available, in Italy, respectively from 2002, 2001, 1995. Up today only HIB vaccine is recommended for all newborns whereas for the others the recommendation is at regional level. We describe the epidemiology of meningitis due to these three pathogens, in Italy, in years 1994–2008.

Methods: In both surveillance systems, cases are notified to the Local Health Units, that transmit the data to the regional and national authorities. Laboratory confirmation for all cases is required. A convenience sample of isolates is sent to the National Reference laboratory, at the National Institute of Health, for confirmation, serotyping and molecular typing.

Results: The trend of incidence in agegroup 0–5:N.meningitidis: it is almost stable from 1994 (2.19*100.000) to 2007 (2.02*100.000). A peak is present in period 2003–2005 (in 2004 4.35*100.000). In 2008(data not definitive) there is a small decrease (1.18*100.000). However this decrement is not present in children under the first year of life.S.pneumoniae: it is stable from 1994 (1.76*100.000) to 2007 (1.60*100.000). H.influenzae: it shows a significantly decrease from 1994 (2.70*100.000) to 2007 (0.11*100.000).

Conclusion: A strong impact of the Italian vaccination policy is evident only for HIB whereas for the other two vaccines the coverage in Italy is not enough to achieve a significant decrease.

P161

COXSACKIE VIRUS RELATED WITH ONYCHOMADESIS. COHORT STUDY

E. Carbonell,* M.J. Borras,† M.A. Bracho,‡ J. Cordoba,§ I. Febrer,¶ M. Gobernado,§ F. Gonzalez-Candelas,∥ S. Guiral,** A. Salazar,† and H. Vanaclocha,** *Preventive Medicine, Hospital Universitario Dr. Peset; †Public Health Surveillance, Public Health Center; ‡Genomic and Health Department, C.S.I.S.P; §Microbiology Department, Hospital Universitario La Fe; ¶Dermatology Department, Hospital General Universitario de Valencia; ∥Genetic Department, Instituto Cavanilles de Biodiversidad; and **Epidemiology Service, Conselleria de Sanitat, Valencia, Spain.

Background: An outbreak of Onychomadesis started on June last year and related with Hand Food and Mouth Disease (HFMD). More than 311 infants were affected in Valencia. (Eurosurveillance, http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18917) Isolated viruses were identified as Coxsackievirus A10 as principal agent related with.

Retrospective study has some bias and misclassification in order to evidence. Our aim was supporting those observations by a prospective cohort study toward a major evidence.

Methods: A Prospective observational study is carrying out. Population from nursery (n = 58) Three month following-up. Age: 14 to 46 months old. Information about children are from diagnosis by paediatricians and complementary data from parents. Stool samples were collected for onset at the beginning-HFMD- Onychomadesis. Data processed with SPSS.

Results: HFMD was identified in 18 children (31%) and others 11 (19%) as unspecified skin rash viral. Latency period between HFMD and Onychomadesis reach a mean of 43 days (Pct 25%: 37/Pct75%: 52). Eleven Onychomadesis cases have had previous HFMD diagnosis and four (25%) were previously diagnosed by unspecified exanthema. Viruses identified at current were CVA-6 in initial samples.

Conclusions: Previous skin rash symptoms were found in all Onychomadesis cases. Currently the stool samples are being processed in the laboratory. Initial results show that 8 cases of HFMD Coxsackievirus A6 has been isolated. 5 of these subjects developed Onychomadesis. Cohort study and their following activities will finish on May 2009.

P162

ROTAVIRUS DISEASE BURDEN AND THE COST-BENEFIT OF ROTAVIRUS VACCINE IN TAIWAN

P.-Y. Chen, Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan R.O.C.

Abstract: Rotaviral gastroenteritis was a common disease both in developing anddeveloped countries. Well established medical system can only avoid the severe complication and mortality. It was quite different in epidemiology and disease burden among each countries and area. Rotaviral vaccine had been licenced in 1998, and was now re-on marketing 2006, which was proved to have good efficacy in preventing mortality and morbidity and was also cost saving. This study was introduced to evaluate the cost-effectiveness of rotavirus vaccine in Taiwan, which combined with the data base of National Health Institute (NHI), surveillance system of Taiwan CDC, those published data and the ongoing active surveillance study.

Those useful data for cost-effectiveness of rotavirus disease included:

(1) Epidemiology of rotavirus in Taiwan: peak age of infection, mortality, prevalence of RV related outpatient and inpatient medical visit and circulating genotypes;

(2) Disease burden of rotavirus, which include direct and indirect medical cost, including those outpatient clinics and inpatient service;

(3) Pyschological stress of family during the course disease.

The age of rotaviral gastroenteritis in Taiwan was older than those developing countries, with the onset of 1 to 2 year-old (similar to Hong Kong and Singapore). Rotavirus vaccines were proved to be still active before children age of 2. The economic burden of rotaviral diarrhea was estimated around 1 billion NTD. Once the rotavirus vaccine is recommended by ACIP of Taiwan, the cost-benefit for the price 2 or 3 doses RV vaccine is evaluated.

P163

INCIDENCE RATE AND ATTRIBUTABLE MORTALITY OF NOSOCOMIAL INFECTION IN PEDIATRIC INTENSIVE CARE UNIT

Y.Y. Chen,* I.H. Chen,† C.S. Chen,† S.M. Sun,* and F.D. Wang,* *Infection Control, Taipei Veterans General Hospital; and †Taipei City Hospital, Branch for Women and Children, Taipei, Taiwan R.O.C.

Background and Aims: Nosocomial infections (NIs) in critically ill patients is an increasingly prevalent problem. Nosocomial infections have been linked to increases in morbidity, length of hospitalization, increased healthcare costs, and increased mortality. Our study was to examine the proportion of sites of NIs and prognostic factors of mortality in pediatric Intensive care unit (PICU).

Methods: A retrospective cohort study was conducted at a PICU with 14 beds in a 2,900-bed tertiary refer medical center. All patients admitted to the PICU who had developed NIs from 2007 to 2008 were eligible. The definitions of the Centers for Disease Control and Prevention were used to categorize specific NIs as bloodstream infection (BSI), respiratory tract infection (RTI), urinary tract infection (UTI), surgical-site infection (SSI), or other.

Results: Seventy and one NIs occurred in 1,455 screened patients. The incidence rate was 4.9%. The most frequent NIs observed were BSIs 30.3%, UTIs 25.8%, RTIs 15.2%, SSIs 12.1%, and others 16.7%. The most common organisms were Escherichia coli 15.7%, Staphylococcus aureus 8.6%, coagulase negative Staphylococci 8.6% and Pseudomonas aeruginosa 8.6%. The crude mortality rate were 31%. Logistic regression analysis of prognostic factors of mortality, Neoplasm (Odds Ratio [OR] 12.89, 95% confidence interval [CI] 1.34–12.62), used day of mechanical ventilator (OR 1.05, 95% CI 1.02–1.09), and used day of Foley catheter (OR 1.43, 95% CI 1.16-1.76) were independent factors (P <.05).

Conclusions: BSIs were the most site of NIs in PICU. Invasive devices and underlying diseases were the important prognostic factors.

P164

LATENT TUBERCULOSIS INFECTION AND DISEASE IN CHILDREN, IN CRETE, GREECE

M. Christaki,* I. Bibakis,† S. Stefanaki,* A. Schoinaki,* T. Tsekoura,* K. Tsikalakis,† S. Michailelis,† K. Athanasaki,† and A. Tsilimigaki-Christaki,* *2nd Paediatric Department; and †AntiTB Unit, Venizelion General Hospital, Crete, Heraklion, Greece.

Background and Aims: The purpose of this study was to investigate the epidemiological characteristics of latent tuberculosis infection (LTBI) and Tuberculosis disease in children in Heraklion region.

Methods: Data was collected from the Anti TB Unit of Venizelion General Hospital from years 2006-2008, involving the evaluation of tuberculin skin test (TST) in 7043 children. Ages ranged between 15 months to 14 years old. In all cases a TST was performed with a 0,1 ml (2TU) tuberculin PPD RT 23 SS1 interdermally. The transversal diameter of induration was evaluated in 48–72 hours. A result of ≥ 7 mm induration in unimmunized children was considered positive result, as well as a result of a ≥15 mm induration with prior BCG.

Results: 41 children were diagnosed with LTBI (91%) and 4 (8,8%) had pulmonary disease. 16 (35%) were boys and 29 (65%) girls. The tuberculin index was found 0,34%, 0,98% and 0,62% respectively for the years 2006, 2007 and 2008. 36 (80%) of them had not been immunized and 9 (20%) were immunized with BCG. At diagnosis the mean age was 6,1 years old and median 6. In 12 (27%) cases at least one adult from their environment was discovered. 11 (24,4%) children were immigrants and 34 (75%) were Greek. All children in the study were treated for tuberculosis.

Conclusions: Tuberculosis infection remains a serious health issue. Tuberculin index is still high in Heraklion, Crete. The majority of cases discovered had latent tuberculosis infection. A considerable proportion of patients were immigrants.

P165

INCIDENCE OF ACUTE OTITIS MEDIA (AOM) AND COMMUNITY ACQUIRED PNEUMONIA (CAP) IN A BRAZILIAN COMMUNITY LEVEL PRIMARY CARE SERVICE (PCS)

O. Cintra,* M. Iwamoto,† M. Iwamoto,‡ L. Delcaro,‡ J. Domingos,† F. Paula,‡ I. Ferraz,§ A. Matsuno,† and E. Arruda,‡ *Biologicals, GlaxoSmithKline Brazil, Rio de Janeiro; †Pediatrics, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo; ‡Cell and Molecular Biology; and §Pediatrics, University of Sao Paulo School of Medicine at Ribeirao Preto, Ribeirão Preto, Brazil.

Background: AOM is the most important cause for pediatric consultations and CAP is an important marker of respiratory infections and we lack of precisely data on those in Brazil. Our objective was to describe the incidence of those diagnoses in a two consequent year clinical surveillance in a large PCS in Brazil.

Methods: Weekly review of all outpatients visits in a PCS in Brazil. The incidence by age range was calculated dividing the total number of each diagnose by the population attended by the center.

Results: Total numbers of outpatients’ visits were 104,101 and 114,229 in 2006 and 2007 respectively. The incidences of AOM per 1000 patients according to the age range in 2006 and 2007 were: 0 to 4 y = 181 and 150; 5 to 14 y = 29 and 24; from 16 to 65 y+ all had incidence under 8/1000. For CAP the incidences were in 2006 and 2007,: 0 to 4 y = 89 and 81; 5 to 14 y = 16 and 10; 15 to 24 y = 8 and 11; 25 to 59 y = 9 and 13; 60 to 65 y = 21 and 35; 65 y+ = 34 and 46.

Comment: Incidence of AOM and CAP were similar between the two years, with a slight reduction of AOM in 2007 and increase of CAP. Overall incidence by age range showed AOM in children under 4 y and CAP in the young and the elderly. This data will help to calculate the impact of interventions such influenza and/or pneumococcal vaccinations.

P166

EPIDEMIOLOGY OF STREPTOCOCCUS PNEUMONIAE INFECTIONS IN PARIS AREA: PREDOMINANCE OF SEROTYPE 19A

L. Dortet,* M.-C. Ploy,† E. Varon,‡ C. Poyart,§ and J. Raymond*Institut Pasteur, Paris; †Bacteriology, CHU, Limoges; ‡CNR Pneumocoques, Hôpital Georges Pompidou; and §Bacteriology, Hôpital Cochin, Université Rene Descartes, Paris, France.

Background: We have studied 457 Streptococcus pneumoniae isolated in 2007 from adults and children living in the west area of Paris. For all isolates we performed capsular typing and determined the antibiotic resistance patterns.

Results: S. pneumoniae 19A was the most frequently isolated serotype (34.7%) both in children and adults. It represented 12.8% (28/219) of the strains isolated from invasive infections in adults and 17/63 (27.0%) in children. Among isolates responsible for meningitis, S. pneumoniae 19A was isolated once in adult. Interestingly, S. pneumoniae 19A was isolated in 5/10 pleural fluids from children and 4/12 from adults. Among the 173 isolates from acute otitis media (AOM), 110 (63.6%) were S. pneumoniae 19A.No difference concerning antibiotic resistance were observed between children and adults. The susceptibility of S. pneumoniae to penicillin, amoxicillin, cefotaxime, erythromycin, pristinamycin and rifampicin was 61.2%, 83.9%, 91.9%, 56.5%, 100% and 100%, respectively in children and 64.4%, 83.1%, 84.9%, 68.9%, 100% and 100% in adults, respectively. However, strains isolated from AOM, were significantly less susceptible to b-lactams (3.2%) and erythromycin (4.5%). This decreased susceptibility was correlated with the prevalence of the serotype 19A. Furthermore, two 19A strains presented a high level of resistance to b-lactams (MICs: penicillin ≥6 mg/L; amoxicillin ≥6 mg/L cefotaxime ≥4 mg/L).

Conclusion: We confirm the predominance of serotype 19A among S. peumoniae responsible for invasive and non-invasive diseases either in children or adults in France.

P167

SEASONALITY OF THE RESPIRATORY SYNCYTIAL VIRUS IN BELGIUM, 2000–2008

G. Ducoffre, and S. Quoilin, Epidemiology Unit, Scientific Institute of Public Health, Brussels, Belgium.

Background and Aims: Respiratory syncytial virus (RSV) is a major cause of respiratory tract infection during the child's first year of life, as well as in subsequent years. In some infants, infection with RSV can lead to lower respiratory tract infection and result in hospitalization.

The present eight-year retrospective analysis aims to describe the seasonality of RSV in Belgium, especially the changes observed in 2008.

Methods: RSV is one of the respiratory viruses weekly monitored by the sentinel laboratory network (62% of all microbiology laboratories), coordinated by the Scientific Institute of Public Health. This study describes the seasonality of RSV in Belgium during a period of 8 years, particularly the changes observed in 2008.

Results: RSV infections begin generally to increase in October and decrease in March, with a peak in mid-December (week 50). In 2008, the onset of RSV infections began 3 weeks earlier and the peak was observed in mid-November (week 46). This change was observed in some other European countries.

The analysis of meteorological parameters such as temperature, humidity and the particulate matter concentrations in ambient air can not explain the changes of the epidemiology of RSV.

Conclusions: Surveillance of RSV should be emphasized and if further changes in epidemiology should persist, it will be necessary to discuss modification of prevention rules.

P168

PEDISURV, A WEB APPLICATION TO REGISTER PEDIATRIC DISEASES

Y. Dupont, S. Quoilin, T. Lernout, and M. Sabbe, Epidemiology Unit, Scientific Institute of Public Health, Brussels, Belgium.

Background: In 2002 the network PediSurv (Pediatric diseases Surveillance) was developed in order to collect information about some vaccine preventable diseases according to European Decision (2119/98/CE). Mumps, measles, rubella, acute flaccid paralysis (AFP) and invasive pneumoccocal diseases (IPD) in 2007 were included since they were not registered by other networks or under mandatory notifications. All Belgian paediatricians and GP working in Brussels were invited to participate to this network. Participation is voluntary and requests a monthly reporting of the diseases even in case of a zero case notification. Since data entry from paper form induced mistakes, a web application was developed also to reduce this time consuming activity. Participants can directly enter the data. PediSurv was born.

Methods: PediSurv is a secured web based application developed by the Institute of Public Health with ASP.Net language linked at a SQL database. PediSurv is also an alert system, when a case of measles is notified; an email or a sms is sent to the public health authorities at Community level.

Results: In 2007, 811 GP and paediatricians participated to the network and among them 40% used the PediSurv application.

Conclusions: PediSurv is a user friendly tool allowing registering of cases and zero case notification as well. This system offers rapid notification permitting Health Authorities to take adapted control measures.

P169

A DETERMINISTIC EPIDEMIOLOGY MODEL TO STUDY PERTUSSIS IN ARGENTINA

G. Fabricius,* A. Lodeiro,† A. Melgarejo,‡ A. Graieb,† and D. Hozbor,† *INIFTA. Facultad de Ciencias Exactas, UNLP. CCT-La Plata, CONICET. Diagonal 113 y 64 CC16, sucursal 4 (1900) La Plata, Argentina; †Ciencias Biológicas, Instituto de Biotecnología y Biología Molecular. Facultad de Ciencias Exactas. Universidad Nacional La Plata. CCT CONICET; and ‡Area Departamental de Ciencias Básicas. Facultad de Ingeniería, UNLP. Calles 47 y 115 (1900) La Plata, Argentina, La Plata, Argentina.

Background and Aims: Vaccination against pertussis started in Argentina in the 70s, coverage being estimated as 90% in average. Despite this, disease incidence is rising, registering a 6-fold increase since 2002. Though a clear increase is observed at all age groups, children <6 months old had the highest proportion of cases. In this age group a delay in vaccine application was registered: around 30% of infants had fewer vaccine doses than they should. To estimate how this delay may contribute to the observed increase in disease incidence, an epidemiological model was used.

Methods: Starting from a SIR-type model we introduced the age-dependent vaccination scheme currently employed in Argentina. The model contains 9 epidemiological classes and 30 age groups. Parameters were taken from literature and local epidemiological data.

Results: We followed a deterministic approach. The steady state was reached by allowing temporal system evolution to constancy of all age epidemiological class sizes. Delay in vaccine application was simulated by modifying the coverage rates of each dose. By setting vaccine efficacy in 90% for all doses, the model estimates that a delay in the first vaccination comparable to that observed caused a 12% increment in infected individuals aged 0–2 year-old. This value went to 22% by simulating such delay also in the second and third doses. If non-uniform vaccine efficacy were considered for each dose the relative impacts changed.

Conclusions: Based on mathematical model analysis, a delay in vaccine application might be related with the observed disease incidence increase.

P170

PERTUSSIS EPIDEMIOLOGY IN ARGENTINA OVER 2006-2008: TRENDS BY AGE GROUP AND STATUS OF VACCINATION

D. Flores,* G. Weltman,† E. Zurita,* C. Lara,† A. Fioriti,* D. Archuby,* D. Bottero,* P. Barbero,‡ M. Bettiol,§ B. Gatti,§ A. Graieb,* M.E. Gaillard,* M. Fingermann,* F. Sisti,* J. Fernández,* C. Castuma,* S. González Ayala,§ M. Galas,† and D. Hozbor,* *Ciencias Biológicas, Instituto de Biotecnología y Biología Molecular. Facultad de Ciencias Exactas. Universidad Nacional La Plata. CCT CONICET, La Plata; †Administración Nacional de Laboratorios e Institutos de Salud ‘Dr Carlos G. Malbrán', Buenos Aires; ‡Area de Epidemiología de Córdoba, Córdoba; and §Hospital de Niños Sor María Ludovica, La Plata, Argentina.

Background and Aims: Pertussis is a vaccine-preventable disease caused by Bordetella pertussis. Despite good vaccination coverage in Argentina, disease incidence increased 6-fold since 2002. Here we describe pertussis epidemiology in Argentina during 2006–2008 and discuss possible reasons for increase.

Methods: Proportion of pertussis cases by age, immunization status, and immunization coverage rate evaluated at the Argentinean National Pertussis Reference Center are reported. CDC criteria were used for diagnosis. B. pertussis isolates were characterized by pulse filed gel electrophoresis (PFGE) and prn and ptx genotypes. Comparisons with vaccine strains are included.

Results: From 8,176 patients with pertussis clinical signs, 22.9% were confirmed: 523 in 2006, 617 in 2007, and 734 in 2008. Approximately 55% occurred at Buenos Aires and Córdoba, the most populated regions. Though a clear increase is observed at all age groups compared to previous data, children <6 months old had the highest proportion of cases. In this age group a delay in vaccine application was registered, 30% of infants had fewer vaccine doses than they should. In addition, molecular characterization of the isolates revealed a genotypic divergence between them and the vaccine strains. PFGE profiles of vaccine strains had only 64% relatedness with all Argentinean isolates analysed. Moreover, while vaccine strains contain prn1/7 and ptxS1 B/D alleles, local isolates have prn2 and ptxS1A.

Conclusions: Pertussis is an important problem for public health in Argentina. Delay in vaccine application, and divergence between vaccine strains and local isolates could contribute to the described pertussis epidemiology.

P171

ACUTE OTITIS MEDIA BURDEN DURING THE FIRST SIX YEARS OF LIFE IN FRANCE IN 2008

M. François,* O. Romain,† T. Lery,‡ and F. Nachit-Ouinekh*Service ORL, Robert Debré Hospital; †Paediatrics, Paris; ‡Medical; and §Epidemiology and Health Economics, GlaxoSmithKline Laboratory, Marly Le Roi, France.

Background and Aims: Acute Otitis Media (AOM) is one of the most common childhood diseases, but its clinical and economic burden is not well characterized. The primary objective of this study was to describe the management of AOM. The secondary objectives were to evaluate the impact of AOM on quality of life of their parents and to evaluate the economic costs.

Methods: This is an observational prospective epidemiological study. Patients aged between 0–6 years, suffering from AOM (GP or pediatrician diagnosis) were eligible. This study was performed in France using CSD's LPD panel. Severity was evaluated by the Faces Pain Scale (FPS rating 0–10) and the quality of life by the PAR-ENT-QOL scale (rating scale 0–100).

Results: 439 children were included. 10.5% included by GP were aged 0–1 year (25.3% by pediatrician), 40.9% 1–3 years (vs 48.5%) and 48.6% 3–6 years (vs 26.3%). 18.2% had recurrent AOM, 45% received pneumococcal vaccination (75.4% in the 0–1 year).

The AOM diagnosis was associated mainly with otalgia (72.4%) and fever (71.0%).

Antibiotic were prescribed in 89.8%, and analgesic-antipyretic drug in 72%. 57% of the parents reported a severity (FPS) between 2 and 4, with a significant difference for age and between GP/Pediatrician. The mean total score of the PAR-ENT-QOL was 25.4 (SD = 17.8).

Direct medical costs (with hospitalization) were 97.3 euros from a societal perspective for GP (vs 93 euros in pediatrician). 31.4% of the parents reported absenteeism from work.

Conclusions: The burden of AOM is substantial in terms of severity and societal impact.

P172

INVASIVE PNEUMOCOCCAL DISEASE IN CHILDREN LOWER 5 YEARS OLD. GRAN CANARY 2004–2008

A. García Rojas,* P. García Castellano,* A. Bordes Benítez,† F. Troncoso Mendoza,† and A. Fenoll Comes,‡ *Epidemiology, Public Health Service; †Microbiology, Gran Canary Hospital, Las Palmas de Gran Canaria; and ‡Microbiology, Majadahonda Center, Madrid, Spain.

Background and Aims: It considers to know the epidemiological decriptive characteristics, the temporary distribution and the mostly prevalents serotypes in Invasive Pneumococcal Disease in children lower 5 years in Gran Canary Island, during the temporal period 2004–2008.

Methods: Prospective study of the Invasive Disease confirmated cases and notified to the Gran Canary Microbiological Informative Sistem, between 2004-2008 that were hospitalized in Gran Canary with laboratory diagnosis as S. Pneumococcal in blood, Cerebral Spinal Fluid, or in other usvally steril places and acute disease with a compatible clinic of Pneumococcal Disease.

Results: There were notified 80 cases, 12 (15%) in 2004, 17 (21%) in 2005, 19 (24%) in 2006, 9 (11%) in 2007, and 23 (29%) in 2008. Also the 37,5% of sickness were below 1 year old, the 50% between 1 and 2 years and the 12,5% older 2 years. Only rested 10 processes without tipifying. Of the 70 tipified, 67,14% were not prepared by the 7-valent conjugate vaccine. The serotype most identified was the 19A (29%), and the 14 (13%).

Conclusions: The appearance of the isolated vaccinal serotypes could be conditioned by the mentioned use of the vaccine in a high percentage of lower 5 years old population. In 2006, 2007 and 2008 was detected a higher numbers of serotypes not predictables for the vaccine (69%,87,5%, 77,2%). We have to increase the knowledge of this disease with a continued alertness, remarking the need of to confirmate the diagnosis and have isolations to identify the causer serotypes.

P173

MENINGOCOCCAL DISEASE IN CHILDREN LOWER 10 YEARS OLD. GRAN CANARY 2004–2008

A.J. García Rojas,* P. García Castellano,* A. Bordes Benítez,† F. Troncoso Mendoza,† J. Vázquez Moreno,‡ and B. Lafarga Capuz,† *Epidemiology, Public Health Service; †Microbiology, Gran Canary Hospital, Las Palmas; and ‡Microbiology, Majadahonda Center, Madrid, Spain.

Background and Aims: It considers to know the epidemiological decriptive characteristics, the temporary distribution and the mostly prevalents serogroups in Meningococcal Disease in children lower 10 years in Gran Canary Island, during the temporal period 2004–2008.

Methods: Prospective study of the Meningococcal Disease confirmated cases and notified to the Gran Canary Compulsory Disease Reporting system, through individualised notification of cases, and the microbiological data from the Microbiological Informative Sistem, between 2004–2008.

Results: In the studied period, there were notified 22 cases, 5 (23%) in 2004, 6 (27%) in 2005, 4 (18%) in 2006, 2 (9%) in 2007, and 5 (23%) in 2008. Also the 14% of sickness were below 1 year old, the 68% between 1 and 5 years and the 18% older 5 years. Only rested 4 processes without tipifying (18%). Of the 18 tipified, 64% were Serogroups B, 9% W135, one case, C, not vaccinated, and 1 case, A, imported.

Conclusions: We have to increase the knowledge of this disease with a continued alertness, remarking the need of to confirmate the diagnosis and have isolations to identify the causer serogroups.

P174

FIVE YEARS OF ACUTE OSTEOMYELITIS IN A BELGIAN PAEDIATRIC TERTIARY HOSPITAL

N. Genis,* S. Redant,* M. El Amine,† M. Bellemans,‡ J. Lamoureux,‡ G. Guissard,§ G. Mascart,¶ C. Fonteyne,∥ A. Vergison,** and D. Biarent,∥ *Emergency, HUDERF/ULB, Bruxelles; †Emergency; ‡Pediatric Orthopedy; §Radiology, HUDERF/ULB; ¶Microbiology, CHU Brugmann/ULB; ∥Emergency and Intensive Care; and **Infectious Disease, HUDERF/ULB, Brussel, Belgium.

Background: Acute osteomyelitis is scarce in Paediatrics. In 36 to 70% of the cases, no germs are found and this raises the question of the choice of the first line antibiotherapy.

Aim: To identify main etiologies of osteomyelitis in our population and to correlate with clinical and biological presentation.

Method: Retrospective study of all files of children admitted for acute or subacute osteomyelitis or arthritis from January 2003 to December 2007.

Results: Thirthy-eight children were included. Mean age was 5.8 years (median 2.4). Delay between first signs and first consultation was 7 days. Pain was present in 36 patients, fever in 26, functional impairment in 31, redness and swelling in 20. Fourteen/22 patients had a contributive ultrasonography, 20/36 children had a positive X-Ray. Five/6 CT scan, 21/21 scintigraphy and 16/16 MRI were positive.

Median of Sedimentation rate was 63 mm/H, CRP was 3.6 mg/dl. Thirteen/33 (36%) blood and 9/24 (37%) osseous biopsy or articular fluid cultures were positive forStaphylococcus Aureus (9), Streptococcus A/B types (6), Kingella Kingae (1), salmonella (1), mycobacterium tuberculosis (1) and negative in 20 children.

Intravenous antibiotics were shifted to oral forms when CRP was negativated. According to this principle, mean duration of intravenous treatment was 11.9 days (median 9) with no relapse.

Conclusion: In our population, first line antibiotherapy must still target staphylococcus and streptococcus. Echography and radiography can be negative and should be completed by scintigraphy and MRI in doubtfull cases. Short intravenous treatment according to SIRS is possible.

P175

MENINGOCOCCAL INFECTIONS: EPIDEMIOLOGICAL SITUATION IN BELARUS

I. Germanenka,* N. Kljujko,† A. Germanenko,‡ and A. Tarasik,§ *Childrens Infectious Diseases, Belarussian State Medical University; †Diagnostics, Hospital of Childrens Infectious Diseases, Minsk; ‡Vitebsk State Medical University, Vitebsk; and §Belarussian State Medical University, Minsk, Belarus.

Background and Aims: Meningococcal infection is still one of the main cause of childhood morbidity and mortality. The aim of this study is to learn epidemiology and evidence to vaccination from meningococcal infection.

Methods: During 3 years epidemiological situation of meningococcal infection was analysed in children under 15 yo.

Results: In our country the lowering sick rate of meningococcal infections from 2,84 (2006 y) to 1,63 (2008 y) per 100000 is indicated. The high level of sick rate is among children younger 15 yo-10,39/100000 (IC 95%: 7,7–13,08). We estimated the prevalence of illness among child aged under 2 yo-73,5% (IC 95%: 67,7–79,2).Thanks to early diagnostic and treatment the level of death decreased from 6,9% to 1,8%. Among admitted to infectious hospital children 52 meningococcus were identified. The structure was following: serogroup A-23,6%, B-27,1%, C-30,1%, nontypical-19,2%. It was estimated high level sensitivity all group of microbes to β-lactam antibiotics.

Conclusions: This study confirms prevalence of patients under 2 yo with meningococcal infection. It is a sign for starting vaccination against meningococcal infection for young children.

P176

EPIDEMIOLOGY OF HOSPITALIZATIONS DUE TO NOSOCOMIAL ROTAVIRUS IN YOUNG CHILDREN IN SPAIN (1998–2007)

R. Gil,* A. López,* A. Alvaro,* C. Cisterna,† A. Sampedro,† and A. Gil,* *Health Sciences I, Rey Juan Carlos University, Alcorcón Madrid; and †Medical Department, Sanofi Pasteur MSD, Madrid, Spain.

Background and Aims: This epidemiological survey was undertaken to estimate the burden of nosocomial rotavirus in children up to 5 years of age in Spain during a ten year period (1998–2007).

Methods: Retrospective survey by reviewing all hospitalizations related to nosocomial rotavirus in the National Surveillance System for Hospital Data (Conjunto Mínimo Básico de Datos). Codes were selected by using the 9th International Classification of Diseases codes: ICD-9-CM 008.61. The annual incidence, average length of hospitalization, mortality and case-fatality rate were calculated by using municipal register data.

Results: A total of 10,990 hospital discharges for nosocomial rotavirus in children up to 5 years old were reported during the study period. The annual incidence was 59.02 cases per 100,000 (CI 95%: 57.91–60.12). The average length of stay was 12 (SD 19) days. A total of 30 deaths were reported. The mortality rate was 0.16 deaths per 100,000 (CI 95%: 0.10–0.22) and the case-fatality rate was 0.27% (CI 95%: 0.18–0.37).

Incidence decreased significantly with age from 226.11 per 100,000 in children up to 1 year old to 1.78 per 100,000 in 4 year old children, respectively. Maximum case-fatality rate was found in children up to 1 year old (0.33%).

Annual average cost for National Heath Care System was 351,965,194€ with a mean hospitalization cost of 32,026€.

Conclusions: Nosocomial rotavirus infections in children up to 5 years of age pose a significant health threat in Spain. Special attention and public health measures as vaccination are required to reduce their incidence.

P177

TEMPORARY EVOLUTION OF PNEUMONIA AND COMPLICATED PNEUMONIA ADMISSIONS IN PAEDIATRIC POPULATION OF NAVARRE (NORTHERN SPAIN)

F. Gil,* M. Herranz,* A. Sagastibeltza,* X. Beristain,† L. Torroba,† B. Salcedo,‡ and E. Bernaola,* *Servicio Pediatría; †Microbiology; and ‡Medicina Preventiva, Hospital Virgen del Camino, Pamplona, Spain.

Background and Aims: In Navarre the pneumonia causes paediatric population morbidity and the pneumococcus is the most frequent agent. In 2001 began not systematic pneumococcal vaccination(PCV7). There are studies that indicate decrease of income for pneumonia and others increase of complicated pneumonias. Our aims are to describe the temporary trend and to evaluate the possible effects of the vaccine.

Methods: Total pneumonia admissions (TP), pleural effusion (PE) and empyema (EP) were analyzed retrospectively in our hospital from 1995 to 2006. The population figures were obtained of Navarre census. The statistical analysis was realized by t student, R pearson and logistic regression. We considered as pneumococcal pneumonias (PP) those with: a culture(+) in blood or pleural liquid (PL) or Ag/pcr(+) in PL.

Results: Total of 1365 TP were registered, with correlative increase with the years (Rp = 0.804; P = 0.002), also in PE (154,Rp = 0,886; P < 0.001), EP (38,Rp = 0,878; P < 0,001) and PP (32,Rp = 0,809; P = 0,001). Comparing the incidence/100.000 children in prevacunal (1995–2001) and postvacunal (2002–2006) period, a significant increase was observed in admissions by TP (176 vs 254, P = 0,018), PE (8 vs 27; P = 0,02), EP (1 vs 8; P = 0,019) and PP (2 vs 9; P = 0,012), diminishing however the number of admissions/100000/year (3748 vs 3191; P = 0,014). Therefore, the TP admissions percentage increase in the postvacunal period (4,75% vs 7,96%; P = 0.004). Analyzing TP hospitilzation risk in periods 1 (1995-1998), 2 (1999-2001) and 3 (2002-2006) it was obtained: 1-2:OR = 1,2(CI95%:1,02-1,4); 1-3:OR = 1,62(CI95%:1,4-1,87).

Conclusions: Pneumonia admissions and its complications have been clearly increased, more evidently in the postvacunal period. The differences found between this and other studies might been explained for epidemiological and microbiological reasons.

P178

EPIDEMIOLOGY OF HOSPITALIZATIONS DUE TO BORDETELLA PERTUSSIS IN CHILDREN UP TO 12 MONTHS OF AGE IN SPAIN (199–005)

R. Gil,* F. Moraga,† J. Santos,* A. Alvaro,* and A. Gil,* *Health Sciences I, Rey Juan Carlos University, Alcorcón Madrid; and †Pediatric Service, Vall d'Hebron Hospital, Barcelona, Spain.

Background and Aims: This epidemiological survey was undertaken to estimate the burden of Bordetella Pertussis in children up to 12 months of age in Spain during a seven year period (1999–2005).

Methods: Retrospective survey by reviewing data of the National Surveillance System for Hospital Data (Conjunto Mínimo Básico de Datos), including more than 98% of Spanish hospitals. All hospitalizations due to Bordetella Pertussis for children up to 12 months of age, reported during 1999–2005 period, were analysed. Codes were selected by using the 9th International Classification of Diseases codes for Bordetella Pertussis: ICD-9-CM 033 (033.0–039.9). The annual hospitalization rate, average length of hospitalization, mortality and case-fatality rate were calculated by using municipal register data.

Results: A total of 3277 hospital discharges for Bordetella Pertussis in children up to 12 months of age were reported during the study period. The annual hospitalization rate was 139.41 cases per 100,000 children (CI 95%: 134.64–144.18). The mean age of the patients was 2.68 months (SD 1.81). The average length of stay was 8.85 (SD 8.3) days. A total of 12 deaths were reported among the total of patients hospitalized. The mortality rate was 0.51 deaths per 100,000 children up to 12 months years (CI 95%:0.22–0.80) and the case-fatality rate was 0.37% (CI 95%: 0.16–0.57).

Conclusions: Bordetella Pertussis infections concentrate in children up to 12 months in Spain. Public health measures as vaccination of care takers, health care professionals and relatives, especially young parents, are required to reduce the Bordetella Pertussis related hospitalizations.

P179

MOLECULAR CHARACTERIZATION OF GROUP A HUMAN ROTAVIRUSES IN SALENTO, ITALY, DURING 2006–2007 REVEALS THE PREDOMINANCE OF UNUSUAL STRAINS

T. Grassi,* A. Idolo,* A. Cavallaro,† G. Gabutti,† and A. De Donno,* *Dept. of Biological and Environmental Sciences and Technologies, University of Salento, Lecce; and †Dept. of Clinical and Experimental Medicine, University of Ferrara, Ferrara, Italy.

Background and Aims: The distribution of rotavirus (RV) genotypes circulating throughout the world changes over time. The purpose of the present study was to monitor the prevalence of the different G and P genotypes of rotaviruses circulating in Salento and detect any uncommon types.

Methods: During the period from January 2006 to December 2007, a total of 243 RV positive stool samples were collected from children with diarrhoea admitted to four Hospitals in the province of Lecce (Copertino, Galatina, Gallipoli and Tricase). All the specimens were tested for RV by real time PCR and genotyped for VP7 (G-type) and VP4 (P-type) gene by reverse transcription (RT) and multiplex PCR using different type specific primers.

Results: We identified 4 common G&P combinations viz. G2P[8], G1P[8], G2P[4] and G9P[8] amongst 59.8% of the typeable rotavirus positives. Rotavirus G2P[8] was recognized as the most widespread genotype during the sentinel-based survey in Salento.

The detection of other novel and unusual strains, such as G2P[10], G4P[10], G8P[4], G9P[11] and G10P[8] is noteworthy. Furthermore, a significant number of mixed infections were observed during the survey period but G3P[8] rotaviruses were not detected.

Conclusions: This study highlights the genetic diversity among rotaviruses isolated from children in Salento and the emergence of some novel strains. Therefore, it is highly essential to continuously monitor for these strains so as to assess the impact of vaccines on RV strains circulating in Salento and understand the effect of strain variation on efficacy of presently available vaccines.

P180

ROTASCORE EXTENSION STUDY: FREQUENCY AND CLINICAL CHARACTERISTICS OF ROTAVIRUS GASTROENTERITIS IN GREECE

I. Grivea,* D. Koukou,† H. Tsioni,‡ E. Galanakis,§ E. Farmaki,¶ E. Iosifidis,¶ G. Trimis,† A. Siamopoulou-Mavridou,‡ M. Kalmanti,§ H. Tsepkentzi,¶ E. Roilides,¶ G. Syrogiannopoulos,* and V. Syriopoulou,† *Department of Pediatrics, University Hospital of Larissa, Larissa; †First Department of Pediatrics, Athens University, Aghia Sophia Children's Hospital, Athens; ‡Department of Pediatrics, University Hospital of Ioannina, Ioannina; §Department of Pediatrics, University Hospital of Heraklion, Heraklion; and ¶First and Third Department of Pediatrics, Aristotle University, Ippokration Hospital of Thessaloniki, Thessaloniki, Greece.

Background and Aims: Rotavirus Gastroenteritis (RVGE) is the most frequent cause of acute gastroenteritis (AGE) in children up to 5 years old worldwide. Aim was to determine the proportion of RG in Greece and compare its clinical burden to that of AGE due to other pathogens.

Methods: The study was conducted in 5 Hospital Emergency Units (HEU) between January 2007 and June 2008. Children up to 5 years of age with AGE were included. A rapid stool immunochromatographic test for rotavirus antigen detection was performed. Symptoms severity score was calculated using Clark scale.

Results: 393 children participated in the study (median age 23 months, 216 boys- 55.1%). RVGE proportion was 42.3% (CI 95%, 37.4–47.1%) in HEU and 47.8% (CI 95%, 41.7–43.9%) in hospitalized patients. Most children with RVGE (77.8%) were between 3 months and 3 years old. The 78.6% of RVGE was in winter months between December and April. Behavioral changes, signs of dehydration, weight loss, fever ≥38°C, vomiting and duration of diarrhea were more prevalent in RVGE (P < 0.01). In children with RVGE a higher severity (P < 0.01), hospitalization rate (P < 0.05) and clinical reevaluation (P < 0.05) was observed, as well as longer hospitalization stay (median 4 vs 3 days) and parents’ days of absence from work (P < 0.05).

Conclusions: It is confirmed that RVGE causes major clinical burden in Greek children up to 5 years and it is responsible for nearly half the cases visiting HEU or requiring hospitalization due to AGE.

P181

FURUNCULOSIS CAUSED BY COMMUNITY-ACQUIRED METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS IN A SCHOOL IN BRUSSELS, 2008: A POSSIBLE OUTBREAK

I. Gutierrez,*† O. Denis,‡ M. Hallin,‡ B. Jans,* M. Sabbe,* M. Gerard,§ D. Fruitier,¶ S. Lokietek,∥ M. Struelens,‡ A. Jumiaux,∥ and S. Quoilin,* *Epidemiology, Scientific Institute of Public Health, Brussels, Belgium; †European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, Stockholm, Sweden; ‡National Reference Laboratory for MRSA, Erasmus Hospital; §Sant Pierre Hospital; ¶School Health Promotion Service; and ∥French Community, Brussels, Belgium.

Background and Aims: Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging pathogen outside health-care settings. In December 2008 a case of furunculosis caused by MRSA was identified school with 800 children in Brussels. The isolated strain expressed genes coding Panton-Valentine Leukocidin (PVL). PVL-positive S. aureus can cause severe invasive infections.Three cases of skin infection had occurred in the same classroom. A quick response was organized by health authorities in order to assess the extent and control a possible outbreak provided that a potentially life-threatening microorganism had been isolated.

Methods: Risk factor questionnaires, and nasal swabs were obtained for 38 persons, children and adults, of the affected classroom. Education and hygiene measures were implemented. A case control study was conducted. Cases were defined as confirmed (positive culture for MRSA) and probable (compatible clinical symptoms). Odds ratios (OR) and 95% confidence intervals were calculated for different exposures.

Results: There were 1 confirmed and 3 probable cases; all of them girls; We did not find any significant association between cases and exposures.* No nasal carriers for MRSA were found.

Conclusions: A case of furunculosis by MRSA and 3 clinical cases in the same school led to a successful public health response. Information, education and communication, remain the cornerstone of public health interventions. Clinicians should be aware of emerging pathogens causing skin infection outbreaks.

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P182

SERIALLY DIFFERENCED MARKERS FOR PATHOGENETIC STAGES EXPRESS THE UNDERLYING TENDENCY FOR OTITIS MEDIA TO CONVERT TO HEARING LOSS

M. Haggard,* H. Spencer,† and I. Williamson,‡ *Experimental Psychology; †MRC Multi-Centre Otitis Media Study Group, University of Cambridge, Cambridge, MA; and ‡General Practice, University of Southampton, Southampton, UK.

Background and Aims: OM pathogenesis is a probabilistic cascade (viral exposure > URTI > bacterial colonisation > (R)AOM > lasting effusion with possible biofilm formation > hearing loss (HL). Risk factor and treatment studies could be strengthened by better reflecting the consequent co- variability patterns.

Methods: We modelled later auditory function (HL or tympanometric equivalent) using untreated occasions and cases in two large OME trial databases: TARGET and GNOME. Across four available occasion-pairings separated by 3 months, generalised linear models adjusting for age and season compared three approaches:

(i) co-optimised coefficients for two earlier independent covariates, namely the prior baselines in HL and a 5-item RAOM questionnaire score; the same information, but as

(ii) the normalised difference [Z(HL)−Z(RAOM score)]; and

(iii) separate univariate predictors.

Results: Within these selected samples, coefficients for prior HL/tympanometry measures were always positive as expected, but for RAOM scores were negative, and mostly significant. Hence normalised differencing (ii) gave prediction generally not inferior to co-optimised covariates (i), and for GNOME, actually superior prediction. Imposed differencing thus reflects a stable and relevant underlying conditionality: the tendency to convert any (further) AOM to HL (again).

Conclusions: Sequential normalised differencing (ii) has already clarified whether atopy is a risk factor in OM and enhanced the prediction of treatment benefit. That appears due in part to the general prediction of non-resolution (in controls) shown here, hence is relevant to selecting persistent cases for targetting interventions. The imposed constraint reduces degrees of freedom (2 to 1), assisting power in small studies.

P183

NEW PENICILLIN SUSCEPTIBILITY BREAKPOINTS FOR STREPTOCOCCUS PNEUMONIAE AND THEIR EFFECTS ON SUSCEPTIBILITY CATEGORISATION IN GERMANY FROM 1992 TO 2008

M. Imöhl,* R.R. Reinert,† and M. van der Linden,* *Institute of Medical Microbiology and National Reference Center for Streptococci, University Hospital (RWTH), Aachen, Germany; and †Wyeth Vaccines Research, Paris La Défense, Paris, France.

Objectives: This study was performed to analyse the penicillin susceptibility of all isolates of S. pneumoniae with IPD that were sent to the German National Reference Center for Streptococci (NRCS) between 1992 and 2008 and to evaluate potential differences in susceptibility categorisation when applying the new and the old CLSI guidelines, respectively.

Methods: A population and laboratory based surveillance study of invasive pneumococcal disease was conducted in Germany. Cases from January 1, 1992 to December 31, 2008 were included in this study.

Results: From 1992 to 2008, 12137 invasive isolates were obtained. Data on penicillin susceptibility were available for 11814 isolates. 2201 isolates (18.1 %) originate from patients with meningitis, and 9936 isolates (81.9 %) are from non-meningitis cases. Penicillin susceptibility categorisation according to the former Clinical and Laboratory Standards Institute (CLSI) guidelines results in 4.3% intermediate resistant and 1.2% resistant isolates. When the new CLSI guidelines (2008) are applied, considerably higher resistance rates are observed in the meningitis group (6.5% resistant, 0.0% intermediate resistant) than among the non-meningitis cases (0.0% resistant, 0.3% intermediate resistant). Irrespective of the guidelines used, a slight increase in pneumococcal penicillin resistance can be noticed in Germany from 1992 to 2008.

Conclusions: Despite the different effects of the new guidelines on meningitis and non-meningitis susceptibility categorisation, their application results in a lower overall rate of penicillin resistant pneumococcal isolates due to the numerical predominance of non-meningitis cases. This should be kept in mind when interpreting surveillance studies on pneumococcal penicillin resistance.

P184

THE DIRECT WET MOUNT EXAMINATION-A FOUR MONTHS PERIOD EVALUATION

S.I. Iurian,* S. Iurian,† B. Neamtu,* and A. Vidrighin,* *Pediatric Clinic, Pediatric Hospital, Lucian Blaga University; and †Clinical Laboratory, Pediatric Hospital, Sibiu, Romania.

Background and Aims: The direct wet mount examination is a microscopic review of a fresh fecal specimen to detect parasites (including motile protozoan trophozoites). The authors have evaluated the incidence of intestinal parasites in feces among hospitalized children using direct wet mount microscopic examination. The direct examination of stool is beneficial to assess the worm burden of a child and provides a quick diagnosis.

Methods: There were performed in pediatric clinic laboratory 863 parasitological stool exams during a 4 months period using direct wet mount microscopic examination in Lugol′s iodine (100 ml distilled water, 1 gram iodine and 2 grams potassium iodide). The examinations were performed using optic microscopy by the same investigator under ×100 and ×400 magnification.

Results: From 863 parasitological exams, 123 specimens (14,25%) were positive: 18 specimens-Ascaris lumbricoides (2,08%), 10 specimens-Entamoeba coli (1,15%), 38 specimens-Giardia intestinalis (4,4%), 40 cases-Blastocystis hominis (4,63%), 6 cases-Trichiuris trichiura (0,69%) and 2 specimens Enterobius vermicularis (0,23%) and 9 cases (1,04%) have presented combined parasitic infections.

Conclusions:

1. We have noticed the low incidence of positive specimens using direct wet mount microscopic exam;

2. Giardia intestinalis and Blastocystis hominis have almost same prevalence;

3. The routine parasitological stool exam has revealed a low prevalence for whipworm infection (0,69%);

4. The direct wet mount is not useful for Enterobius vermicularis infection diagnosis (the Graham test is useful).

P185

COMPARISON BETWEEN QUELLUNG REACTION AND SEQUENTIAL MULTIPLEX PCR FOR THE DETERMINATION OF STREPTOCOCCUS PNEUMONIAE CAPSULAR SEROTYPES AMONG CARRIAGE ISOLATES

S. Jourdain,*† P.-A. Drèze,* A. Vergison,† L. Van Melderen,* and P. Smeesters,*† *Génétique et Physiologie Bactérienne, IBMM, Gosselies; and †Paediatric Infectious Diseases Department and Infection Control Unit, HUDERF, Brussels, Belgium.

Background and Aims: The gold standard for S. pneumoniae serotype determination is the Quellung reaction determined with specific antisera. The high cost of these antisera, the technical expertise requirements and subjectivity in interpretation are drawbacks of this method. Current sequential multiplex PCR was developed for the detection of serotypes associated with IPD in USA (Pai and al JCM 2006). A S. pneumoniae carriage study was carried out and 317 strains were collected. Both serotyping methods were compared to evaluate the accuracy of PCR in carriage studies.

Methods: S. pneumoniae were isolated from nasopharyngeal aspirates in healthy children in Brussels and identified as recommended by CLSI. Serotyping was performed using the PCR-based method and the Quellung reaction.

Results: 317S. pneumoniae were collected. PCR-based serotyping allowed serotype determination of 188 strains (60%). Concordance between PCR and Quellung reaction was observed for 70% of the isolates (131 out of the 188 strains). Although the specificity was globally excellent (>95%), the sensitivity varied widely among serotypes (6% for serotype 15 to 84% for serotype 19A). At the bioinformatics level, the number of cps sequences available for each serotype in databases is low for most of the serotypes and probably precludes for optimal design of specific primer pairs.

Conclusions: PCR-based serotyping is undoubtedly a promising method even epidemiological differences may play an important role. To increase the sensitivity of the method, primers may have to be designed based on a larger sample of cps sequences from the same serotype.

P186

EPIDEMIOLOGY OF NASOPHARYNGEAL FLORA IN 299 HEALTHY CHILDREN ATTENDING KINDERGARTEN IN BRUSSELS

S. Jourdain,*† V. Sputael,‡ X. Malaviolle,§ O. Denis,§ M. Struelens,§ L. Van Melderen,* P. Smeesters,*† and A. Vergison,† *Génétique et Physiologie Bactérienne, IBMM, Gosselies; †Paediatric Infectious Diseases Department and Infection Control Unit; ‡Paediatrics, HUDERF; and §Microbiology, Hôpital Erasme-Université Libre de Bruxelles, Brussels, Belgium.

Background: A cohort study in healthy, 3 to 6 year old children was conducted in Brussels over 2 school years to determine nasopharyngeal carriage rates and antimicrobial resistance of 5 different bacteria: S. pneumoniae, S. aureus, H. influenzae, M. catharralis and S. pyogenes.

Methods: Demographic data were collected. Three sequential naso-pharyngeal aspirates were performed (autumn, winter, spring). Identification of the 5 bacteria was performed as recommended by CLSI. Antibiotics resistance profiles were determined by disc diffusion and E-tests. S. pneumoniae serotyping was carried out by the Quellung reaction.

Results: 299 healthy children (median age 4.4 years) were included. 19% children had received at least one dose of PCV7. Carriage rate was 42% for S. pneumoniae, 33% for S. aureus, 58% for H. influenzae, 40% for M. catarrhalis and 3% for S. pyogenes. 87 patients showed a dual carriage of S. pneumoniae and S. aureus. 110 children presented a carriage of both S. pneumoniae and H. influenzae. 23 different S.pneumoniae serotypes were determined; the most frequent ones were: 6B, 19F, 23F,19A, 6A, 15A, 11A, 23A, 1 and 29. Among 317 pneumococcus isolates, 15% were penicillin non susceptible, 24% were erythromycin resistant, 11% were coresistant to penicillin and erythromycin. 4% S. aureus were MRSA.25% H. influenzae and 100% M. catarrhalis were beta-lactamase producers.

Conclusions: These data provide a dynamic overview of naso-pharyngeal flora in healthy children in Brussels. Unusual S. pneumoniae serotypes (eg 1, 7F) were isolated in this population. Antibiotic resistance rates are globally comparable to clinical isolates exept for MRSA.

P187

AGE SPECIFIC SEROEPIDEMIOLOGY OF DIPHTHERIA, TETANUS AND PERTUSSIS AMONG KOREANS

J.H. Kang,* S.Y. Lee,* G.Y. Gwack,* J.H. Kim,* J.K. Hur,* S.H. Ma,† J.S. Park,‡ and H.M. Kim,§ *Pediatrics, The Catholic University of Korea, Medical College, Seoul; †Pediatrics, Fatima Hospital, Changwon; ‡Pediatrics, Soon Cheon Hyang University, Ceonan; and §Pediatrics, Wonju Yonsei University, Wonju, South Korea.

Background: This study was conducted to make the strategy of preventing diphtheria, tetanus and pertussis through age specific seroepidemiology of diphtheria, tetanus and pertussis among Koreans.

Purpose: The primary focus of this study was to assess the usefulness of DTaP and Td vaccination and get the basic data for making the strategy of DTaP and Td vaccine policy. Secondary focus was to find out the changes of defense immunity against diphtheria and tetanus in adolescents and adults after the introduction of Td vaccine.

Methods: We detected the anti-diphtheria and tetanus toxoid antibodies from the age specific samples by using ELISA, and compared those levels between age groups. Also, we detected and compared the anti-PT antibody levels with same methods.

Results: We found that the immunity against diphtheria and tetanus were well maintained in children with age below 10 years old, but the level of anti-diphtheria and tetanus Ab. were markedly decreased after 20 old aged persons. Also, anti-PT antibody levels in the group with age below 10 years old were statistically higher than the levels in other aged groups. And there were no different anti-PT levels between other aged groups.

Conclusions: We concluded that the usefulness of DTaP vaccination was acceptable through confirming the high antibody levels of diphtheria, tetanus and pertussis in the group with age below 10 years old. However, we found the necessity of active Td vaccination in persons with age more than 30 years, because of very low anti-diphtheria and tetanus antibody levels in those people.

P188

PRIMARY AND SECONDARY PROPHYLAXIS OF RHEUMATIC FEVER-OUR EXPERIENCE

M. Kelmendi,* and R. Beqiraj,† *Cardiology, University Children's Hospital; and †University Institute of Histology, Prishtina, Albania.

Abstract: One of the most important contributing factors for the decline in rheumatic fever (RF) is the successful primary, as well as secondary prevention of RF.

Objectives:

1. to stress the role of prophylaxis in the appearance of first atack and RF recurrences and

2. to underline some problems with RF prophylaxis we are faced with.

Material and Methods: Retrospective study of patients with group A beta haemolyticus streptococcal infections (GABS) and RF treated at University Children′s Hospital, Prishtina, between 1974/2007. A total number of 1254 children, aged from 5 to 16 yrs have been treated from RF (first attack and recurrences) for that period. After first attack of RF, the secondary prophylaxis was performed at all patients with benzathin penicillin G. Many years ago, the interval between two injections was 1 mo, but our experience revealed that despite the regular monthly prophylaxis certain number of RF recurrences ocurred. Then the interval between two injections was shortened to three weeks which results in lowering of FR recurrences.

2. Like in secondary prophylaxis, the medicament of choice for the treatment of GABS infections was also benzathin penicillin G, in one doses or repetitive ones (for months or years) in chronic throat infections. Following ASO titer in such patients, some of them manifested high ASO titer, despite regular benzathine penicillin injections every three weeks.

Conclusion: Fail to benzathin penicillin therapy in some patients with GABS means GABS carriers or maybe something unmentioned before: streptococcal rresistance to penicillin therapy?

P189

RHEUMATIC FEVER AND ITS NEW IMAGE

M. Kelmendi,* and R. Beqiraj,† *Cardiology, University Children's Hospital; and †University Institute of Histology, Prishtina, Albania.

Abstract: Despite the fact group A beta streptococcus infections (GABS) remain the same, rheumatic fever (RF) in our country, like many, developed and developing countries in decreasing too.

Objective: To present RF during last eight years and to stress some changes ocurred in RF.

Material and Methods: Retrospective study of in, and out patients, treated at Univesrity Childrens Hospital, Prishtina, between 2000/2007. Study group consists of 153 patients with RF, aged from 5 to 16 yrs. Diagnosis of RF was established using history, revised Jones criteria, laboratory, including echocardiography with its modalities. Diagnosis of GABS was performed using throat culture and following antistreptococcal antibodies for ASO.

Results: Analysis a group of 153 pts with RF, diagnosed at Prishtina Childrens Hospital, revealed some changes occured in RF features, in comparison with earlier period (twenty years ago). According to clinical features: arthritis remains the same, 36.8% as pure and in 37.5% in combination with carditis, chorea is decreasing (20% vs 7.6%), while carditis is increasing (63.1%, as pure, or in combination with arthritis or chorea).

The most dramatic change in RF appearance is the number of recurrences, which are rapidly decreasing, from 20% to 8.3%, underlying that the number of RF recurrences for the last four years was zero.

Conclusion: Like many reports, RF is becoming less prevalent and is changing its features-manifested mainly with mild and moderate cases and low number of recurrences.

P190

HOSPITAL BASED EPIDEMIOLOGICAL STUDY OF INFLUENZA VIRUSES AMONG CHILDREN

M. Khanna,* B. Kumar,† V. Kunddi,‡ V. Singh,§ and A.C. Mishra,¶ *Respiaratory Virology, VP Chest Institute, University of Delhi; †Respiartory Virology; ‡Respiratory Medicine, VP Chest Institute, University of Delhi, Delhi Chest Institute, Delhi; §Medcine, Kalawati Saran Hospital, New Delhi; and ¶Virology, National Institute of Virology Pune, Pune, India.

Abstract: Surveillance effort is being implemented that monitors the antigenic changes of influenza virus isolates in India. Since March 2003 to Janaurary 2009, total 3000 Nasopharyngeal swab (NPS) and Throat swab (TS) specimens have been collected from the Kalawati Saran Children's Hospital (KSCH), New Delhi, Clinical Research Centre (CRC), VPCI, New Delhi, Lok Nayak Jai Prakash Hospital (LNJP), India. All the clinical specimens were inoculated in MDCK cell lines after processing of the specimens. Positive isolates were typed and sub-typed by HAI and confirmatory test has been done with RT PCR using strain specific primers for HA gene. Out of 3000, 241 specimens were found positive for H1N1, H3N2 or Influenza B. The monthly distribution of influenza viruses revealed the peak season for influenza virus circulation to be during the month of January-March and June-July. According to meteorological data influenza virus isolation rate increases as the temperature decreases, humidity increases and in rainy season. The data indicates that Influenza A and B are co-circulating in the community with characteristic marked seasonality.

P191

MOLECULAR EPIDEMIOLOGY OF MEASLES VIRUS IN THE CONTEXT OF GLOBAL MEASLES CONTROL

J. Kremer, and C.P. Muller, Immunology, LNS/CRP-Santé, Luxembourg, Luxembourg.

Abstract: The genetic diversity of recently identified measles virus (MV) strains from Europe and Africa was analysed in the context of regional measles elimination and global measles mortality reduction programs led by the WHO.

In Europe, the prevalence and genetic diversity of indigenous MV genotypes (C2 and D6) was considerably lower than during the 1990s. However, multiple importations of other genotypes from Africa and Asia as well as their introduction into highly mobile and unvaccinated communities caused a major spread of MV in Europe during recent years. Many of the imported MV genotypes originated from regions with high measles lethality but in Europe case fatality rates remained low.

In Kinshasa (DRC), different MV genotypes, B3 and B2, were found in two consecutive epidemics (2002–03 and 2004–06), suggesting that MV circulation had been temporarily interrupted despite sub-optimal vaccination coverage in the local population. The small genetic distance (0.2%) between B2 strains from Kinshasa 2005 and those identified 20 years earlier in Gabon revealed a remarkable genetic stability of the corresponding viruses. In contrast a high genetic diversity of genotype B3 viruses (1.8–2.9%) was found within different cities of Nigeria, even though they were collected within a period of maximum 2 months. The co-circulation of many genetically distinct MV strains suggested that measles remains highly endemic in Nigeria.

Molecular epidemiology of MV is a powerful tool to monitor virus transmission within and between regions with different vaccination coverage and thus helps to develop optimized strategies for global measles control.

P192

THE ROLE OF INTERNATIONAL TRAVEL AND VACCINE EXEMPTORS IN THE EPIDEMIOLOGY OF MEASLES IN THE U.S., 2008

P. Kutty, S. Redd, A. Barskey, J. Rota, P. Rota, W. Bellini, and K. Gallagher, Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Background and Aims: Measles was declared eliminated in the United States (U.S.) in 2000. In 2008, the U.S. reported its highest number of measles cases since 1996. We describe the characteristics of measles cases reported in the U.S. during 2008.

Methods: Measles cases, reported to the Centers for Disease Control from state health departments, are categorized as internationally imported (II) if they resulted from exposure to measles virus outside the U.S., import-linked (IL) if they were epidemiologically linked to an II case, or associated with imported-virus (IV) [viral evidence indicating an imported measles genotype]. An outbreak was defined as ≥3 cases linked in time or place.

Results: During 2008, 140 measles cases and seven outbreaks were reported. The majority (126 [90%]) were associated with importations (24 II, 29 IL, 22 IV, 51 linked to IV); 60% of these were associated with Europe. Fourteen cases were of unknown source. Case-patients ranged in age from 5 months to 71 years; 14% were under 12 months, 20% were 1–4 years, and 42% were school-aged (5–19 years). Among U.S. residents (127 case-patients), 91% were unvaccinated. Of the 98 case-patients eligible for vaccine, 67 (68%) were unvaccinated because of personal or religious beliefs.

Conclusions: In the U.S., measles elimination has been maintained through high vaccination coverage. However, measles importations into the U.S. will continue to occur until global control of measles is achieved. Unvaccinated or under-vaccinated individuals, including infants and school-aged children whose parents refuse or defer vaccination, remain at risk for infection.

P193

BACTERIAL COLONISATION AND ASTHMA-LIKE SYMPTOMS IN INFANTS. THE GENERATION R STUDY

A. Lebon,*†‡ J.A.M. Labout,*† J.C. de Jongste,† H.A. Verbrugh,‡ A. Hofman,§ V.W.V. Jaddoe,*†§ A. van Belkum,‡ and H.A. Moll,*† *The Generation R Study Group, Erasmus MC; †Department of Paediatrics, Erasmus MC-Sophia Children's Hospital; ‡Department of Medical Microbiology and Infectious Diseases; and §Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.

Background and Aims: An association between early bacterial colonisation and childhood asthma has recently been described in high-risk infants. Our aim was to investigate, in a population-based prospective birth cohort, nasopharyngeal colonisation with bacterial pathogens in early life and asthma-like symptoms in young children.

Methods: A group of 1,079 infants participated in the Generation R Focus Study: a cohort study from fetal life onwards. Nasopharyngeal swabs were cultured for the airway pathogens Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae and a nasal swab was cultured for Staphylococcus aureus. Swabs were obtained at 1.5, 6 and 14 months of age. Questionnaires on asthma-like symptoms and potential confounders (gestational age, birth weight, gender, maternal smoking, maternal educational level, breast-feeding, day care and siblings) were obtained at 6, 12 and 24 months of age.

Results: Infants who were culture positive for any of the airway pathogens at least four times in the first year of life had an increased risk to develop asthma-like symptoms in the second year of life (aOR 3.62 95%CI 1.51–8.68). Colonisation with M. catarrhalis, H. influenzae as well as any of the three airway pathogens together at 6 months carried the highest risk (aOR 1.54 95%CI 1.13–2.09). S. pneumoniae alone and S. aureus did not significantly associate with the development of asthma-like symptoms.

Conclusion: The frequency of airway pathogen colonisation during the whole first year of life, rather than colonisation as such, determines the risk of asthma-like symptoms in childhood.

P194

CHANGING EPIDEMIOLOGICAL PROFILE OF LEPROSY IN CHILDREN IN THE NAMPULA DISTRICT (MOZAMBIQUE) AT THE TURN OF THE ELIMINATION CAMPAIGN

P. Lopes,*† A. Alves,†‡ and V. Barnabé,† *Department of Pediatrics, Hospital Dona Estefânia; †Associação Portuguesa Amigos de Raoul Follereau (APARF), Non-Governmental Organization Against Leprosy, Lisbon, Portugal; and ‡Department of Neurology, Centre Hospitalier de Versailles, Versailles, France.

Background and Aims: Leprosy detection rate in children is an indicator of disease prevalence and transmissibility in general population. Mozambique achieved the WHO elimination target of <1 case of leprosy per 10.000 inhabitants in 2007; however, endemic pockets still present a threat to public health in some remote and low resource areas. The aim of this study is to analyse the disease's epidemiological profile in children in the Nampula district during the 2006–2008 period.

Methods: From January 2006 to December 2008 APARF cooperated closely with the Health Ministry in the active search of new cases in the Nampula district (>200.000 inhabitants), providing access to disease information, diagnosis and multidrug therapy.

Results: During 2006 144 new cases were detected, and thedetection rate decreased to 45 in 2008 (estimated prevalence fell from 8 to 2 cases per 10.000 inhabitants, the difference being very close to statistic significance [P = 0,057]). The proportion of children <18 years decreased from 32 to 20% (P = 0,14) during the same period and there was a trend towards new cases being detected in older children, suggesting decreased transmissibility. The multibacillary proportion increased from 77 to 89% and the cumulative proportion was a significant 71% (P < 0,001), which is a phenomenon observed when leprosy is close to elimination.

Conclusions: This changing epidemiological profile in children, although still not statistically significant, suggests that leprosy is decreasing as a result of a sustained effort towards elimination, but a strong commitment is still required to achieve this goal.

P195

CLINICAL PROFILE OF LEPROSY IN CHILDREN IN THE NAMPULA DISTRICT (MOZAMBIQUE) DURING THE 2006–2008 PERIOD

P. Lopes,*† A. Alves,†‡ and V. Barnabé,† *Department of Pediatrics, Hospital Dona Estefânia; †Associação Portuguesa Amigos de Raoul Follereau, Non-Governmental Organization Against Leprosy, Lisbon, Portugal; and ‡Neurology, Centre Hospitalier de Versailles, Versailles, France.

Background and Aims: Leprosy is a devastating disease in children, because, along with the physical disabilities it may cause, the stigma too often undermines the child's opportunities to live a normal live. From January 2006 to December 2008, APARF underwent active search of leprosy cases in the Nampula District (>200.000 inhabitants), working in close cooperation with the Health Ministry.

Methods: A descriptive retrospective study was conducted, based on the clinical files of children diagnosed with leprosy during the project period.

Results: Since inception of the project, there were diagnosed 85 leprosy cases in children and adolescents under 18 years (median 13 years), with no significant preponderance between sexes. All of them received the WHO-recommended multidrug regimen. Multibacillary forms were a significant majority (71%, P < 0,001) and the peak incidence (48%) was observed in the 10–14-year old age group. Complications such as type 1 and 2 reactions were observed and treated with steroids in 10% and 12,5% of the patients, respectively, and physical disability at the time of presentation was observed in an alarming 11% of children. Among the latter, 4% were found to have WHO Grade 1 and 7% Grade 2 disabilities, with only 22% having improved with physical therapy, or steroids or surgery as needed. The abandon rate fell from 17% in 2006 to 0% in 2008.

Conclusions: At present there are still many children living with physical disabilities and many more stigmatized by the disease. Leprosy complications were unusually high in this population.

P196

PREVALENCE, CUMULATIVE INCIDENCE AND SOCIO-DEMOGRAPHIC DETERMINANTS OF VARICELLA ZOSTER VIRUS (VZV) INFECTION IN EARLY CHILDHOOD IN THE UK

G. Manikkavasagan, H. Bedford, and C. Dezateux, MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, London, UK.

Background: Germany is the only European country to have introduced universal childhood varicella vaccination. In the UK, age-related data on susceptibility to VZV infection are lacking to inform vaccination policy and optimal timing of vaccine schedules.

Aims: To report prevalence, cumulative incidence, and socio-demographic determinants of VZV infection acquired by age 5 years.

Methods: 12509 UK Millennium Cohort Study members. Maternal report of: VZV infection at age 3 and 5 years; maternal ethnicity, socio-economic status, education; family size; pre-school day-care attendance. Weighted prevalence and cumulative incidence were calculated and Poisson regression used to estimate adjusted relative risks (aRR; STATA v9).

Results: 5350 children acquired VZV infection by age 3 (44.8%; [95% CI: 43.5%, 46.0%]), and a further 3989 (32.2%; [95% CI: 31.1%, 33.3%]) between 3 and 5 years of age, giving a cumulative incidence to age 5 of 76.9% [95% CI: 75.9%, 78.0%]. Children of mothers from professional backgrounds (aRR 1.04; [95% CI: 1.02, 1.05]), and those from larger families (aRR 1.03; [95% CI: 1.02, 1.05]) or who attended pre-school day-care (aRR 1.05; [95% CI: 1.03, 1.07]) were at higher risk of VZV infection by age 5, while those with mothers from ethnic minorities (aRR: 0.95; [95% CI: 0.92, 0.98]) were at lower risk.

Conclusions: Three quarters of UK children acquire VZV infection by 5 years of age; almost half by age 3 years. The risk of VZV infection is higher in children attending day care or from larger families. An infant vaccination schedule would be optimal for the UK.

P197

STUDY OF FOOD POISONING IN NAVODARI CAMP, IN THE SUMMER OF 2007

C. Marcas, Infectious Diseases, Clinical Infectious Diseases Hospital Constanta, Constanta, Romania.

Introduction: Food poisoning is a problem specific for the summer season, given that 90% of the total patients hospitalized at our hospital during summer present digestive pathology and 50% of them are tourists. The camp was closed because of the food poisoning epidemic.

Objectives: The work aims to study epidemidemiologic, clinical, biological and therapeutic aspects related to food poisoning in Navodari camp.

Material and Method: Retrospective study of 72 patients with food poisoning.

Results: Out of the 101 patients who showed up at the emergency room, 72 were hospitalized. The debut was within a few hours (less than 10 hours) from the food ingestion (cooked in the camp's kitchen). Over 90% of the patients had general toxic symptoms and vomiting; 95% had mild and severe dehydration symptom. 40% cases were diagnosed with Salmonella group D identified in fecal samples; in 11% of the cases, the fecal samples had both Salmonela as well as E. Coli. In 2/3 of the cases, the inflammation was high. Many patients being rehospitalized in their own city.

Conclusions:

1) Association of Salmonella and E Coli in so many cases make us believe that, beside food, some of the kitchen personnel had E. Coli.

2) Navodari camp had epidemic outbreaks each year, which proves that the measures taken along the years to combat it were insufficient. The camp closure is not a happy measure for the children whose families have average or low income.

P198

DESCRIPTIVE EPIDEMIOLOGY OF DOG BITES/MAULINGS& RABIES/RELATED INFECTIONS IN PICU/ED WITH IMPLICATIONS FOR A MORE CRITICAL/HOLISTIC EVALUATION/MANAGEMENT STRATEGIES

E. Onyekwelu, Paediatrics, Royal Victoria Teaching Hospital, Banjul, The Gambia.

Background/Purpose: Dogs bites/maulings, particularly affecting children could be fatal, causing global public health concerns. 50% of children are affected at some point, predominantly males. Related infections are polymicrobial, Pasturella/Bacteroides represents earlier pathogens, staphylococcus invades latter, its aetio-pathogenic nomenclature gets exponentially grotesque. Mortality was significant at >2%. Teenagers survived most. Deaths were newsworthy, made headlines and were acceptable indicators. Anecdotally direct attributive mortalitiy were unduly contingent on rabies, without adequate re-appraisal of simulating co-morbidities causing encephalopathies in dog maulings, such as severe infections/trauma. This misconception could espouse uninterventional management strategies, given its even/uniform case fatality. Accurate mortality figures were poorly documented/difficult to decipher. Its evaluation is more difficult in developing countries, making revisiting the investigation/management of dog bites/victims worthwhile.

Cases/Interventions: Review of cases at an ED/PICU from September 1999 to September 2008. Most cases presented within 24 hours. 213 were admitted, most of the dogs were unknown, boys were mostly afflicted 65.4%, most cases were <10 years, most bites involved the head, face, scalp/neck. Wound sepsis in 35%, encephalopathies 5.23%, hydrophobia/compatible rabies/death 1.41%.

Interventions: Radiography/Wound cultures, tetanus toxoid/rabies vaccine, broad spectrum antibiotics, analgesia/appropriate nursing/critical care with sedatives if encephalopathic. Co-amoxiclav/tetracyclines were not used.

Conclusion: Managing dog bites/maulings is complex/critical. Rabies should not be implicated in all encephalopathies related to dog maulings.Most critical/holistic evaluation/management strategies should be applied to eschew preventable fatalities from its simulating co- morbidities. Ongoing antibiotic policies are more appropriate for latter onset infections than earlier onset ones.

P199

A PREDICTION RULE FOR PNEUMONIA IN CHILDREN WITH FEVER AND COUGH FOR PEDIATRIC ASSESSMENT UNITS AND EMERGENCY CARE

R. Oostenbrink,* M. Thompson,† J. Roukema,* E.W. Steyerberg,‡ N. Coad,§ M. Lequin,¶ J. van der Lei,∥ D. Mant,† and H.A. Moll,* *Outpatient Department General Pediatrics, Erasmus MC-Sophia, Rotterdam, The Netherlands; †Department of Primary Health Care, University of Oxford, Oxford, UK; ‡Department Public Health/Clinical Decision Making, Erasmus MC, Rotterdam, The Netherlands; §Department of Pediatrics, University Hospital Coventry and Warwickshire NHS Trust, Warwickshire, UK; ¶Department of Radiology, Erasmus MC-Sophia; and ∥Department of Medical Informatics, Erasmus MC, Rotterdam, The Netherlands.

Background and Aim: To develop and validate a prediction rule for identification of children at risk for pneumonia to support clinical decisions in emergency care.

Methods: Patients aged 1 month-16 years with fever and cough at the emergency department of the ErasmusMC-Sophia, Rotterdam, The Netherlands (n = 504, 2003–2005; median age 1.6 year; interquartile range (IQR) 0.8–2.9) and at the paediatric assessment unit at the University Hospitals Coventry and Warwickshire NHS Trust, UK (n = 237, 2005–2006; median age 2.1 yr; IQR 1.2–5.2) were included. Independent predictors for pneumonia assessed by multivariable logistic regression were derived in the Dutch cohort and validated in the UK cohort.

Results: The derivation cohort included 78 (16%) children with pneumonia; the validation cohort 34 (14%). Laboratory tests were performed in 51% of the patients (259/504 and 120/237). Predictors for pneumonia included illness duration, ill appearance and tachypnea (ROC-area 0.74; 95% CI 0.63–0.85). These clinical signs remained diagnostically useful when applied to the validation cohort (ROC-area 0.71; 95% CI 0.53–0.89). Using these predictors children can be categorized into low, intermediate and high risk for pneumonia to guide management. C-reactive protein significantly improved risk estimation of pneumonia in those with intermediate risk.

Conclusion: The risk of pneumonia can reasonably be assessed by general appearance, illness duration and breathing rate. Serum CRP contributes to risk prediction in particular in children with an intermediate risk of pneumonia. Children categorized as having low risk of pneumonia do not require antibiotics or further investigation and can be safely discharged.

P200

THE OUTCOMES OF UNIVERSAL PCV-7 IMMUNISATION IN INFANTS IN KIELCE REGION

M. Patrzalek, Children Hospital of Kielce, Kielce, Poland.

Abstract: The aim of study was to evaluate the effect of PCV-7 on incidence of pneumonia.

Methods:

* On the 1st of January 2006 there was initiated program of common PCV-7 vaccination in infants founded by authorities of city of Kielce.

* There was applied a modified 3-dose vaccination program 2+1 (3/12-6/12-13/12)

* There was compared a frequency of hospitalization due to pneumonia in children in age groups of 0–1 and 2–4 years in the period before (2004–2005) and after implementation of universal immunization (2007 and 2008).

Results:

* Compared to 136 children with pneumonia in age group of 0 -1 year in a control period (2004 and 2005) there were hospitalized 53 and 51 children in the year 2007 and 2008 respectively.

* Compared to 30 children with pneumonia in age group of 2–4 year in a control period (2004 and 2005) there were hospitalized 23 and 19 children in 2007 and 2008 respectively.

Conclusions:

* A number of pneumonia hospitalizations in vaccinated children (aged 0–1 year) was reduced by 61% in 2007 and by 62.5% in 2008. In 2007 in unvaccinated children aged 2–4 years a reduction in pneumonia hospitalization was 23%. In 2008 the reduction rate in this age group increased to 37% and was result of vaccination started in 2007.

* PCV-7 vaccination schedule 2+1 was effective in reduction of pneumonia hospitalization in children.

P201

TICK-BORNE ENCEPHALITIS IN CHILDREN AND ADOLESCENTS IN THE WEST BOHEMIAN REGION (CZECH REPUBLIC) BETWEEN 1960 AND 2008

P. Pazdiora,* V. Struncová,† and M. Svecová,‡ *Department of Epidemiology, Regional Hygiene Station; †Clinic of Infectious Diseases, Medical Faculty of Charles University; and ‡Department of Microbiology, University Hospital, Pilsen, Czech Republic.

Background and Aims: After lyme borreliosis, tick-borne encephalitis (TBE) is the second most common infection transmitted by ticks in Europe. The West Bohemian Region ranks among the highest incidence areas in the Czech Republic.

Methods: The retrospective survey analysed 0-19-year-old patient′s records with serologically established TBE as reported to the Hygienic Service of West Bohemian Region from 1960–2008.

Results: During the surveyed period 420 cases of TBE in children and teenagers were confirmed by laboratory testing (3.4 per 100,000 inhabitants p.a.). The highest incidence rate for both male and female sexes (6.2 and 4.1 respectively) concerns the same age group of 15–19 years old. Of all the reported cases, one case was fatal (a 15-year-old boy, 0.2%). None of the sick reported TBE vaccination. Over the years the risk of transmission in particular areas of the region has changed. The current highest incidence rate is reported in the Klatovy District (14.9 per 100,000 inhabitants p.a.). In 5.2% cases patient's anamnesis showed data on the consumption of non-pasteurized milk or non-pasteurized diary products. As a result of the gradual prolongation of the infection season, the transmission period currently falls between March and November. The preschool category reported the highest incidence in June and September, while schoolchildren fall predominantly in the standard summer holiday months of July and August. Based on officially available data, 13.7% of the Pilsen Region′s young population has been vaccinated, so far.

Conclusions: Low vaccination coverage may hardly influence the unfavorable TBE epidemiological situation.

P202

HIGH RATES OF ANTIBIOTIC PRESCRIBING DURING PREGNANCY WITH POTENTIAL CONSEQUENCES FOR CHILDHOOD OUTCOMES: UK PRIMARY CARE DATABASE STUDY

I. Peteresen,* R. Gilbert,† E. Stephen,‡ and I. Nazareth,* *Primary Care and Population Health, University College London; †Centre of Paediatric Epidemiology and Biostatistics, UCL-Institute of Child Health; and ‡Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.

Background and Aims: To evaluate antibiotic prescribing patterns in pregnancy.

Methods: Primary care data for 4% of patients in the UK between 1992 and 2007 were analysed for pregnant women aged 15 to 45 years.

Results: Overall, 37,494/114,734 (33%) women received at least one antibiotic prescription during pregnancy. Two-thirds (65%) received just one prescription and less than 5% received more than three antibiotic prescriptions. The most frequently prescribed antibiotics were broad-spectrum penicillins (48%), cephalosporins and other betalactams (21%). Erythromycin accounted for 7% of all prescriptions and was prescribed at the same rate throughout pregnancy. Trimethoprim, tetracyclines and quinolones, and metronidazole were prescribed in the first four weeks of pregnancy, but the number of prescriptions of these antibiotics declined substantially thereafter. In the four weeks before delivery, 3,041 (8%) women received an antibiotic prescription and 337 (1%) women received Erythromycin. The level of antibiotic prescribing declined from nearly 40% in 1997 to 35% of pregnant women in 2007. Young maternal age and social deprivation were associated with increased antibiotic prescribing: relative risk 1.34 (95% CI 1.29–1.38) for women in most deprived v least deprived area, adjusted for age.

Conclusions: Antibiotic prescribing is common in pregnancy. Further research into prescribing of antibiotics in primary care during pregnancy is urgently needed in view of emerging evidence that maternal antibiotics can potentially affect long term neurological outcomes, gut flora and immune development in children.

P203

SEROTYPE-SPECIFIC CLINICAL OUTCOMES OF INVASIVE PNEUMOCOCCAL DISEASE IN HOSPITALIZED PEDIATRIC PATIENTS IN MADRID (MAY 2007–APRIL 2008)

J. Picazo,* J. Ruiz-Contreras,† J. Casado-Flores,‡ S. Negreira,† F. Del Castillo,§ T. Hernandez-Sampelayo,¶ I. Rodriguez-Avial,∥ and C. Méndez,** *Faculty of Medicine. Univ. Complutense; †Hospital 12 de Octubre; ‡Hospital Niño Jes&uacute;s; §Hospital La Paz; ¶Hospital Gregorio Marañón; ∥Hospital Carlos III; and **Wyeth Pharmaceuticals, Madrid, Spain.

Background: The PCV7 vaccine was only available privately in Spain from October 2001. Use of this vaccine increased from 2002 onwards, with reported coverage in 2006 below 50%. In October 2006, the Madrid local health authority approved its inclusion in the childhood vaccination schedule. This 3-year hospital-based surveillance study (21 centres) aimed to assess changes in pneumococcal serotype distribution and clinical outcomes in Madrid after the introduction of PCV7.

Methods: Inpatient cases younger than 15 years old with confirmed invasive pneumococcal disease (IPD) confirmed by culture or PCR were included. Conventional serotyping was performed by an agglutination test (Pneumolatex) and Quellung reaction. Cases of culture-negative empyema were serotyped using real-time PCR.

Results: 163 cases were identified. The Table shows the distribution of clinical outcome by serotype focus on STs: 1, 3, 5, 6A, 7F, and 19A.

Figure. cases by cli...
Figure. cases by cli...
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Conclusions: Serotypes 19A and 5 did not appear to favor a particular site, whereas serotypes 1 and 3 were only involved in lung disease. As previously reported, ST 1 was the most prevalent serotype in patients with empyema, and ST 19A was the most prevalent in patients with meningitis.

For Heracles Study Group, Madrid, Spain.

P204

SEROTYPE DISTRIBUTION OF INVASIVE STREPTOCOCCUS PNEUMONIAE AMONG HOSPITALIZED PEDIATRIC PATIENTS IN MADRID (MAY 2007–APRIL 2008)

J. Picazo,* J. Ruiz-Contreras,† J. Casado-Flores,‡ E. Giangaspro,† F. Del Castillo,§ T. Hernandez-Sampelayo,¶ E. Culebras,∥ and C. Méndez,** *Faculty of Medicine. Univ. Complutense; †Hospital 12 de Octubre; ‡Hospital Niño Jes&uacute;s; §Hospital La Paz; ¶Hospital Gregorio Marañón; ∥Hospital Carlos III; and **Wyeth Pharmaceuticals, Madrid, Spain.

Objectives: This 3-year active hospital-based epidemiological study aimed to assess the changes in pneumococcal serotype distribution, clinical syndromes, and underlying conditions associated with invasive pneumococcal disease (IPD) after the introduction of the PCV7 vaccine in Madrid in November 2006 (21 centres involved).

Methods: Inpatient cases younger than 15 years old with laboratory-confirmed IPD or culture-negative empyema were included. Pneumococci were identified using microbiologic and molecular genotyping methods. Conventional serotyping was performed by an agglutination test (Pneumolatex) and Quellung reaction. Cases of culture-negative empyema were serotyped using a real-time PCR that targeted different capsular locus genes. Data for the period May 2007-April 2008 are presented.

Results: 163 cases were identified during this period. The Figure shows the serotype distribution of cases.

Figure. serotype dis...
Figure. serotype dis...
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Conclusions: Only three serotypes (1, 5, and 19A) were responsible for 60% of the cases. Only a very low proportion of IPD cases were due to one of the PCV7 serotypes after the introduction of the PCV7 vaccine (6%). The high number of IPD cases due to serotype 5 could suggest an outbreak in Madrid. Continuous surveillance is needed to monitor the development of this strain.

For Heracles Study Group, Madrid, Spain.

P205

PROSPECTIVE POPULATION-BASED SURVEILLANCE OF BACTERIAL MENINGITIS IN CHILDREN <5 YEARS OF AGE IN NINE RUSSIAN CITIES

A. Platonov, Central Institute of Epidemiology, Moscow, Russia.

Background and Aims: The burden of meningitis caused by Haemophilus influenzae type b (Hib) in Russia was estimated only by hospital-based surveillance or by retrospective Hib-RAT assessment. In this study the incidence rates of bacterial meningitis per 100,000 children < 5 years of age (U5-children) was evaluated prospectively in the capital cities of 9 Provinces of Russia (Map).

Methods: Both bacteriological culture and non-cultural methods (latex agglutination, PCR) were used for diagnostics.

Results: Etiological agent was identified in about 85% of 343 probable bacterial meningitis cases. Hib caused 27% of all bacterial meningitis cases on average (Table), whereas N.meningitidis caused about 54% of cases. The annual incidence rate of Hib-meningitis varied greatly (Map). The mean incidence rate of laboratory confirmed Hib-meningitis in these 9 cities was equal 8.8 cases per 100,000 U5-children. The incidence rate of systemic meningococcal disease in the same populations ranged from 17 cases/100,000 U5-children in Ulan-Ude to 77 cases in Murmansk with the mean value 30.

Conclusion: Hib-meningitis ranks after meningococcal meningitis in Russian U5-children. The introduction of Hib-vaccine may be considered, at least in such Provinces with high Hib-incidence as Murmansk, Tula, Vladivostok, and Ulan-Ude.

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For The Russian Hib Study Team, Regonal Russian Hospitals, Moscow, Murmansk, Tula, Nizhni Novgorod, Novosibirsk, Irkutsk, Ulan-Ude, Yakutsk, Vladivostok, Russia.

P206

CHANGING EPIDEMIOLOGY OF PERTUSSIS IN SÃO PAULO, BRAZIL, 2000–2008

S.R.T.S. Ramos,*† S.S. Oliveira,† R.M.B. Fernandes,† and M.L. Nerger,† *Pediatrics, School of Medicine, University of São Paulo; and †Health Surveillance, Secretary of Health, São Paulo, Brazil.

Background and Aims: In the last decades many countries reported pertussis resurgence, but data from São Paulo were lacking. The aim of this study is to describe the epidemiology of pertussis in the city of São Paulo, Brazil, from 2000 to 2008.

Methods: The study was conducted in São Paulo, a city with 11 million people including 170,000 infants. Vaccination coverage for 3 doses of DTP in the first year of life is over 95% in the last 5 years. Until 2002 the surveillance system was passive and thereafter active in sentinel hospitals. The data sources were the on-line National Information System of Reporting Diseases (SINAN-net) and Brazilian Institute for Geography and Statistics. We adopted the case definition recommended by WHO. The information analyzed in each case was: age, date of onset of pertussis symptoms, vaccination status, and outcome. Incidence rates by age group and year and case fatality ratio were calculated.

Results: During the period, a total of 883 suspects and 236 confirmed pertussis cases were reported, 41% from sentinels. Figure 1 show 2 peaks of cases: one in 2003 after active surveillance implementation, and another in 2008. 90% of cases occurred in infants < 1 year old (Figure 2 and 3) with incomplete vaccine basic series. The case-fatality ratio in infants was 5%.

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Conclusions: Pertussis continuous to be a significant public health problem in São Paulo, mainly in infants < 6 moths. The surveillance system is not sensitive to detect pertussis in adolescents and adults.

P207

SCREENING TO DETERMINE THE PREVALENCE OF RHEUMATIC HEART DISEASE IN ASYMPTOMATIC CHILDREN IN GUYANA SOUTH AMERICA

S. Roth,* J. Levenstadt,† N. Musewe,* L.A. Gallant,* L. Linett,‡ J. Ross,* L. Aronson,§ and M. Silverman,¶ *Cardiology; †Medicine; ‡Family Medicine, University of Toronto; §The Hospital for Sick Children; and ¶Infectious Disease, University of Toronto, Toronto, ON, Canada.

Background and Aims: The prevalence of Rheumatic Heart Disease (RHD) in tropical rural Western Hemispheric settings is unknown.

Methods: A Canadian medical team visited six remote Amerindian villages along the Upper Mazzaruni River of Guyana. Teachers randomly selected 68 healthy children in the villages. The children were asked basic questions about symptoms and past history of rheumatic fever, underwent clinical examination and echoDoppler (ED) study using portable equipment to determine the prevalence of RHD. 2 cardiologists using pre-specified criteria reviewed all ED studies. If RHD was detected, a long-term supply of penicillin for secondary prophylaxis was provided.

Results: 68 children between the ages of 8 and 17 years were assessed: 11 recalled an illness of fever with joint soreness and 21 felt that they were unable to keep up with their peers on exertion. Four asymptomatic children had definite echo evidence for RHD (6%). Only one child with RHD on ED had a systolic ejection murmur and this was related to an incidental small muscular VSD.

Conclusions: Screening for RHD in remote areas of developing countries using portable ED equipment is feasible. Stethoscope auscultation is not helpful in identifying asymptomatic rheumatic heart disease in children but may be helpful in identifying congenital heart disease. There is a very high prevalence of asymptomatic RHD in this population. Approaches to the diagnosis and management of streptococcal pharyngitis in the developing world need to be reassessed and appropriate treatment algorithms formulated to reduce the prevalence of RHD.

P208

THE BELGIAN PAEDIATRIC SURVEILLANCE UNIT “PEDISURV”: MORE THAN COUNTING CASES

M. Sabbe,* T. Lernout,† Y. Dupont,* and S. Quoilin,* *Epidemiology, Scientific Institute of Public Health, Brussels, Belgium; and †Cellule Interrégionale d'Epidemiologie Réunion-Mayotte, Mayotte, France.

Background: In several countries, Paediatric Surveillance Units have been established to facilitate surveillance for a range of conditions. In Belgium, a network “PediSurv” was set up to contribute to polio-free certification and measles elimination goal of the World Health Organization.

Methods: As of October 2002 a prospective surveillance is carried out by 40% of the Belgian paediatricians and 37% of the general practitioners in Brussels. 80% of the hospitals with a paediatric department participated. Participation is voluntary with monthly reporting of cases of Acute Flaccid Paralysis (AFP), measles and mumps. Invasive pneumococcal disease (IPD) was added in October 2005 following introduction of the 7-valent pneumococcal conjugate vaccine and congenital rubella syndrome (CRS) in 2007. A standardized form is used to obtain case-specific information. Notification is done by mail or Internet and zero-reporting is requested.

Results: Between 2003 and 2007 approximately 550 clinicians participated monthly (response rate 64%–70%). Non-polio AFP rate ranged from 0.06 to 0.50. Measles incidence remained above the elimination threshold of < 1 per million. Besides a measles outbreak in 2007, several clusters of measles and mumps were identified every year. Incidence of IPD in children < 5 year was estimated at 67/100 000 in 2006 and 58/100 000 in 2007. No cases of CRS were reported.

Conclusions: Although PediSurv is not an exhaustive surveillance system, the stable participation allowed to observe trends and to detect clusters and outbreaks. Information is being used for decision-making in public health and monitor progresses in different elimination goals.

P209

SEROPREVALENCE OF TOXOCARIASIS IN SCHOOL-CHILDREN IN NORTHERN IRAN

M. Sharif, A. Daryani, M. Nasrolahei, and G. Barzegar, Mazandaran University of Medical Sciences, Sari, Iran.

Abstract: This cross-sectional study was carried out on 1210 randomly selected schoolchildren, attending sixteen primary and secondary schools, during the period between November 2005 and June 2006. Students who accepted to include their children were requested to be present at sampling time and to fill in a simple questionnaire with personal and epidemiological data. Three ml of venous blood were taken by vein puncture under sterile conditions from each subject for detection and titration of antibodies to T.canis and eosinophil counts. Total IgG anti-Toxocara antibodies study was carried out by T.canis IgG ELISA kit. According to the manufacture recommendations, an index positivity >11 U was considered positive. Of the 1210 serum specimens tested, an overall seroprevalence for Toxocara antibodies of 25% was obtained. There was no association between positive seroprevalence and age (P = 0.69). Boys and girls differed significantly with regard to Toxocra titre (P < 0.001). Eosinophilia in peripheral blood (≥5%) was detected in 24.5% (297/1210) of the population studied, 97/297 (32.8%) of whom were seropositive for toxocariasis. The findings of this study confirm that infection with Toxocara is quite high and widespread in children in Northern Iran. Therefore health promotion efforts must be directed at increasing the awareness of the population about the potential zoonotic hazards associated with the disease and how to minimize them.

P210

PARETIC COMPLICATIONS OF ASEPTIC CNS INFECTIONS IN CHILDREN AND ADULT PATIENTS IN THE CZECH REPUBLIC

D. Smiskova,* Z. Blechova,* S. Polivkova,† K. Labska,‡ and V. Maresova,* *1st Department of Infectious Diseases, Bulovka University Hospital, Charles University in Prague, 2nd Medical Faculty; †Department of Infectious Diseases, Charles University, Third Faculty of Medicine; and ‡National Health Institute, Prague, Czech Republic.

Background: Arboviruses (tick born encephalitis—TBE), Borrelia burgdorferi sensu lato (neuroborreliosis-NB) and enteroviruses are the most frequent causes of aseptic CNS infections in the Czech Republic. All of these diseases can have the same complication- paresis. We evaluated a frequency, severity and clinical recovery of palsies depending on age.

Methods: Four hundred thirty patients (144 children, 286 adults) hospitalized in Bulovka University Hospital (2005–2007) with final diagnosis of neuroborreliosis,(60 adults, 34 children), TBE (204 adults, 15 children) and enteroviral meningitis (22 adults, 95 children) were enrolled to the retrospective study. They were monitored during stay in hospital and after 1 and 6 months.

Results: Seventy eight patients suffered from palsies. Most of them was in NB group, 16 children (41%) had facial nerve palsy, 45 adults (71%) had affected facial nerve or other cranial or peripheral nerves, in 5 cases quadruparesis or paraparesis was present. In followed period no changes of palsy frequency had appeared. Clinical recovery was generally good. In TBE group no child had palsy, 15 adult patients (6,8%) had serious paretic complications with long lasting sequelae. The frequency of palsies 6,0% in 2005 and 3,3% in 2006 increased to 15,2% in 2007. Enteroviruses caused mild palsies in 2 cases (1,5%), only.

Conclusion: Cerebrospinal fluid examination is recommended in every patient with facial nerve palsy to exclude neuroborreliosis. Our results confirm the importance of TBE vaccination especially in elderly persons.

P211

EPIDEMIOLOGY OF TUBERCULOSIS AMONG KIDS IN BOSNIA AND HERZEGOVINA AFTER WAR

L. Sporisevic,* A. Bajraktarevic,† and Z. Begic,‡ *Pediatrics Department, First Medical Aid; †Pediatrics Department, Public Health Institution of Canton Sarajevo; and ‡Pediatrics Department, Pediatrics Clinic Sarajevo, Sarajevo, Bosnia-Herzegovina.

Introduction: Tuberculosis in childhood is different from that in adults, and requires different expertise. Children generally have a much smaller bacterial population and there is less secondary resistance. Treatment was usually with isoniazid, rifampicin, and pyrazinamide for Bosnian children.

Methods: Authors analyzed data from the national tuberculosis surveillance database. Evaluated risk factors and kids patient characteristics included demographics, social contacts, economic status, travel history,living and social environment, medical history, family history, and exposure to tuberculosis.

Results: This study demonstrates that the incidence of tuberculosis children in Bosnia and Herzegovina has followed this pattern with a clear resurgence in childhood tuberculosis occurring between 1995 and2008. Bosnian incidences of tuberculosis are decreasing, but it is one of the most highest in Europe (20 to 30 on 100.000 children until 19 years, before more than 60).

Discussion: Poverty was strongly associated with tuberculosis in this study. This confirms earlier estimates and counters thoughts that those estimates were high. The diagnosis of TB in children, particularly in children younger than five years, remains difficult.

Conclusion: These findings point to an unrecognised burden of kids disease, ongoing community transmission, and missed opportunities for prevention. To reverse the current trend of increasing tuberculosis morbidity, both a more aggressive search for cases and the use of preventive therapy among high-risk kids populations will be necessary. Tuberculosis is presently one of the major kids problem in Bosnia and Herzegovina.

Keywords: Tuberculosis, Epidemiology, Children, Prevention.

P212

EPIDEMIOLOGY OF VARICELLA AFTER INTRODUCTION OF GENERAL VARICELLA VACCINATION—FIRST RESULTS FROM THE ’BAVARIAN VARICELLA SURVEILLANCE PROJECT’ 2006–2008

A. Streng, I. Schicker, A. Köhn, V. Grote, and J.G. Liese, Dr. von Haunersches Kinderspital, LMU München, München, Germany.

Background and Aims: Since July 2004, varicella vaccination has been recommended for all children aged 11–14 months in Germany. An epidemiology surveillance project was initiated in 2006.

Methods: Monthly reports of varicella patients (≤16 years of age) and varicella vaccinations were collected from 88 (67%) of 132 paediatric practices in the Munich area (Bavaria). Detailed information was collected for varicella complications and vaccinated cases. Vaccine coverage was determined yearly, in random samples (n = 600) of children 18–36 months of age.

Results: From October 2006 to April 2008, practices reported a total of 8,795 varicella cases (5.7 cases per month and practice; 64% in children < 5 years of age), and 13,828 (first) varicella vaccinations (8.9 per month and practice). Vaccine coverage increased from 38% in 2006/2007 to 51% in 2007/2008. From October 2006 to April 2007, there were 3,913 varicella cases (7.2 cases per month and practice), compared to 2,661 cases (5.0 cases per month and practice) from October 2007 to April 2008. In 42 (0.5%) of all varicella cases, a total of 57 complications were reported (skin complications 51%, otitis media 11%, pneumonia 9%, central nervous system 7%, others 22%). Ten (0.1%) children were hospitalised; 3 (0.03%) showed permanent scars. There were 379 (4.3%) cases in varicella-vaccinated children.

Conclusions: Further follow-up is necessary to confirm the observed decrease of about 30% in the burden of varicella disease, which currently is still dominated by mostly unvaccinated cases.

P213

CHARACTERISTICS OF VARICELLA DISEASE IN VACCINATED CHILDREN FROM THE ‘BAVARIAN VARICELLA SURVEILLANCE PROJECT’ 2006–2008

A. Streng, I. Schicker, V. Grote, and J.G. Liese, Dr. von Haunersches Kinderspital, LMU München, München, Germany.

Background and Aims: Long-term surveillance studies on varicella vaccination generally show a large decrease of varicella disease burden, but indicate an increase in annual rates of varicella in vaccinated children. In Germany, after general recommendation for vaccination (one dose at 11–14 months of age) in 2004, a varicella surveillance project was initiated in 2006.

Methods: Detailed reports on vaccinated varicella cases (VVC) in children ≤16 years of age were collected from a network of 88 paediatric practices in the area of Munich City and County.

Results: From October 2006 to April 2008, the paediatricians reported a total of 8,795 varicella cases; of those, 379 cases (4.3%) occurred in vaccinated children. In VVC, age (median, IQR) at varicella vaccination was 1.9 years (1.1–3.1); age at varicella disease was 3.8 (2.6–4.9) years; the delay (median, IQR) from vaccination to disease was 16.9 months (9.6–25.9). About 91% of the VVC were varicella breakthrough cases (VBC), occurring more than 42 days after vaccination. Four (1%) children of the VBC had received 2 doses. Out of 199 VBC with reported counting of lesions, 186 (93.5%) showed less than 50 lesions indicating mild varicella disease. Complications were reported for 5 VBC (including 1 hospitalisation); 1 child showed few permanent scars.

Conclusions: Correspondingly to a 30% decrease of varicella cases (see separate abstract), a small increase in varicella breakthrough cases with mostly mild clinical presentation has been observed. Continued surveillance is necessary to determine the optimal age for a second dose of varicella vaccine.

P214

CLINICAL AND MOLECULAR EVIDENCE OF INFLUENZA TRANSMISSION WITHIN HOUSEHOLDS

D. Sutter,* L. Daum,† K. Myhre,‡ and G. Fischer,† *Pediatric Infectious Disease, Wilford Hall Medical Center, Lackland AFB; †Longhorn Vaccines and Diagnostics, San Antonio, TX, and ‡Pediatrics, Wilford Hall Medical Center, Lackland AFB, USA.

Background and Aims: Influenza virus is associated with significant morbidity and mortality, causing 83 pediatric deaths during the 2007–08 season. The understanding of influenza transmission is critical to pandemic influenza preparedness. This report focuses on the transmission of influenza virus within households, as children are the primary source of family infections.

Methods: Children with influenza-like illness during the 2007–08 influenza season had nasal washings submitted for rapid antigen testing, culture and PCR. Accompanying parents or siblings, regardless of clinical illness were also enrolled. Transmission was defined as 2 or more family members developing influenza with onset at least one day apart.

Results: 118 children (114 symptomatic) and 104 adults (56 symptomatic) from 89 families were enrolled. Forty-four families had at least one member who was influenza PCR-positive (1 H1N1, 27 H3N2 and 16 Influenza B), including 3 families with one asymptomatic influenza-positive person.Suspected transmission of influenza was noted in 16/28 (57%) families with influenza A versus 4/16 (25%) families with influenza B (P = 0.05) Transmission was molecularly confirmed (conserved sequence homology in two PCR-positive family members) in 14/28(50%) families with influenza A versus 2/16 (12.5%) families with influenza B (P = 0.02). 11/16 (68%) confirmed transmissions originated from a child (ages 10m-17y, mean 6.6y).

Conclusions: Influenza is highly transmissible within families, with young children being the most common source. Transmission of influenza A was significantly more common than influenza B. Subclinical influenza infections occur in contacts of clinically ill patients, and molecular diagnostics have the potential to identify pre-symptomatic patients during an influenza pandemic.

P215

SEROPREVALENCE OF VACCINE-PREVENTABLE DISEASES IN BELGIUM

H. Theeten,1 V. Hutse,2 H. Dedeakayogullari,3 D. Baetens,4 J. Billiet,5 P. Couck,6 A. Dediste,7 H. De Puydt,8 A. De Smet,9 C. Fillee,10 M.-C. Frere,11 P. Goffinet,12 T. Ledant,13 M. Martin,14 A. Mewis,15 C. Neve,16 C. Pacco,17 C. Potvlieghe,18 L. Sergooris,19 S. Vanderschueren,20 T. Lernout,2 and P. Van Damme;1 1Vaccine and Infectious Disease Institute, University of Antwerp, Antwerpen; 2Institute of Public Health, Brussel, Belgium; 3Istanbul University, Istanbul, Turkey; 4ZNA Campus Middelheim, Antwerpen; 5AZ Sint Jan, Brugge; 6UZ Brussel, Vrije Universiteit Brussel; 7CHU St. Pieters Ziekenhuis, Brussel; 8AZ St Lucas, Gent; 9Rode Kruis, Leuven; 10UCL Cliniques Universitaires Saint-Luc, Brussel; 11Crois-Rouge, Namur; 12Les Cliniques du Sud Luxembourg, Arlons; 13CHR Mons- Warquignies, Mons; 14UZ Antwerpen, Antwerpen; 15Virga Jesse Ziekenhuis, Hasselt; 16CHR De La Citadelle, Liège; 17Centre Hospitalier de Dinant, Dinant; 18Centre Hospitalier de Tivoli, La Louviere; 19AML, Antwerpen; and 20AZ Groeninge, Kortrijk, Belgium.

Background and Aims: To evaluate the susceptibility to vaccine-preventable diseases in Belgium, a seroprevalence study was carried out in 2006 and compared to a previous study in 2002.

Methods: Residual sera from 3974 Belgian inhabitants (aged 1–65 years), stratified for age and gender, were collected through hospital laboratories and blood transfusion centres that were geographically well distributed.

The IgG antibody titers for measles, mumps, rubella (MMR) and diphtheria (D) at all ages, for tetanus (T) from the age of 40 years on, and hepatitis B (HBV) markers in up to 19-year-olds were defined by different ELISA's.

Results: In 2006 and in 2002, ≥10% of 5–9 year-olds, and ≥5% of 10–29 year-olds were seronegative for measles and 12–13% of women of childbearing age (15–40 years) had < 10 IU/ml rubella-antibodies. In under-20-year-olds, 2% were seropositive for anti-HBc+ and 1% for HBsAg.

In the infant and adolescent age cohorts targeted by the universal HBV vaccination campaign, 89% and 66% respectively had anti-HBs ϖ10 IU/ml in 2006 versus 75% and 56% in 2002.

In 2006, the proportion with anti-D ≥0.1IU/ml was 75–80% in 1–29 year-olds, but diminished steeply with age to 24% in 50–65 year-olds. The proportion of adults with anti-T ≥0.1IU/ml diminished little with age (40–65 years) from 92% to 85%.

Conclusion: A remaining risk for circulation of measles and for Congenital Rubella Syndrome was demonstrated in Belgium. Universal HBV vaccination was well implemented in both targeted age cohorts. At adult age, immunity against tetanus was much better than against diphtheria.

P216

COVERAGE OF RECOMMENDED VACCINES IN INFANTS IN FLANDERS, BELGIUM, ANNO 2008

H. Theeten,* M. Roelants,† N. Hens,‡ M. Aerts,‡ A.-M. Depoorter,§ C. Vandermeulen,† M. Boonen,† K. Hoppenbrouwers,† and P. Van Damme,* *Vaccine and Infectious Disease Institute, University of Antwerp, Antwerpen; †K.U.Leuven, Leuven; ‡I-biostat, Hasselt; and §Vrije Universiteit Brussel, Brussel, Belgium.

Background and Aims: Previous surveys in Flanders demonstrated a high coverage of vaccines recommended in infancy, though not yet optimal for MMR. To evaluate any trends, including the uptake of the recently introduced pneumococcal (PCV-7) vaccine, and to obtain more information on reasons for non-vaccination, a new EPI-based survey was performed in 2008.

Methods: The study population consisted of 1002 infants aged 18–24 months selected randomly by EPI cluster sampling (S1) and 404 infants (S2) selected for having incomplete vaccination data in Vaccinnet, Flanders’ web-based vaccine registration system. Their parents were interviewed at home, vaccination documents were checked and if they were incomplete, additional information was asked and vaccination data were updated from medical files if possible. Coverage rates were measured for poliomyelitis (IPV) (mandatory), tetanus-diphtheria-pertussis (DTP), H. influenzae type b (Hib), hepatitis B (HBV), measles-mumps-rubella (MMR), PCV-7, and meningococcal C (MENC) vaccine.

Results: In S1 the coverage rate was 95% or above for IPV, DTP, Hib, HBV,MMR and MenC; 80.0% were fully vaccinated with PCV-7. Nevertheless 2–13% of vaccine doses were administered more than 2 months after the recommended age, and 8% of infants had not yet completed the primary course of IPV-DTP-Hib-HBV by 6 months of age. In S1+S2, infants who were not immunised in well-baby clinics or who had more older siblings were more at risk for not (yet) being fully vaccinated by 18 months of age.

Conclusions: Universal vaccination reaches infants very well in Flanders, but compliance to recommendations on timing leaves room for improvement.

P217

TRANSMISSION OF ROTAVIRUS TO HOUSEHOLD MEMBERS OF SWEDISH CHILDREN HOSPITALIZED FOR SEVERE ROTAVIRUS GASTROENTERITIS RESULTS IN LOSS OF PARENTAL PRODUCTIVITY

A.N. Tran,* R. Bennet,† T. Cassel,‡ K. Johansen,* J. Storsaeter,§ B. Österlin,* and M. Eriksson,† *Swedish Institute for Infectious Disease Control; †Astrid Lindgren Children's Hospital, Karolinska University Hospital; ‡Sanofi Pasteur MSD; and §GlaxoSmithKline, Stockholm, Sweden.

Background and Aims: Rotavirus Gastroenteritis (RV GE) is responsible for >500,000 deaths and millions of hospitalization annually among younger children worldwide. A larger prospective hospital-based surveillance estimates the incidence for hospitalization due to rotavirus infection in Sweden to range from 300 to 500/100,000 children < 5 years. Information regarding household transmission of rotavirus and its impact is limited. In this sub-study, we aimed to investigate the transmission pattern of rotavirus among household members of hospitalized children and subsequently the impact on parental productivity.

Methods: Household members of children hospitalized for RV GE at the Astrid Lindgren Children's Hospital during winter season 2007/2008 were asked whether they developed GE symptoms in association with the child being hospitalized. Stool samples from family members, collected within 14 days after discharge of their child, were tested for rotavirus by ELISA (Oxoid).

Results: 155 households of the RV GE children were interviewed of which 97 provided stool samples for testing. In 51% of these (n = 49), rotavirus was detected in at least one additional family member who either was symptomatic or asymptomatic. Among the household members 32 of 96 mothers, 17 of 86 fathers and 18 of 64 siblings excreted rotavirus. All rotavirus positive siblings were < 5 years of age and no difference between genders was noted. Significant loss of parental productivity was observed.

Conclusions: In more than 50% of households, at least one additional family member of children hospitalized for RV GE excreted rotavirus most likely contributing to further spread of the virus.

P218

SYSTEMIC ANTIMICROBIAL DRUGS USAGE IN A PEDIATRIC UNIVERSITY CLINIC FROM BUCHAREST, ROMANIA

C. Ulmeanu,* M.D. Craciun,† and N. Ion-Nedelcu,‡ *Toxicology; †Infection Control, Emergency Clinical Hospital for Children ’Grigore Alexandrescu’ Bucharest, Romania; and ‡Epidemiology, Public Health Authority of Bucharest Municipality, Bucharest, Romania.

Background: Antibiotic use significantly contributes to increasing rates of resistant pathogens and hospitals are advised to measure antibiotic use and monitor its relationship to resistance. The aim of this study was to describe the antimicrobial consumption (ABC) in pediatric inpatients of Bucharest, Romania.

Methods: A random sample accounting 895 (≈30%) out of the 2917 patients discharged from “Grigore Alexandrescu” Emergency Hospital for Children, during October 2008, has been draw first. By reviewing medical charts of enrolled patients, appropriate demographic, clinical, and pharmacological data have been captured and filled in an Epi6 software database. ABC have been expressed as usage density rate where the nominator was the pooled number of days of therapy (DOT) with each type of antimicrobial agent and the denominator the pooled number of patient days (PDs), respectively.

Results: The patients’ median age was 5 years, the median duration of hospitalization was 3 days and the pooled number of PDs accounted 4049. The exposure to overall antibacterial agents accounted 2607 DOT and the correspondent ABC density rate was 64.44 DOT/100 PD. Fifty-two percents of patients received at least one antimicrobial agent. The top five antibacterial agents used were ceftriaxone, gentamicin, cefoperazone, cefazolin and cefuroxime.

Discussions: ABC density rate found by us is consistent with values recently reported abroad in similar settings; however, the high prevalence of patients exposed to antibacterial agents and the cephalosporins’ overuse are matters of concern.

Conclusion: ABC density rate based on DOT metric appears as a value indicator for driving antimicrobial usage proper stewardship.

P219

HOW TO DETERMINE URGENCY FOR CHILDREN WITH FEVER IN EMERGENCY CARE? A RISK CHART FOR TRIAGE

M. van Veen,* E. Steyerberg,† M. Ruige,‡ A. van Meurs,‡ J. van der Lei,§ and H. Moll,* *Paediatrics, Erasmus MC-Sophia Children's Hospital; †Public Health, Center for Medical Decision Making, Erasmus MC, Rotterdam; ‡Paediatrics, Haga Hospital—Juliana Children's Hospital, The Hague; and §Medical Informatics, Erasmus MC, Rotterdam, The Netherlands.

Background and Aims: Triage aims to identify patients who benefit most from immediate medical care. According to the Manchester Triage System, a commonly used triage system in Europe, all children with fever are triaged as high urgent, and have to be seen within 10 minutes. We aimed to assess the value of body temperature alone and combined with age and presenting problem to predict high urgency in children.

Methods: Prospective observational study. Children attending the emergency department of two hospitals were included. Missing values on temperature were imputed (14.7%). Data were analyzed using logistic regression analysis. As a predefined reference standard for urgency we used a proxy, consisting of a combination of vital signs at presentation, presence of a potentially life threatening condition, performed diagnostics and therapy, and scheduled follow-up. We developed a score chart based on the final model to decide on urgency.

Results: 12,562 patients were eligible. In 1,407 (11.2%) patients the reference standard for urgency was missing. Temperature alone had a moderate discriminative ability to predict urgency, but its combination with presenting problem and age led to better performance. The influence of temperature (75th versus 25th percentile) on high urgency is high for patients presenting with urinary tract problems (OR 3.0, 95% C.I.1.0-9.2) and low for neurological problems (OR 0.8, 95% C.I.0.6–1.1).

Conclusions: Body temperature combined with age and presenting problem is an important discriminator in triage to predict urgency in children. However, the presence of fever itself is not sufficient to classify children as highly urgent.

P220

REPLACEMENT OF PNEUMOCOCCAL SEROTYPES AMONG COLONISED CHILDREN FOLLOWING INTRODUCTION OF PCV-7 IN THE NORWEGIAN VACCINATION PROGRAMME

D.F. Vestrheim, I.S. Aaberge, E.A. Høiby, and D.A. Caugant, Department of Bacteriology and Immunolgy, Norwegian Institute of Public Health, Oslo, Norway.

Background and Aims: The seven-valent conjugated pneumococcal vaccine (PCV-7) was introduced in the Norwegian childhood vaccination programme in July 2006. A cross-sectional study of nasopharyngeal carriage of Streptococcus pneumoniae among children attending day-care centres (DCC) was performed in the autumn of 2006. In order to evaluate the changing epidemiology of pneumococci colonising children, a follow-up was performed in the autumn of 2008, two years after start of widespread use of PCV-7.

Methods: Cross-sectional studies of nasopharyngeal carriage of pneumococci among children attending DCC, using a sensitive sampling method. Briefly, nasopharyngeal swabs were transported to the laboratory in a serum broth and plated within 3–4 hours. Pneumococci were identified directly from the broth by serotyping, and confirmed by growth on blood agar.

Results: Nasopharyngeal swabs were obtained from a total of 1213 children, 611 in the 2006-study and 602 in the 2008-study. The proportion of children vaccinated at least twice with PCV-7 increased from 3.4% in 2006 to 39.2% in 2008 (P < 0.001). In total, 475 (77.7%) and 484 (80.0%) children carried pneumococci in 2006 and 2008, respectively. The proportion of isolates belonging to PCV-7 serotypes decreased from 235 of 539 isolates (43.6%) in 2006 to 116 of 563 isolates (20.6%) in 2008 (P < 0.001).

Conclusions: The rate of nasopharyngeal colonisation with pneumococci among children attending DCC remains high and unchanged after introduction of PCV-7 in the childhood vaccination programme. The ecological niche vacated by the PCV-7 serotypes has been replaced by non-PCV-7 serotypes.

P221

PRESENCE OF ROTAVIRUS AND ADENOVIRUS ANTIGENS IN OUTPATIENT WITH GASTROENTERITIS IN PRIVATE HOSPITAL IN ANKARA-TURKEY

A. Yousefi Rad (Taner),* and A. Gozalan,† *Clinical Laboratory, Private MESA Hospital; and †Refik Saydam National Hygiene Center, Ankara, Turkey.

Aim: Especially in childhood, one of the most important causes of mortality is infectious diarrheas. We aimed to determine distribution of gastroenteritis case occurred due to rotavirus and adenovirus factors according to various age groups, months and years, epidemiology of which is not well-known in our country.

Materials and Methods: Antigens of rotavirus and adenovirus were investigated by immuno-chromatographic method (CerTest Biotec-Spane; rota-adeno blaster) in stool samples of 2,962 patients, who applied to various clinics of our hospital between January 2005–June 2008 and who had the diagnosis of acute gastroenteritis.

Results: Viral antigens were determined in 605 (20,4%) of 2,962 stool samples. Of those 2,962 samples, 483 (16,3%) were found to be positive for rotavirus and 77 (2,6%) for adenovirus. Combination of positivity of rota and adenovirus was determined in 45 (1,5%) samples. Cases of viral gastroenteritis (rota and adenovirus) are observed most frequently in 0–5 years-old group, and rotavirus is seen more during winter and adenovirus throughout the year.

Conclusions: It is observed that rotavirus and adenovirus are important factors in gastroenteritis developing in the region where our hospital gives service and in 0–5 years-old group. Preventing empirical use of antibiotics for patients, whose test results are positive by rapid and valid (specific and sensitive) diagnostic methods such as the immuno-chromatographic method, is important for reducing development of antibacterial resistance.

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FUNGAL INFECTIONS, INFECTIONS IN THE IMMUNOCOMPROMISED AND HIV/AIDS

P222

MICAFUNGIN: OVERVIEW OF SAFETY IN CHILDREN

A.C. Arrieta,* P. Maddison,† and A.H. Groll,‡ *Children's Hospital, Orange, CA, USA; †Astellas Pharma Europe B.V., Leiderdorp, The Netherlands; and ‡University Children's Hospital, Muenster, Germany.

Background and Aims: Children at risk of invasive fungal infections are often fragile hosts with multiple underlying conditions. Since drug safety is critical in such patients, we evaluated the safety of micafungin, a novel antifungal agent, by pooling pediatric safety data from clinical trials.

Methods: Adverse event (AE) data were pooled from clinical trials conducted in Europe, the Americas and Asia.

Results: 296 patients received at least one dose of micafungin. The mean ± SD age was 6.5 ± 5.1 years; 66 patients were < 1 year. Common underlying conditions were malignancies (37.5%) and hematopoietic stem cell transplantation (33.8%). Neutropenia (ANC < 500 cells/μL) at baseline was present in 40% of patients. Overall, the median maximum daily micafungin dose was 1.7 mg/kg (interquartile range [IQR]: 1.0–2.4 mg/kg). Median treatment duration was 15 days (IQR: 6–29 days). Consistent with the multi-morbid underlying conditions of this population, AEs, irrespective of causality, were experienced by most (93.2%) patients, and a large proportion of these (34.1%) were serious. Few AEs were considered by the investigator to be treatment related or led to treatment discontinuation (see table). No trends were seen with analysis of AEs by dose or duration of treatment.

Conclusions: Micafungin has a favorable safety profile in pediatric patients with complex and life-threatening underlying conditions.

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P223

MICAFUNGIN: OVERVIEW OF EFFICACY IN CHILDREN

A.C. Arrieta,* N.L. Seibel,† T.J. Walsh,† L. Arnold,‡ and A.H. Groll*Children's Hospital, Orange, CA; and †National Institute of Health, Bethesda,MD.

Abstract: 3Astellas Pharma Global Development, Deerfield, MA, USA, 4Children's Hospital, Muenster, Germany

Background and Aims: Invasive fungal infections are a major source of morbidity and mortality in immunocompromized children; however, information on new antifungal therapies in children is limited. We evaluated the efficacy and pharmacokinetics (PK) of micafungin, a novel antifungal agent, by reviewing pediatric data from micafungin clinical trials.

Methods: A retrospective review of pediatric data from clinical trials was performed.

Results: A total 296 children received micafungin (MICA) for invasive candidiasis (IC), refractory IC, refractory invasive aspergillosis (IA), prophylaxis in hematopoietic stem cell transplantation (HSCT) patients, or to assess PK. Most patients age < 1 year were premature (38/66), whereas most children age >1 year were HSCT recipients or malignancy patients (181/230). Median maximum daily dose for patients < 1, 1 to 4, 5 to 8, 9 to 12 and 13 to 15 years were 2.0, 1.5, 1.5, 1.9 and 1.5 mg/kg, respectively. Treatment success rates are shown in the table. MICA showed linear PK, with a higher clearance in neonates than in older children and adults.

Conclusions: MICA is an efficacious agent for the treatment and prophylaxis of pediatric invasive fungal infections.

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P224

CLINICAL AND MICROBIOLOGICAL FACTORS AFFECTING OUTCOME IN HOSPITALIZED CHILDREN WITH CANDIDEMIA

N. Ashouri, J. Singh, O. Vargas-Shiraishi, and A. Arrieta, Infectious Diseases, Children's Hospital of Orange County, Orange, CA, USA.

Background: Candidemia is a major cause of morbidity and mortality in pediatrics. The purpose of this study was to review the epidemiology and outcome of candidemia at a major pediatric center to identify features related to increased mortality.

Methods: Retrospective chart review of patients hospitalized at our institution between June 1, 2002–December 31 2008 with blood culture positive for Candida spp.

Results: There were 165 candidemic episodes in 151 patients. Most common species were C albicans (58 isolates) and C parapsilosis (57 isolates). Primary gastrointestinal disorder, (41pts; 27%), underlying malignancy (37pts, 24.5%), and neonatal intensive care unit (NICU) stay (34; 22.5%) were common risk factors. Neonates accounted for 41.6% (17/41) of gastrointestinal pathology and had the highest number of candidemic days (mean 6.3d vs 3.9d). All but 9 patients had a central line at time of diagnosis. Death occurred in 23 (13.9%) events, mortality associated with C albicans and C parapsilosis was similar (8/58; 13.8% and 7/57; 12.3%), though less common, C glabrata and C krusei had a higher fatality rate (3/12; 25% and 2/7; 28.6% respectively). Mean days candidemic were 5.7 and 4.45 days in those who died and survived respectively. Mortality was higher in patients candidemic for >72 hours 35% vs 2.4% (OR 14.35; CI 3.24–63.55).

Conclusion: Candidemia remains an important cause of morbidity and mortality in children. Gastrointestinal pathology, malignancy, and NICU stay were risk factors for candidemia. C glabrata and C krusei had high mortality rate. Delayed sterilization of the blood was associated with higher mortality.

P225

SUCCESSFUL TREATMENT IN A CHILD WITH ANAPLASTIC LARGE CELL LYMPHOMA AND COEXISTENCE OF PULMONARY TUBERCULOSIS

M. Baka,* D. Doganis,* M. Tsolia,† A. Pourtsidis,* D. Bouhoutsou,* M. Varvoutsi* C. Michail,‡ and H. Kosmidis,* *Oncology Department, P.&A. Kyriakou Children's Hospital; †2nd Department of Pediatrics, University of Athens, P.&A. Kyriakou Children's Hospital; and ‡Pathology Lab, P.&A. Kyriakou Children's Hospital, Athens, Greece.

Abstract: A 13 year old girl was admitted to our department with a history of severe pain of her left axilla and limitation of her left arm active movements. Fever (39°C) with chills developed 3 days later whereas on physical examination a block of lymph nodes in her left axilla, small cervical lymph nodes, diffuse papular rash and red-violet swelling of her supraclavicular and subclavian region were seen. She was initially treated with antibiotics without improvement. Ultrasound and computed tomography investigations revealed left axillar and supraclavicular lymphadenopathy and a small nodular shade in upper lobe of her left lung. Bone marrow aspiration, spinal fluid and bone scanning were negative. A biopsy from an axillary lymph node was performed and the diagnosis of anaplastic large cell lymphoma (LCAL) (LCA, MCHL-1, EMA, CD30 and ALK-1 positive) was established. Moreover DNA of Mycobacterium Tuberculosis was detected in the tissue biopsy. Patient was started on chemotherapy according to current protocols for LCAL and achieved remission of all initially involved fields before maintenance chemotherapy was started. Nevertheless, two nodular lesions (with a diameter of 1cm and 2 cm respectively) were detected in the left lower lobe of the lung. Biopsy from the lesions revealed granulomas and PCR was positive for Mycobacterium Tuberculosis. She received treatment with combination of isoniazide, pyraziînamide and ethambutol and maintenance chemotherapy for her LCAL for one year simultaneously. One year later she is disease free for both mycobacterial infection and lymphoma.

P226

SUBSTANCE AND SEXUAL ABUSE AND HIV AMONG STREET CHILDREN OF KOLKATA, INDIA

B. Bal, Epidemiology, National Institute of Cholera & Enteric Diseases, Kolkata, India.

Abstract: Globally, street children are often seen to struggle for their survival without food, shelter and proper dresses. Apart from poor living conditions and ill health, they appear to be vulnerable to substance and sexual abuses that results blood borne infections including STIs & HIV. A community-based cross-sectional study was conducted among 554 street children (6–18 years) of Kolkata, one of the four major metropolitan cities of India, to understand their substance as well as sexual abuses scenario. Interview was followed by collection of 3–4 ml blood samples to find out HIV, HBV and VDRL status. The study revealed that the overall prevalence of substance abuse was 52% and sexual abuse was 9.2% in them. Commonest abusing substance was ’Dendrite’ (43%), cannabis (25%), alcohol (16%), brown sugar (11%), pure heroin (3%) and nitrazepam (2%). Exclusive tobacco smoking was found in 22% children. Similarly, commonest form of sexual abuse was ‘attempted to have sex against will’ (65%), ‘forceful exposure of genitalia’ (61%), ‘forceful touching of genitalia’ (53%), rape (23%) etc. Both substance as well as sexual abuses was associated with factors like orphan children, children having no contact with family and children spending night at public places. Serological test revealed that 1%, 6% and 4% of the studied children were suffering from HIV, HBV and VDRL respectively. It may be interpreted as the beginning of an epidemic in this vulnerable population. An urgent community-based intervention must be targeted that might also include vaccination against hepatitis-B as one of the required measures.

P227

IMMUNIZATION STATUS OF CHILDREN WITH HIV: FAILURE TO PROTECT A VULNERABLE POPULATION

A. Bamford,* A. Cunnington,† J. Daniels,‡ E. Menson,§ H. Lyall,¶ B. Kampmann,*¶∥ and P. Heath,* *Academic Department of Paediatrics, Imperial College; †Immunology Unit, London School of Hygiene and Tropical Medicine; ‡Department of Paediatrics, North Middlesex University Hospital; §Paediatric Infectious Diseases, Evelina Children's Hospital; ¶Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust; ∥Wellcome Centre for Tropical Medicine, Imperial College; and *Vaccine Institute, St George's, University of London, London, UK.

Background and Aims: Despite effective treatment with ART, children with HIV are at increased risk of vaccine preventable infections. We aimed to assess immunization status of children with HIV in London.

Methods: Audit of immunization status of children attending four (3 tertiary, 1 secondary care) paediatric HIV clinics. Immunization histories were obtained from clinical records, primary care, and/or parental recall. Each child's status was compared to UK guidelines.

Results: For 75 children: median age 11 years, 55% UK born, median CD4 26%, median viral load 185 copies/mL.

shows the proportion of children known to be fully immunized with each vaccine according to the routine UK schedule, stratified by vaccine course and place of birth. For the additional vaccines recommended for HIV infected children, 32%, 4%, 0% and 28% were fully immunized against influenza, hepatitis B, varicella and pneumococcal polysaccharide respectively.

Figure 1...
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Conclusions: Immunization of children with HIV is suboptimal in these clinics. Booster doses, recently introduced, and non-routine vaccines are most commonly omitted. Immigrant children are particularly unlikely to be appropriately immunized. As life expectancy and the proportion of immigrant children with HIV increase, appropriate routine and catch-up immunization becomes even more important. Development of evidence-based standards for immunization of children with HIV, improved accessibility of immunization records, and opportunistic immunization in clinic may all improve this situation.

P228

INCIDENCE OF ANEMIA IN HIV INFECTED CHILDREN UNDER TREATMENT AND FELLOWED IN ORAN(ALGERIA)

N. Berekhedja,* I. Ouali,* A. Benabdellah,† and A. Aoudjena,* *Service of Infectious Diseases, CHU d'Oran; and †Infectious Diseases, Faculté de Médecine d'Oran, Oran, Algeria.

Aim: To estimate incidence of anemia in HIV infected children under treatment and fellowed in Oran.

Methodology: Retrospective study of all HIV infected children aged more than 18 months and presenting anemia after receiving antiretroviral drugs and fellowed from 2003 to 2008 in CHU of Oran(Algeria).

Results: 21 children were studied and 07 presented anemia(30%).

4/7 were male.

30% of cases were aged less than 04 years.

03 cases lived in Oran.

50% of cases presented anemia during the month fellowing the onset of antiretroviral drugs.

Anemia was important in 50% of cases.

Blood transfusions were used in 50% of cases.

Antiretroviral drugs were changed in one cases.

Conclusion: 30% of HIV infected children under antiretroviral treatment and fellowed in Oran have presented anemia.

P229

BLOOD ASPERGILLUS PCR RARELY DETECTS INVASIVE ASPERGILLOSIS

L. Coxon,* and A. Riordan,† *Alder Hey Children's NHS Foundation Trust; and †Paediatric Infectious Diseases, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.

Background & Aims: Invasive aspergillosis is an increasing problem in immunocompromised children. PCR may improve the early diagnosis of invasive aspergillosis. Few PCR assays have been tested in body fluids from children with invasive aspergillosis. We audited the use of blood Aspergillus PCR in our children's hospital.

Methods: Blood Aspergillus PCR assays sent April 2005–March 2008 were identified from the microbiology database. All Aspergillus isolates cultured in the laboratory during the same time period were also identified. Detailed information was obtained for children with positive results.

Results: 251 blood Aspergillus PCRs were sent from 53 children. Median number per child was 7 (range 1–14). Four children had proven invasive aspergillosis. Only one of 22(5%) blood Aspergillus PCRs sent during invasive aspergillosis were positive.Overall, 6/251 (2.4%) blood Aspergillus PCR assays were positive, from 5 children. Positive results did not change clinical management; three children were not given antifungals and had negative PCRs when repeated, one child had disseminated mycobacterial infection and one had CT changes of invasive Aspergillus and had already started on antifungal treatment.

Conclusion: Blood Aspergillus PCR did not alter clinical management. Most results were negative, even in children with invasive aspergillosis. Positive results were assumed to be false positives or occurred when there were other clinical features suggesting invasive aspergillosis. Blood Aspergillus PCR methods require further validation before introduction into routine clinical use in paediatrics.

P230

FAVORABLE OUTCOME OF CHRONIC DISSEMINATED CANDIDIASIS IN FOUR PEDIATRIC PATIENTS WITH HEMATOLOGICAL MALIGNANCY

A.E. Donker,* A.M.C. Mavinkurve-Groothuis,* L.E. van Die,† P.E. Verweij‡ P.M. Hoogerbrugge,* and A. Warris,§ *Department of Pediatric Hematology and Oncology; †Department of Radiology; ‡Department of Medical Microbiology; and §Department of Pediatric Infectious Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

Background and Aims: Chronic disseminated candidiasis (CDC) is seen mainly in patients with hematological malignancies after recovery of neutrophils. Diagnosis is troublesome due to negative blood cultures for Candida species and relies on proper imaging and invasive biopsies to reveal the exact fungal pathogen.

Case-Reports: Four children (aged 2 to 4 years) with a hematological malignancy developed CDC during chemotherapy. Time between onset of neutropenic fever and diagnosis of CDC ranged between 20 and 49 days. In all patients, CDC became evident after neutrophil counts had recovered. Three patients developed hepatomegaly. Main reasons for the delayed diagnoses were negative results on imaging (ultrasound 2, CT-abdomen 1) or fever explained by other infections (disseminated varicella zoster infection, catheter-related infection). In two patients, diagnosis was made by liver biopsy, in the other ones the biopsy confirmed the diagnosis after abnormalities were seen on PET-scan and leucocyte-scintigrafy. C. albicans was cultured from the liver biopsy in two patients, in one patient yeast cells were observed by direct microscopy. Duration of antifungal therapy ranged from 153 days to 24 months. Chemotherapy was temporary discontinued in 3 patients for respectively 21 days, 7 days and 4 months. All 4 patients survived CDC and all are in hematologic remission.

Conclusion: Common used imaging procedures may fail in the diagnostic process of CDC. Liver biopsy should be considered if fever persists after resolution of neutropenia in children with hematological malignancies without a clear explanation. Outcome in our patients appears favorable compared to mortality reported in the literature.

P231

TINEA CAPITIS IN PRIMARY AND MIDDLE SCHOOL STUDENTS IN SOUTH-EAST OF IRAN

A. Ebrahimzadeh, Medical Parasitology and Mycology, Zahedan University of Medical Sciences, Zahedan, Iran.

Introduction and Aims: Tinea capitis, is a common infection among schoolchildren and increasing public health importance in developing countries. The present study designed to determine the prevalence of Tinea capitis based on laboratory examination of the causative fungal in primary and middle school students in Iran, 2007.

Methods: During this cross-sectional study, 2060 children from urban and rural primary and middle schools were randomly selected. Specimens were collected from suspicious students by scraping the scalp and removing hair stubs. The collected samples were directly examined microscopically and cultured using Sabouraud's dextrose agar (S), SCC and Slide culture.

Results: The results showed that 56.7% were female. A number of 110 students (5.8%) were suspected to Tinea capitis. Thirty-seven cases of Tinea capitis were confirmed by demonstration of dermatophytes spores or mycelium in direct smears, 25 cases (22.73%) Ectothrix, 8 cases (7.27%) Endothrix and 4 cases (3.63%) were Favus. The isolated dermophytes included 17 anthropophilic, 9 zoophilic and 3 geophilic species.

Conclusions: The results implied that control programs with concern to the sources of infections is of great importance. Health education and development of knowledge among schoolchildren are recommended to be taken into account. It was resulted that all three sources of dermatophytic infections are involved with the incidence of Tinea capitis in children in the studied area, although the anthropophilic and zoophilic reservoirs are predominant.

P232

IMPACT OF TRANSITION TO ADULT SERVICES ON CLINIC ATTENDANCE AND VIROLOGICAL CONTROL IN HIV-INFECTED ADOLESCENTS

S. Eisen,* L. Barkley,† C. Schepers,‡ K. Gurney,‡ M. Clapson,§ D. Shingadia,§ and E. Jungmann,‡ *Infectious Diseases and Microbiology; †Paediatric Psychology, Institute of Child Health, UCL; ‡Mortimer Market Centre; and §Infectious Diseases, Great Ormond Street Hospital, London, UK.

Background and Aims: Since introduction of highly active antiretroviral therapy (HAART), more perinatally HIV-infected children survive into adolescence, requiring support for the transition to adult services. We reviewed the impact of transition on engagement with services and disease management.

Method: Notes of perinatally-infected adolescents transitioning from paediatric services to a specialist adolescent service from May 2005 to March 2008 were reviewed retrospectively. Data collected from the 12 months pre- and post-transition included rate of clinic attendance, CD4 count, viral load and details of HAART. Additional data on perceived impact of transition on self-management were collected using a self-report questionnaire.

Results: 17 young people were identified. Age at transition ranged from 15y 6m to 17y 11m. All remained engaged with services at 1 year post-transition. Post-transition, 75% of patients had an increased non-attendance rate (mean rate rose from 21% to 43% (z = −2.827, P < 0.005)). 8 participants had existing adherence difficulties which persisted post-transition; 1 further patient became non-adherent. No statistical difference was found between mean CD4 count pre- and post-transition (z = −0.047, P = 0.962). The 2 patients with consistently undetectable viral load, and the 6 patients who had viral load < 400 copies/ml during pre-transition year maintained this degree of viral control post-transition.

Conclusion: Adherence and virological control remained consistent post-transition; however, clinic attendance rates declined. This may imply potential long-term negative consequences for disease control, particularly relating to engagement with services, and highlights the need for close and dedicated support as transitioning adolescents take responsibility for independent management of their condition.

P233

HIGH INCIDENCE OF INVASIVE GROUP B STREPTOCOCCAL INFECTIONS IN UNINFECTED INFANTS BORN TO HIV-1-INFECTED MOTHERS

C. Epalza,* T. Goetghebuer,* M. Hainaut,* P. Barlow,† A. Dediste,‡ P. Melin,§ and J. Levy,* *Pediatric Departement; †Obstetrical Departement; ‡Microbiological Department, St Pierre Hospital, Université Libre de Bruxelles; and §Microbiological Department, Centre de Référence des Streptocoques du Groupe B, Centre Hospitalier Universitaire de Liège, Brussels, Belgium.

Background: The occurrence of an unusual number of group B streptococcal (GBS) infections in uninfected infants born to HIV-infected mothers followed in our center prompted this study.

Objective: To describe the incidence and clinical presentation of GBS infections in uninfected HIV-exposed infants born between 2001 and 2008 in comparison to the population of infants not exposed to HIV born in the same hospital.

Methods: The medical charts of all uninfected HIV-exposed infants prospectively followed since birth and the microbiology laboratory records were reviewed to identify GBS infections.

Results: 8 episodes of GBS infection occurred in 7/397 uninfected HIV-exposed infants; 97 % of the mothers were treated with antiretroviral agents during pregnancy, including 6/7 mothers of children with GBS infection. Five episodes occurred >7 days of life (days 9, 26, 33, 64 and 72). One of the infants had a recurrence 28 days after completion of treatment. Restricting the analysis to the infants born in our centre, GBS infection occurred in 5/322 (15.5/1000) HIV-exposed infants compared to 16/20158 (0.79/1000) infants in the control population (OR = 19.6 P < 0.0001). In the latter, median age of onset was 1 day.

Conclusion: Between 2001 and 2008 the incidence of GBS infection was significantly higher in uninfected infants born to HIV-infected mothers than in the control population born in our centre. The majority of GBS infections in HIV-exposed infants were late or very late onset and one child had a recurrence; 2 features that were strikingly different than in the general population.

P234

OFF-LABEL ANTIRETROVIRALS IN PEDIATRICS: USE IN A COHORT OF HIV-INFECTED CHILDREN

E. Fernandez-Cooke,* M. Santos,* I. Gonzalez-Granado,* D. Blazquez,* M. Taida,† J.T. Ramos,‡ M.I. Gonzalez-Tome,* M.J. Mellado,§ M.I. de Jose,† M. Navarro,¶ S. de Ory,¶ and P. Rojo,* *Pediatrics, Hospital 12 de Octubre; †Pediatrics, Hospital la Paz; ‡Pediatrics, Hospital de Getafe; §Pediatrics, Hospital Carlos III; and ¶Pediatrics, Hospital Gregorio Marañon, Madrid, Spain.

Background: There has been an enormous development on antiretrovirals for HIV. But not all of them have been approved in children mainly because they have not been sufficiently studied in them.

Objective: To determine the extent of off-label antiretrovirals use in a large cohort of HIV-infected children.

Methods: A cross-sectional observational study involving 210 HIV-infected children from the cohort of Madrid, Spain. The instrument used was the data base of this cohort updated to December 2008.

Results: The medium age of the cohort is 13.5 years, 124 (61%) of the patients are girls. The median CD4% is 27 and 121 patients (63%) have < 50 copies/ml. Off-label antiretrovirals are used in 45 (21%) children: 38 (85%) are only on one off-label drug, 4 (9%) are on 2 and 3 (6%) are on more than 2 off-label drugs. The most common ones used are tenofovir (n = 16), etravirine (n = 9), darunavir (n = 8). In the group of children who are receiving off-label drugs, 47% are females versus the 66 % in the group that receives approved drugs, which is statistically significative (P = 0.022). No difference is significant in age, immunological situation and viral load among both groups.

Conclusions: In our study we find that off-label drugs are used in a high proportion of HIV-infected children, this evidences the need of further studies of these drugs in pediatric age. In our cohort there seems to be a trend to use off-label drugs more frecuently in males.

P235

CORRELATION BETWEEN THE TROFILE AND VIROLOGICAL RESPONSE TO A SHORT-TERM MARAVIROC EXPOSURE IN HIV-INFECTED PATIENTS

M. Genebat,* J.A. León,† I. Pulido,* E. Ruiz-Mateos,* M. Á. Muñoz-Fernández,‡ and M. Leal,* *Infectious Diseases Service; †Paediatrics Service, Virgen del Rocio University Hospital, Sevilla; and ‡Molecular Immunobiology Laboratory, Gregorio Marañón University Hospital, Madrid, Spain.

Background and Aims: Current validated assay to determine tropism of HIV variants is Trofile®, which has multiple limitations. The aim of this work was to correlate the virological response to a short-term maraviroc exposure with the Trofile®.

Methods: Since July 1st up to December 1st 2008, 18 HIV-infected patients with detectable viral load during the last year began a 7–10 days exposure to maraviroc (MRV group); six HIV-infected patients without antiretroviral therapy received no treatment (control group). Plasma viral load was evaluated at days 0, 2, 4–5 and 7–10. Baseline genotype resistance testing and tropism assay were performed. The clinical approach (MCT) was considered positive if viral load was undetectable (<50 copies/ml) or a reduction >1 log10 copies/ml was achieved after 7–10 days of maraviroc exposure.

Results: No significant viral load modification was observed in control group patients (figure 1A). In MRV group patients Trofile® and viral load evolution was: in nine patients the Trofile® was informed as R5 and all of them showed a positive MCT (figure 1B); in six cases Trofile® was informed as dual/tropic, but two of them showed a reduction >1 log10 copies/mL (figure 1C); three patients showed a non-reportable result of the Trofile®, but all of them achieved undetectability after MCT (figure 1D).

Conclusions: A cheaper and faster alternative to Trofile® could be a clinical approach consisting in a short-term exposure to maraviroc. Using this approach, some patients with non-reportable or dual/tropic virus attending to Trofile® could be benefited from maraviroc therapy.

P236

HLA B5701 PREVALENCE IN A COHORT OF HIV INFECTED CHILDREN

L. Gonzalez-Granado,* L. Lopez Fernández,† M.I. Gonzalez-Tome,* M. Navarro,‡ M.J. Mellado,§ M.A. Muñoz-Fernández,† M.I. de Jose,¶ D. Gurbindo,‡ P. Rojo,* P. Martin Fontelos,§ and J.T. Ramos Amador,∥ *Pediatria, Hospital 12 Octubre/Universidad Complutense; †Inmunología, Hospital Universitario Gregorio Marañon; ‡Pediatria, Hospital Universitario Gregorio Marañón; §Pediatria, Hospital Carlos III; ¶Pediatria, Hospital Universitario La Paz; and ∥Pediatria, Hospital de Getafe, Madrid, Spain.

Introduction: It has been recognized HLA-B57 as a critical factor to develop abacavir hypersensitivity. As international guidelines recommend, abacavir should be more safely used after ruling out the HLA-B*5701 positivity. Due to the lack of data in children, the aim of this study has been to address the prevalence of HLA-B*5701 in the pediatric population.

Methods: An observational, cross-sectional study was performed in 135 HIV-infected children. HLA-B*5701 was determined to 135 HIV-infected children included in the Madrid cohort of HIV-infected children followed at 5 public hospitals in Madrid. In most children HLA-B*5701 was determined long after initiation of abacavir. Hypersensitivity reaction was assessed by clinical evaluation.

Results: One hundred and thirty five patients were screened. Baseline characteristics: Mean age 13,2; range 1–22. Ethnicity: Caucasian 75%, African 9%, Gipsy 9%, Latin American 7%. Fifty children had received abacavir (37%). Of them, there were 40 patients on treatment with abacavir, whereas 10 had been exposed to abacavir, previously. The prevalence of HLA-B*5701 was 3.7% (5/135). None of African children presented HLA-B*5701. Three children HLA-B5701negative developed a hypersensitivity reaction (2,2%). Another child HLA-B5701+ had been treated with abacavir uneventfully. None of the HLA-B5701+ children was currently on treatment with abacavir.

Conclusions: Similarly to previously reported data in adult cohorts, the prevalence of HLA-B5701 has been 3.7% in this Spanish pediatric cohort. Abacavir hypersensitivity is a serious condition that might be prevented by determining HLA-B*5701 as guidelines recommend.

P237

CARE OF 108 CHILDREN ON ANTI-RETROVIRAL THERAPY (ART) IN BURKINA FASO: ADHERENCE AND ART-RESPONSE EVALUATION

C. Gualeni,* R. Fausti,* M. Cattalini,* C. Ravelli,* M.T. Sinelli,* E. Soncini,* V. Consolati,* D. De Martiis,* E. Marniga,* R. Marzollo,* S. Aliprandi,* V. Bennato,* E. Bertoni,* S. Boccacci,* P. Ouedraogo,* M. Filisetti,* M. Pinotti,* S. Guarisco,* G. Sawadogo† V. Pietra,† and R.F. Schumacher,* *Clinica Pediatrica, Spedali Civili di Brescia, Brescia, Italy; and†Centre Medicale Saint Camille, Ouagadougou, Burkina Faso.

Abstract: Since 2003 Brescia University, carry on a health care project for HIV infected children at S.Camille Hospital (Ouagadougou-Burkina Faso). At May 08, 210 children were enrolled, of which 108 (51.4%) were on ART (42F, 66M). Mean age at first examination was 5yy (0.37–15.7yy, median age 3.43yy). Mean follow-up length was 2.18yy (0.07–5.39yy).

Mean start age of ART varied between 0.24–15.38yy (median age 4.26yy). ART was started after an average of 53 from first examination and mean treatment period was 1.82 yy (0.02–5.4yy).

Compliance was measured by pills count, syrup measurements and caregivers interview. 81.9% assumed >95% of doses, 13.8% 90–95%, 3.2% 80–90% while just one patient < 80%. During follow-up ART adherence didn't vary.

At 6 months the majority of patients on ART switched from immunological-stage IV to lower classes; these modifications were slower in patient with lower compliance. Our statistical analysis demonstrated significant weight-gain (P < 0.001) after 6 months of ART, which persisted after 24 months.

At follow-up end, 3.7% of our patients were sent to adult clinic, 1.8% to other centres, 8.3% deceased. Survival Rate (Kaplan-Meier) was 92% after first year of ART and 89% (CI95%:78–95%) after 2yy; beyond this period no deaths were observed.

In regard to age, SR was 93% after 6yy, 91% after 10yy and 87% (CI 95%:75–93%) after 11yy. Deaths were primarily observed during first years of life.

Those high SR has to be ascribed to strict observance to social criteria, accurate clinical/biochemical monitoring, precise therapy-understanding check, qualified personnel and little fixed-dose-combinations use.

P238

UPTAKE, IMPLEMENTATION AND OUTCOME OF EARLY INFANT DIAGNOSIS OF HIV EXPOSED CHILDREN IN A RURAL AREA IN KENYA

A. Hassan, Family Clinic, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.

Abstract: Each year 50,000 infants become infected with HIV in Kenya. Increased access to PCR has led to the availability of Early Infant Diagnosis (EID) of HIV since 2006 with national guidelines recommending follow-up and testing of HIV-exposed children upto 18 months of age.

A retrospective analysis of routine data collected in the provision of HIV care in a district hospital in rural Kenya was done to describe the uptake, implementation and outcome of EID over a period of two years.

A total of 371 (71.2%) of all HIV-exposed children seen at first contact had a DBS for PCR done. At the end of the study period 170 (45.8%) were still on follow-up and 61 (16.4%) had attended care upto 18 months of age. Five children (1.4%) had transferred care to other facilities while 10 (2.7%) and 125 (33.7%) were reported dead and had dropped out of care respectively.

Although majority of the children dropped out after receiving their PCR results, there was no association between PCR status and completing the EID process (P-value 0.262). However, there was a strong association between mothers who are lost to follow-up with children who dropped out of care (P-value < 0.001).

Despite a good uptake, majority of HIV-exposed children did not complete the EID process as recommended. This was mainly attributed to mothers dropping out of HIV care. To enhance early identification of HIV infected children, involvement and support of other members of the family as well as the community should be encouraged.

P239

ASPERGILLUS (TELEOMORPH: EMERICELLA) NIDULANS INFECTION IN CHRONIC GRANULOMATOUS DISEASE (CGD): REVIEW OF THE LITERATURE

S. Henriet,*† P.E. Verweij,†‡ R. de Groot,* and A. Warris,*† *Department of Paediatric Infectious Diseases and Immunology; †Nijmegen Institute for Infection, Inflammation and Immunity; and ‡Department of Medical Microbiology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.

Background: Previous reports of our group have shown the difficulties in accurate identification of Emericella spp based on morphologic characteristics. There is increasing evidence that the efficacy of antifungal agents is different for the various species underscoring the need for correct identification and in-vitro susceptibility testing. We reviewed the literature to determine the diagnostic yield and management of invasive A. nidulans infection in CGD patients.

Methods: Through a systematic search of the PubMed database all reported cases of invasive A. nidulans infections in CGD patients were reviewed.

Results: Twenty-four cases were found, 22 were male, with a median age of 8 yrs (range 3–21). Of those whose genetic pattern was reported, 89% were X-linked gp91phox.

In only 4 cases details of the microscopic morphology were given on which the strain identification was based.

Lung invasion with direct spread to adjacent chest-wall structures is the main clinical presentation. An unusual mild and localized course of the disease showed to be caused by A. rugulosa, originally misidentified as A. nidulans.

Extensive and early surgery remains a cornerstone of treatment. All patients received amphotericin B.

Susceptibility testing was performed in only 3 cases. Fifty percent received granulocyte transfusions and 36% were treated by INF-γ additionally. Thirty-five percent died, but follow-up ranged from “still under treatment” to 8 years.

Conclusion: Details regarding strain identification and in-vitro susceptibility testing were scarce in CGD patients with reported invasive A. nidulans infections. Correct identification and susceptibility results are needed to guide optimal therapy and improve outcome.

P240

RECURRENT CRYPTOCOCCAL MENINGITIS IN RENAL TRANSPLANT ADOLESCENT ASSOCIATED WITH ENVIRONMENTAL EXPOSURE

T. Jamal Mohamed,* Y.C. Yap,† Y.N. Lim,† and K.A. Mohd Razali,* *Paediatric Infectious Diseases Unit; and †Nephrology Unit, Institut Pediatric, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia.

Abstract: Fungal infection in renal transplant recipients are less common than bacterial but pose significant problem because of immunosuppresion and use of nephrotoxic drugs.We report one adolescent who presented with recurrent cryptococcal meningitis,5 months post transplant.

This 17 years old boy,with end-stage renal disease secondary to FSGS presented for renal transplant in July,2007.He is a student and stays in a small town where his grandparents rear poultry.CMV status preoperatively was negative.He had cadeveric renal transplant and he received OKT3,mycophenolate mofetil and prednisolone as immunosuppresive agents.

Five months post transplant,he presented with 1 week history of fever and headache.

On examination,he was febrile with no apparent respiratory distress. Neurological examination was normal.His spinal tap showed a positive cryptococcal antigen (titre1:>512) and culture grew cyptococcal neoformans.He was started on conventional amphotericin B (CAB) and after 1 week changed to Fluconazole since his creatinine went off.

Follow-up lumbar puncture was normal except for persistent cyptococcal antigen but in October,2008 his Indian ink became positive again.He was otherwise asymptomatic and was on fluconazole maintenance therapy.He was re-induced with Amphotericin B colloid dispersion and his physical examination showed an otherwise well child with no fever,paronycia of nails and normal neurological examination.His eye examination showed evidence of retinitis but examination of heart,lung and sinuses were normal.

He completed 4 weeks course of amphocil and was started back on fluconazole.

This case showed how in immunocompromised child,serious infection can be asymptomatic and need to have repeated examination and full anti-fungal induction course to eradicate infection.

P241

DIFFERENT PLASMA LEVELS OF INTERLEUKINS AND CHEMOKINES: COMPARISON BETWEEN CHILDREN AND ADULTS WITH AIDS IN CHINA

C. Jin,* F. Zhang,† Y. Zhao,† H. Yao,* L. Wu,* and N. Wu,* *State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine Zhejiang Univesity, Hangzhou; and †National Center for AIDS/STD Control and Prevention (NCAIDS), Beijing, China.

Background: The immunological differences between children and adults with AIDS in China are not well documented. This study aimed to identify changes in plasma levels of Th1/Th2 cytokines and chemokines in HIV-1-infected children and adults in China.

Methods: Seventy-five children with AIDS and 35 adult AIDS patients were recruited and clinical datas were collected. CD4+ T lymphocyte counts were measured by flow cytometery and plasma HIV RNA levels were measured by quantitative RT-PCR. Plasma levels of IL-18, IL-10, IL-16, RANTES, MCP-1, SDF-1α and SDF-1β were quantified by enzyme-linked immunosorbent assay(ELISA). The levels of β2-MG and sFas were measured to validate the level of humoral and cellular immune activation.

Results: The mean levels of all cytokines in pediatric and adult AIDS patients were significantly higher than in their healthy controls(P < 0.01). Mean levels of these cytokines were higher in pediatric patients than in adult patients (P < 0.05, except for SDF-1α and β2-MG). Some of the cytokines of patients younger than 6 years old was higher than both older children and adults with AIDS (IL-10, IL-18, SDF-1α, MCP, RANTES and sFas, P < 0.05). Levels of IL-18, IL-10, RANTES and β2-MG of pediatric patients increased as the levels of viral load ascending (P < 0.05).

Conclusions: Our research demonstrates that abnormal immune activation is highly initiated in pediatric and adult patients with AIDS, and is higher in children patients than in adult patients. The cytokines levels are coincided with disease progression of AIDS, but have no direct relationship with total CD4+ T cell count.

P242

PREVENTION OF PERINATAL HIV TRANSMISSION IN A GREEK PEDIATRIC COHORT

K. Katsibardi, V. Spoulou, K. Theodoridou, I. Zervaki, G. Mostrou, and M. Theodoridou, Unit of Pediatric HIV-Department of Infectious Diseases, 1st Department of Pediatrics, University of Athens, “Aghia Sophia Children's Hospital, Athens, Greece.

Background and Aim: Vertical HIV transmission is estimated 14–25%, in the absence of intervention. The aim of the present study is to evaluate the degree of prevention of vertical HIV transmission, in a pediatric patient cohort, during a 3 year period.

Methods: Thirty four neonates (14 days-12 months years old) were assessed for HIV infection. Their mothers were HIV positive: 22/34 had known HIV infection and were under antiretroviral treatment (ART) during pregnancy, 7/34 were found HIV positive at the end of first trimester of pregnancy and began ART, while in 5/34 cases HIV positivity was detected after delivery. HIV virus RNA was detected with real time-polymerase chain reaction, in three subsequent samples.

Results: 30/34 (88%) children were delivered with cesarean section, received prophylaxis with zidovudine (AZT), according to PACTG076 protocol and did not breastfeeding. All of them had negative viral load (<50 viral copies/mL).

In 1/34 (3%) neonate, delivered with cesarean section, AZT was not administered and did not breastfeeding, HIV viral load was negative.

Positive HIV viral load was detected in 3/34 (9%) children, delivered vaginally, while 2/3 received AZT in the first day of life. In these cases, mothers’ HIV positivity was detected after pregnancy.

Conclusions: Although the prompt administration of AZT is important for the prevention of perinatal HIV transmission, there are cases that the implementation of perinatal HIV interventions is insufficient. The detection of mothers’ HIV serostatus before pregnancy and the advocacy for perinatal interventions are essential for the reduction of perinatal HIV transmission.

P243

CLINICAL AND ANTHROPOMETRIC FOLLOW UP OF CHILDREN INFECTED BY HIV-1 AND M.TUBERCULOSIS TREATED AT TRAC AND THE HOSPITAL OF KIGALI

K. Kayumba,* C.A. Peltier,† A. Umubyeyi,‡ N. Muganga,§ C. Omes,† and M. Kramer,¶ *Care and Treatment, TRAC Plus; †Esther Project, Lux-Development, Kigali; ‡Faculty of Sciences and Technology, National University of Rwanda, Butare; §Departement of Paediatrics, University Teaching Hospital; and ¶Director General, TRAC Plus, Kigali, Rwanda.

Background and Aims: The care and treatment of HIV/TB co-infection is challenging in the children. This study was aimed at evaluating clinical and anthropometrical aspects of children followed during a 9 months period.

Methods: Children under 3 years (or less than 10 kg) co-infected by AIDS and TB were treated in the clinic of TRAC and in the CHU of Kigali (RWANDA). Clinical and anthropometrical parameters were collected before the beginning of the treatments, at 1 month, 3 months, 6 months and 9 months. The side effects and deaths were noted.

Results: From January 2005 to April 2006, 46 children were followed. The average of age was 19 months.The tuberculin test was positive in 5 cases (11%), the microscopy for acid-fast bacilli was positive in 2 cases. Contact with tuberculous adult was reported in 61% of the cases. All the children had anti-TB treatment (RHZ). Further, 69% of them had 2NRTI+2xDose of NVP, 31% had 2NRTI+EFV.The side effects were: 6 cases of anaemia, 3 cases of cutaneous rash, 1 case of pancreatitis, 25 cases of vomiting. Mortality was 41 %. For the survivals, the weight for age Z-scores passed from -4, 28 to -0, 76 (P = 0,000) and the height for age Z-scores passed from -4, 14 to -2, 48 (P = 0,023) after 9 months of treatment.

Conclusion: The anthropometrical parameters have significantly increased among our patients: in 9 months, weight deficit was corrected but height retardation couldn’t be corrected. Mortality remains high following the delay of diagnosis and beginning the treatments.

P244

ANALYSIS OF BACTEREMIA IN PEDIATRIC PATIENTS WITH SECONDARY IMMUNODEFICIENCY

H.M. Kim,* and D.S. Kim,† *Department of Pediatrics, Yonsei University, Wonju College of Medicine, Wonju Christian Hospital, Wonju; and †Department of Pediatrics, Yonsei University College of Medicine, Severance Children's Hospital, Seoul, South Korea.

Background and Aims: Pediatric patients with secondary immunodeficiency receiving chemotherapy are more vulnerable to bacterial infection. This study is to analyze the pathogens causing bacteremia and their antimicrobial resistance patterns in pediatric patients with secondary immunodeficiency.

Methods: A retrospective medical records review of 188 episodes of bacteremia in 172 pediatric patients with secondary immunodeficiency between January 2001 and January 2008 was conducted at Yonsei University Severence Children's Hospital.

Results: Among the 188 episodes of 172 pediatric patients with secondary immunodeficiency, gram-positive organisms were 52.1%, gram-negative organisms were 37.8% and fungal infections were 8.0%. Staphylococcus epidermidis was the most common pathogen and Pseudomonas spp. was the most common gram-negative organisms. Gram-positive organisms are resistant to ciprofloxacin 37.8%, erythromycin 75.5% and clindamycin 53.1%. Some of them were resistant to vancomycin but all gram-positive organisms were susceptible to teicoplanin. E. coli was resistant to ampicillin 71.4%, Pseudomonas spp. was resistant to imipenem 33.3%, ceftazidime 16.7%, and cefepime 25.0%. The patients with central venous catheters showed higher incidence rate of gram-positive organisms and fungus than in them without it (P = 0.02). Neutropenia and high C-reactive protein are the risk factors of bacteremia (P = 0.003).

Conclusions: Gram positive organisms were more frequent than gram negative as pathogen in immnunocompromised patients, especially in them with central venous catheter. We should carefully choose the antibiotics in case of impending sepsis on the base of patient's conditions including laboratory data such as C-reactive protein, neutropenia, or indwelling catheter and of institutional environment like the specific antimicrobial resistant pattern.

P245

ANTIRETROVIRAL-RELATED SHORT-TERM TOXICITY IN HEALTHY INFANTS: IMPLICATIONS OF THE NEW NEONATAL 4-WEEK ZIDOVUDINE REGIMEN

R. Lahoz,* A. Noguera,* N. Rovira,* A. Català,* E. Sánchez,† R. Jiménez,* and C. Fortuny,* *Hospital Sant Joan de Déu, Esplugues; and †Agència d'Avaluació de Tecnologia i Recerca Mèdiques, Barcelona, Spain.

Background and Aims: British and Spanish Guidelines on HIV mother-to-child transmission have recently shortened the duration of neonatal zidovudine prophylaxis to 4wk for most infants; whether this regimen leads to a reduction in haematological and mitochondrial short-term toxicity remains unknown.

Methods: Prospective observational study in a cohort of infants born to HIV-infected mothers. Mother-infant pairs demographic, clinical, and laboratory data were collected at birth, 6wk, and 3, 6 and 12 months of age, including full blood count and lactate levels. Infants were compared according to the length of their neonatal zidovudine regimen, either 6wk or 4wk.

Results: As of September 2007, 168 infants had been included (6wk zidovudine regimen, n = 137; 4wk, n = 31). Mother′s age and use of nevirapine-based HAART regimens were significantly higher in the 4wk group. No other differences were observed in baseline characteristics between groups.

Macrocytosis was observed in both groups up to the age of 3 months: MCV values were higher in infants receiving the 6wk regimen (107fl vs 100fl at 6wk, 86fl vs 82fl at 3 months of life; P < 0.0001). No differences were noted in mean haemoglobin and haematocrit levels, platelet, leukocyte, neutrophil or lymphocyte counts at any of the time points assessed. Mild hyperlactatemia up to the age of 3 months was observed, without differences between groups.

Conclusions: Only an incidental decrease in MCV values was noted in infants exposed to the 4wk neonatal zidovudine regimen. This suggests that mitochondrial and haematological toxicity are mainly due to antiretroviral exposure during foetal life.

P246

PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV IN GEORGIA

M. Lomtadze, T. Tsertsvadze, and T. Kakabadze, AIDS and Clinical Immunology, Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia.

Background and Aims: Prevention of mother-to-child transmission (PMTCT) of HIV is one of the strategic priorities as defined by the National Strategic Plan of Action (NSPA) of Georgia in 2006–2010 years. The comprehensive approach to PMTCT is based on existing evidence and includes: provision of prophylactic ART in pregnant and newborn, counseling and support for delivery and infant feeding, including infant PCP prophylaxis by TMP-CTX.

Methods: Testing on HIV/AIDS was based on identification of HIV antibodies b screening method, using Rapid Anti-HIV Test InTec PRODUCTE, INC. Positive result are referred to IDACIRC for confirmation by Western Blot and management that implies: antiretroviral therapy, caesarian section, infant feeding by formula and PCP prophylaxis by TMP-CTX. Data were collected using national HIV/AIDS Data Base.

Results: Throughout the period 1999–2008 total 84 pregnancies were registered at the IDACIRC. Prophylactic strategy was tailored individually according to the national acting guideline, women gestation age, HIV diseases stage, ARV availability. Totally 36 pregnant women received full PMTCT service. In this group no vertical transmission of HIV infection was recorded. 33 pregnant women received partial PMTCT service. The reasons were: late HIV diagnosis, limited access to ARV (from 1999 till 2004), refusal by pregnant women. Number of HIV transmission cases was 3 in this group. As of November, 2008 eight women are still pregnant.

Conclusions: Since 2005 Georgia Ensured comprehensive and sustainable PMTCT service throughout the Country and universal access for all pregnant women. Provision of full package of this service minimized the risk of vertical transmission.

P247

HIV/AIDS

J. Lundja, Global Youth Coalition on AIDS, Kinshasa, Congo.

Background: India ranks third in the world in absolute burden of HIV. While increasing numbers of Government-sponsored clinics are providing free antiretroviral therapy (ART), its utility is limited by lack of affordability and acceptability and the requirement for lifelong administration. Allopathic practitioners in India are outnumbered by practitioners of traditional Indian medicine and homeopathy (TIMH), which is used by two-thirds of its population in rural areas to help meet its primary health care needs.

Results: Of 160 original articles reviewed, 19 laboratory studies, 17 clinical studies and six previous reviews of the literature were identified that covered at least one system of TIMH, which includes Ayurveda, yoga, naturopathy, Unani medicine, and Siddha medicine and homeopathy. Most studies examined either Ayurvedic or homeopathic treatments.

Conclusions: This review exposes a broad gap between the widespread use of TIMH therapies for HIV/AIDS, and the dearth of high-quality data supporting their effectiveness and safety. In light of the suboptimal effectiveness of vaccines, ART, barrier methods, and behavior change strategies for prevention and cure of HIV infection, it is both important and urgent to develop a rigorous research agenda that uses innovative methodologies to investigate, evaluate and maximize the role of TIMH in managing HIV/AIDS and associated illnesses in India.

P248

CEREBELLAR DEGENERATION IN PACIENTS WITH HIV CASE PRESENTATION

C. Marcas, Infectious Diseases, Clinical Infectious Diseases Hospital Constanta, Constanta, Romania.

Background: The neurologic manifestations in HIV infected long term survivor pacients with HAART determine serious diagnosis and treatment problems.

Objective: We present the case of a 19 years old adolescent with HIV/AIDS, C2 with cerebellar syndrom.

Results: The 19 year old patient was hospitalized with neurologic symptoms consisting of: left deviation of the ocular globes and head, gait ataxia, dysarthria, nystagmus, symptoms that progressively emerged 4 months before. The clinical examination at hospitalization revealed: no fever, good general state, consciousness, dysarthria, nystagmus, gait ataxia. The neurologic examination highlighted: VI oculomotor nerve paralysis, associated with dysarthria, nystagmus, hypermetria, intention tremor, absence of cognitive decline or dementia. Cerebral MRI was performed at this stage, highlighting left cerebellar cortical atrophy, left cerebellar emispehere with oval image area, areas of demielinization of the white substance (fig 1,2 and 3).

At this diagnosis stage, there were the following diagnosis suspicions:

1. Cerebellar Degeneration a novel variant of progressive multifocal leucoencephalopathy (PML)

2. Dementa HIV

3. Cerebral toxoplasmosis

4. Cerebral lymphoma

5. Tuberculosis

6. Meningo encephalitis with CMV

7. It was highlighted the diagnosis of a cerebellar neurologic disorders

8. Limited therapy choices.

9. Slight neurologic improvement.

P249

NON-TUBERCULOUS MYCOBACTERIAL IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME IN A SEVERELY IMMUNOCOMPROMISED HIV-INFECTED PAEDIATRIC PATIENT

A. Martin,* P. Soler-Palacin,* I. Barber,† and C. Figueras,* *Paediatric Infectious Diseases and Immunodeficiencies Unit; and †Pediatric Radiology Service, Vall d′Hebron Hospital, Barcelona, Spain.

Background: The use of antiretroviral therapy (ART) in HIV infection is associated with significant reductions in morbidity and mortality by restoring immunity. Non-tuberculous mycobacteria (NTM) infection in severely immunocompromised patients who start HAART can be associated with immune reconstitution inflammatory syndrome (IRIS) with clinical deterioration due to an excessive inflammatory response.

Case Report: 13-year-old boy admitted with diarrhoea, low grade fever and weight loss. HIV was performed at that point with positive results. Viral load was 47.000 RNA/ml and total CD4 cell count 3/mm3. Acid-alcohol-resistant bacilli were detected in the bowel biopsy with negative PCR for Mycobacterium tuberculosis complex. Therefore diagnosis of NTM infection in an stage C3 HIV infected patient was made. Both ART with abacavir, lamivudine and efavirenz and NTM treatment with azytromicin, rifabutin and etambutol were started at that point. As significant pharmacokinetic interactions have been reported, plasma drug levels were determined and doses adjusted subsequently. Eight weeks later, fever reappeared at the same time that immunological restoration (CD4 cell count was 3.7%) with decreased in HIV viral load (420 RNA/ml) were observed. Abdominal CT scan showed enlarged mesenteric lymphadenopaties and the diagnosis of abdominal NTM-associated Immune reconstitution inflammatory Syndrome (IRIS) was made. A mesenteric node biopsy ruled out lymphoma. Corticosteroids were started with partial response.

Conclusions: IRIS should be suspected in any severely immunocompromised HIV-infected patient starting ART with rapid immunological response and clinical deterioration. Abdominal NTM-associated IRIS is usually difficult to treat and prognosis is often unfavourable.

P250

APOPTOSIS AS MARKER OF EFFECTIVENESS OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPIES AT HIV POSITIVE CHILDREN

K. Munusamy,* S.S. Charanjit Singh,† and Y.V. Vyaltseva,‡ *Crimea State Medical University, Simferopol, Ukraine; †National University of Malaysia Hospital, Kuala Lumpur, Malaysia; and ‡Children Infectious Diseases, Crimea State Medical University, Simferopol, Ukraine.

Abstract: There are still important and difficult questions on its beginning and tactics in case of development of resistency to the preparations of highly active antiretroviral therapy (HAART) in children despite long enough successful experience of application. The aim was to investigate FAS receptor level as additional marker in estimation of efficiency of HAART, FAS-receptor (CD95) a method of REEF with a set of monoclonal antibodies “Status”. 47 HIV positive children receiving HAAR were examined. 25 were getting combination of two NIOT, and one NNIOT while 22 received two NIOT and one IP. Before HAART, children of both groups had equally high levels of FAS-receptor - 51,35±1,79%. During the observation of these children during 14 months, the decreasing of FAS receptors were noted. In 6 children resistancy to APB preparations developed. In 1-st case progress of resistancy in 1 year from beginning of HAART was connected with low commitment of patient to treatment, in other 5 the commitment was high and made 95–100 %. Nonefficiency of HAART was observed in clinical, immunological and virological aspects. Research of FAS-receptor levels in children resistant to HAART revealed that formation of resistancy at HIV-positive children was accompanied by substantial growth of basic apoptosis marker (FAS-receptor) in blood plasma. In comparison with reference values, CD95 levels increased on the average of 19,6 ± 1,3 %. We suggest to use the FAS receptor level as additional prognostical criteria of resistancy formation to HAART.

P251

MORBIDITY AND MORTALITY OF UNINFECTED CHILDREN BORN TO HIV POSITIVE MOTHERS FROM AMATA STUDY

G.F. Ndayisaba,* P.C. Ndimubanzi,* K. Kizito,† C. Rutanga,* E. Havuga,* A. Mujawamariya,* A. Musonera,* and A.C. Peltier,* *Lux Development; and †TRAC Plus, Kigali, Rwanda.

Background and Aims: The choice of infant feeding mode for HIV positive mothers is very difficult in resource-limited countries. The formula feeding (FF) is disputed, whereas breast feeding (BF) remains the main way of HIV mother to the child transmission. The objective of this study is to compare the morbidity and the mortality and to identify the principal reasons of consultation and hospitalization according to the feeding mode.

Methods: In AMATA study, women chose between the FF and exclusive BF for 6 months. The FF group had education sessions on preparation of formula which was provided free of charge. Regular follow-ups were done at D15, D45, M3, M5, M6, M7 and M9 and all diseases events and deaths were recorded.

Results: 525 uninfected children have born, 57.5% were on FF and 42.5% on BF. 173 diseases’ events occurred, with an average of 1.5 episode per child in FF group and 1.3 in BF group (P = 0.20). Mortality was 6% in FF, against 4% in BF [Relative risque (RR) of 1.4 (CI 95%: 0.6–3.2; P = 0.56)]. The main causes of morbidity were: Upper respiratory infections (27%), gastroenteritis (21%) and pneumonia (15%). Pneumonia was more frequent in FF group [RR of 1.6 (CI 95%: 1.1–2.4; p = 0,007)], while there was no difference for gastroenteritis and Upper respiratory infections according to feeding mode.

Conclusion: In a context of persistent and regular councils on hygiene and formula preparation, there seems to be no evidence of increased morbidity or mortality related to FF compared to BF.

P252

CHARACTERIZATION OF THE BIRTHS OF NEWBORNS OF MOTHERS HIV+, IN THE PERIOD 2003 TO 2007, RIBEIRÃO PRETO, BRAZIL

L.A.S. Neves,* M.C.G. Reis,† F.R.A.L. Neves,‡ M.C. Barbaro,† and M. Motta,† *Ribeirão Preto City Health Department, IST/Aids Programme, and University of São Paulo; †Ribeirão Preto City Health Department, Child and Adolescent Programme; and ‡Ribeirão Preto City Health Department, IST/Aids Coordinator, Ribeirão Preto, Brazil.

Background: The epidemic of AIDS is a serious problem of Public Health. The knowledge of the characteristics of the patients is basic for effective action on prevention and assistance. This study aimed to characterize the births of children of mothers HIV+ in the city of Ribeirao Preto, from 2003 to 2007, according to partner-demographic variables.

Methodology: Descriptive study, retrospective, which were analyzed the records of the Program of Child's Health. The data had been analyzed: age and residence of the mother, number of pregnancies, accomplishment of prenatal, sex and birth weight of newborns. The data were organized in tables and then analyzed.

Results: In the period from 2003 to 2007, 37645 children were born. Of these, 196 children whose mothers were HIV + (0.5%). Most mothers were aged 20 to 34 years (75.2%), 81.4% lived on the outskirts of the city, in districts with population of less economic class. As the number of pregnancies, only 17% were in the first pregnancy and 30% had more than 5 children, 6.1% did not have prenatal care. For infants, 50.8% were male, and 18.1% had weight below 2500g.

Conclusions: The results confirm the trend of the epidemic in accentuate in groups with less advantaged social, and with number of children above the brazilian average. The rate of low weight was higher than the average city in this period. It must include all pregnant women in prenatal care, promote the integration of these in programs of counseling, family planning and childcare.

P253

HIV AND HAART-MEDIATED MITOCHONDRIAL DNA DEPLETION COULD BE COMPENSATED AT TRANSCRIPTION LEVEL TO MAINTAIN MITOCHONDRIAL FUNCTION IN CHILDREN

A. Noguera,* C. Morén,† G. Garrabou,† N. Rovira,* M. Nicolás,† F. Cardellach,† Ó. Miró,† and C. Fortuny,* *Hospital Sant Joan de Déu, Esplugues; and †Laboratorio de Funcionalismo Mitocondrial, Hospital Clínic; CIBER de Enfermedades Raras (CIBERER), Barcelona, Spain.

Background and Aims: Both HIV infection and highly-active-antiretroviral therapy (HAART) lead to mitochondrial (mt) dysfunction, a major pathway for some adverse events in HIV-infected adults. Little is known about mt toxicity in the pediatric age. To determine whether there exist alterations in mtDNA and mtRNA content, and mitochondrial respirarory chain (MRC) function in peripheral-blood-mononuclear-cells (PBMCs) from HIV-infected children.

Methods: A cross-sectional study in PBMCs was performed in 64 HIV-infected children (47 HAART-treated and 17 off treatment) and 35 healthy children. We measured mtDNA and mtRNA content by Real-Time PCR. MRC enzymatic activity (complexes IV, II-III, G3PDH, G3PDH-CIII, and CII function) was measured by means of spectrophotometry, and mitochondrial mass was estimated by cytrate synthase activity. Cytochrome-C-oxidase subunits of CIV and mt content were assessed by western-blot analysis.

Results: A reduction in PBMCs mtDNA levels was observed in HIV-infected children compared to healthy controls (4.35 ± 0.25 and 5.82 ± 0.48, respectively; 25%, P =.005), together with similar levels of mtRNA (0.07 ± 0.01 and 0.06 ± 0.01, P =.19), enzymatic activities and protein subunit content. Among HIV-infected children, mtDNA levels didn′t correlate with viral load, CD4 counts or percentages, and lactatemia at the time of assessment. No further differences were observed among treated patients when HAART-related variables (time on treatment, use of ddI or d4T, IP or NNRTI-based regimens) were considered.

Conclusions: The observed depletion in mtDNA content in HIV-infected children did not lead to differences in mtRNA levels or MRC function. Homeostatic compensatory mechanisms at transcription level could explain the lack of correlation between mtDNA depletion and MRC function.

P254

MONITORING OF ANTIRETROVIRAL THERAPY IN HIV-INFECTED CHILDREN. RESULTS OF A MULTICENTRE STUDY IN SPAIN

A. Nso Roca,* B. Larru,† J.M. Bellon,† M.J. Mellado,‡ J.T. Ramos,§ M.I. Gonzalez,¶ M. Navarro,† M.A. Muñoz Fernandez,† and M.I. De Jose,* *Infectious Diseases, Hospital La Paz; †Hospital General Universitario “Gregorio Marañón”; ‡Hospital Universitario “Carlos III”; §Hospital de Getafe; and ¶Hospital Universitario “Doce de Octubre”, Madrid, Spain.

Background and Aims: HIV-infected children life expectancy has improved dramatically since highly active antiretroviral therapy began. However, between 20% and 50% of children suffer virological failure during the first year of treatment. One of the factors that limit the success of therapy is suboptimal plasma concentrations of antiretroviral drugs. We present here a study evaluating antiretroviral plasma concentrations in HIV infected children on non-nucleoside reverse transcriptase inhibitors and protease inhibitors based regimen.

Methods: We carried out a multicentre, observational study, including HIV-infected children from five large Hospitals in Madrid, Spain. Clinical, haematological, biochemical and immuno-virological parameters were assessed. Antiretroviral plasma trough concentrations were assessed using a validated high performance liquid chromatography method.

Results: Between April 2006 and April 2008, 134 children were enrolled in the study, with median treatment duration of 41.8 months. 28% of the non-nucleoside reverse transcriptase inhibitors levels were low and 19.4%, high. 25% of the protease inhibitors levels were low and 17.4%, high. Adequate or high levels of antiretrovirals correlated with high CD4 and CD8 percentage and low viral load. Interestingly enough a significant correlation between high lopinavir/ritonavir levels and lipodystrophy was found. Tanner stage 5 was associated with higher plasma levels. Full adherence was reported for all the participants by a questionnaire.

Conclusions: Many HIV-infected children show ARV plasma levels out of the therapeutic range which demand and intensive, child-adjusted approach. However, larger studies are urgently needed in pediatric populations to define optimal reference values.

P255

ASPERGILLOSIS—A CASE REPORT IN A CHILD WITH AIDS

A. Oldakowska,*† M. Marczynska*† M. Szczepanska-Putz,*† and S. Dobosz,*† *Department of Children's Infectious Diseases, Medical University of Warsaw; and †XI, Hospital of Infectious Diseases, Warsaw, Poland.

Background: Aspergillosis is uncommon in HIV-infected individuals (incidence < 10%). Predisposing risk factors include: neutropenia, severe immunodeficiency and prolonged antibiotic use. Pulmonary infection by Aspergillus is the most common, but hepatic involvement has been also documented.

Aim: To present a child with AIDS with suspicion of aspergillosis.

Methods: A case report.

Results: 10-years old girl with newly diagnosed HIV diagnosis (most probably vertical infection) with clinical manifestations of hepatitis was admitted to the Department. She was soon after severe pancreatitis, cholecystitis and had prior history of recurrent pneumoniae (suspicion of mucoviscidosis). HIV diagnosis was established at the AIDS stage with single CD4 cells and HIV RNA VL of 5,7 log. Neutropenia, high aminotransferase level, GGTP and direct bilirubin elevation were observed. PCR DNA Aspergillus from gastric lavage and monoclonal antibody to galactomannan in serum were positive. DNA PCR Candida from gastric lavage was also positive. Other opportunistic infections (TB, MAC, PCP, cryptococcosis) were excluded. With a suspicion of aspergillosis she received treatment with voriconazole for 3 months with rapid clinical improvement. After 10 days she has started combined antiretroviral therapy. After 6 weeks of voriconazole treatment the bilirubin and aminotransferase levels were normal. GGTP remained high. cART resulted in decrease in HIV RNAVL to 2,6 log, but no improvement in CD4 count was observed.

Conclusions: Good response to voriconazole confirmed the diagnosis of invasive aspergillosis with liver involvement.

P256

HIV/AIDS; MODE OF TRANSMISSION, OUTCOME AND OUR EXPERIENCE WITH ANTI RETRO-VIRAL DRUGS IN A POOR RESOURCE SETTING

B. Onankpa, Paediatrics, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria.

Background: Paediatric HIV/AIDS and its management is still poor and of serious concern in poor resource settings.

Aims: To determine the mode of transmission and outcome in children with HIV/AIDS on ARVDs at the Usmanu DanFodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria.

Methodology: A 5-Year retrospective study of children with HIV/AIDS from January, 2001 to December, 2005. Screening was based on WHO criteria. Confirmation of HIV seropositivity was from a positive ELISA and then a Western Blot assay.

Results: Ten thousand, one hundred and seven (10,107) children were admitted over the 5 year period, 1,359 died giving a mortality rate of 13.5%. Eight hundred and forty (8.3%) of the admitted children had HIV/AIDS and were put on pediatric ARVDs based on WHO clinical criteria, 305 (36.3%) died. Mother to child transmission (MTCT) accounted for the highest mode of transmission, 794(94.5%). There were 44(5.3%) cases of unidentified route of infection and 2(0.2 %) cases of sexual abuse in males aged, 11 and 13 years. Fever (81.3%), diarrhea (75.0%), vomiting (41.4%), difficulty in breathing (39.8%) and refusal of feeds (39.8%) were the commonly encountered clinical features. Septicaemia (49.5%) and acute respiratory tract infections (40.9%) were the major admitting diagnoses and major causes of deaths. Deaths from HIV infection accounted for 22.4% of the total deaths for the study period.

Conclusions: Mother to child transmission of HIV is still high in the area of study and paediatric HIV/AIDS remains a significant cause of childhood morbidity and mortality.

Keywords: Paediatric HIV/AIDS, ARVDs, outcome, Sokoto.

P257

INADVERTENT NEONATAL LOPINAVIR/RITONAVIR OVERDOSE

D. Pace,* S. Attard-Montalto,† and H. Lyall,‡ *Department of Paediatrics; †Department of Paediatrics, Mater Dei Hospital, Tal-Qroqq, Msida, Malta; and ‡Department of Paediatrics, Imperial HealthCare NHS Trust, London, UK.

Background and Aims: The ritonavir boosted protease inhibitor, lopinavir (LPV/r), may be used off label, as part of combination therapy to prevent mother-to-child transmission (MTCT) of Human Immunodeficiency Virus (HIV), when maternal infection is diagnosed at delivery. Parental understanding of the correct administration of the small volumes of antiretrovirals might be hindered by language differences and psychological trauma precipitated by HIV disclosure.

Methods: Despite meticulous education on the correct dose using a 2ml syringe, a Somalian mother with a language barrier inadvertently overdosed her 16 day old twin girls with a tenfold higher dose of zidovudine, lamivudine and LPV/r, by using the 10ml syringe prepacked with zidovudine.

Results: A drastic decrease in the residual volume of LPV/r led to disclosure of the accidental overdose 48 hours after its occurrence. Physical examination revealed two infants who were failing to thrive. Repeated assessments of haematological indices, acid-base balance, liver and renal function, blood glucose and creatine kinase levels were normal. An electrocardiogram and an echocardiogram, performed 7 days later, were unremarkable. Plasma lopinavir levels plotted on the 75th centile.

Conclusions: LPV/r toxicity may be caused by its high alcohol content, but symptoms of overdose are unknown and only one neonatal case of overdose, which resulted in death from cardiogenic shock, has been reported. Although no sequelae were noted in our cases we recommend that only 2ml syringes should be provided to parents administering LPV/r to their newborns. Parental administration of LPV/r should be reassessed again in the community following discharge.

P258

ASSOCIATION BETWEEN MANNOSE-BINDING LECTIN POLYMORPHISMS AND BACTERIAL INFECTIONS IN CHILDREN WITH ACUTE LYMPHOBLASTIC LEUKEMIA

Z. Pana, T. Papageorgiou, A. Tragiannidis, V. Tsotoulidou, and F. Athanassiadou, 2nd Pediatric Department, Aristotle University of Thessaloniki, Thessaloníki, Greece.

Background: With the development of genomic technology there is an increasing interest in determining the genetic predisposition of immunocompromised patients to infections. Mannose-binding lectin (MBL), a protein that recognizes a variety of microorganisms and activates the complement system, is considered to be a potential predictive factor of susceptibility to infections.

Objectives: The aim of this study was to determine whether MBL deficiency influences the frequency and the duration of infections in children with acute lymphoblastic leukemia (ALL) during episodes of febrile neutropenia (FN).

Methods: In a cohort of 30 children with ALL treated at a single pediatric hematology-oncology unit with an almost identical chemotherapy regimen, we studied the relationship between polymorphism of MBL2 gene and the risk of infections during FN episodes retrospectively.

Results: The male/female ratio was 2/1. The mean age was 4.33 years. In 122 FN episodes a total number of 52 infections were microbiologically documented. The predominant Gram-positive microbes were coagulase negative staphylococci (40.3%). The predominant gram-negative bacteria were E. coli (17.3%) followed by Pseudomonas aeruginosa strains (9.62%) and Klebsiella pneumoniae (7.69%). 19 children carried the normal MBL2 gene (A/A) and 11 a mutant allele B (A/O or O/O). A statistical significant difference was found between MBL2 genotype and number of infections (P = 0.024), number of FN episodes (P = 0.017), duration of first FN episode (P = 0.05) and overall duration of FN episodes (P = 0,009).

Conclusions: MBL deficiency might predispose children with ALL to more frequent and prolonged febrile episodes during chemotherapy.

P259

INFANT HIV-1 DIAGNOSTIC TESTING AT CLINICAL SITES IN NORTH AMERICA: 2002–2006

J.S. Read,* S. Brogly,† M. Basar,‡ and G. Scott,§ *PAMA Branch, CRMC, NICHD, National Institutes of Health, Bethesda,MD, †Center for Biostatistics in AIDS Research, Harvard University School of Public Health, Boston, MA, ‡Frontier Science and Technology Research Foundation, Inc., Buffalo; and §Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA.

Background and Aims: Our objectives were to assess the timing of testing, the types of diagnostic assays used, and the costs associated with the diagnosis of HIV-1 infection among infants born to HIV-1-infected women enrolled in the IMPAACT Protocol 1025 (P1025).

Methods: P1025 is a prospective cohort study of HIV-1-infected women and their infants at multiple clinical sites in the U.S. and Puerto Rico. Enrollment began in 2002 and is ongoing. Follow-up of infants continued for at least six months after delivery/birth. The study population for this analysis comprised all live born infants of known HIV-1 infection status born by December 31, 2006 to women enrolled in P1025.

Results: A total of 5147 HIV-1 diagnostic test results were reported for the 998 infants in the study population. The median number of HIV-1 diagnostic assays performed per infant was 5 (10th, 90th percentiles: 3, 7), and the greatest number of tests reported per infant was 13. The median ages at the time of the first, second, third, and fourth HIV-1 diagnostic assay was 0.1, 2.3, 7.0, and 17.6 weeks, respectively. Nucleic acid amplification assays (NAATs) represented 86.9% of all diagnostic assays. The median cost per infant for HIV-1 diagnostic testing was $1168 (10th, 90th percentiles: $762, $1642).

Conclusions: The great majority of assays reported for HIV-1-exposed infants at clinical sites in the U.S. and Puerto Rico were NAATs. However, the number of HIV-1 diagnostic assays performed per infant, and the cost associated with HIV-1 diagnostic testing per infant, varied greatly.

P260

NURTURING DIAGNOSIS OF CHILDREN STRICKEN BY MOTHER-TO-CHILD TRANSMISSION OF HIV IN PROGRAM OF NURTURING SUPPORT

M.C.G. Reis,* L.A.S. Neves,† F.R.A.L. Neves,† M.L.M.E. Mauad,* and M.N.C.M. Vieira,‡ *Ribeirão Preto City Health Department, Child and Adolescent Programme; †Ribeirão Preto City Health Department, IST/Aids Programme; and ‡São Paulo University / Medicine College at Ribeirão Preto, Nutrition Course, Ribeirão Preto, Brazil.

Background: Newly born from mothers HIV+ are under high nutritional risk, once they must not be breastfed. The Brazilian Government praises milk free distribution for these children until they are six months old, to decreasing the risk of malnutrition and vertical transmission. Our purpose is featuring the nurturing status of HIV+ mothers’ children, around six months old, who were born in the city of Ribeirão Preto-Brazil, inserted in program of nurturing support.

Methods: Transversal, descriptive study in which the Health Services handbooks of children born out of HIV+ mothers in the first semester of 2006 were analyzed, according to variables: sex, weight at birth and weight at around 6 months old. Data were analyzed as shown on chart NCHS,1977.

Results: Out of 29 children born from HIV+ mothers in 2006, 13 were born in the first six months of the year. With regard to the weight at birth, two showed low weight. The average weight was 2903g. In a final evaluation with 11 children, the average weight was 7186g; about 82% of them showed signs of normal development, whereas 18% were at nutritional risk. Among those at risk, one did not follow the procedures completely. Children showing low weight at birth, at that moment were found having normal development.

Conclusion: Preliminary data show the following up of medical care, as well as milk delivery and mothers’ acceptance to the program, all these contribute significantly to the maintenance or recovery of the nurturing status of these children at risk.

P261

METABOLIC CHANGES ASSOCIATED WITH LPV/R TREATMENT IN A COHORT OF HIV-1 INFECTED CHILDREN

S. Resino,* C. Palladino,†‡ R. Lorente,† J.M. Bellón,§ B. Larru,† M.D. Gurbindo Gutiérrez,¶ and M.A. Muñoz-Fernández,† *Unidad de Investigación, Instituto de Salud Carlos III; †Laboratorio de Inmuno-Biología Molecular, Hospital General Universitario ’Gregorio Marañón', Madrid, Spain; ‡Istituto Pasteur, Fondazione Cenci-Bolognetti, Università degli Studi di Roma “La Sapienza”, Rome, Italy; §Unidad de Investigación, Fundación para la Investigación Biomédica del Hospital ’Gregorio Marañón'; and ¶Inmuno-Pediatría, Hospital General Universitario ’Gregorio Marañón', Madrid, Spain.

Background and Aims: Highly active antiretroviral therapy (HAART) might lead to the development of toxic effects as dyslipidaemia and lipodystrophy syndrome. Our aim was to evaluate the trend of adipokines and serum lipids in a group of vertically HIV1-infected children treated with lopinavir/ritonavir-based HAART as salvage therapy.

Methods: A multicenter prospective study of 22 PI-experienced children on salvage therapy with LPV/r recruited in 2000–2003. Every 3 months were determined CD4+, CD8+, viral load (VL), cholesterol, triglycerides, lipoproteins and cytokines. Comparisons between children with lipodystrophy (LD) and without lipodystrophy (N-LD) were performed by Fisher exact test, U Mann-Whitney test and Mantel-Haenszel chi-square test.

Results: Median follow-up on LPV/r therapy was 49.0 weeks (IQR: 43.8; 50). We did not find differences in %CD4+, %CD8+, log10VL, cholesterol, triglycerides, HDL, LDL, C-peptide, PAI-1, insulin and HOMA at baseline and during follow-up between LD and N-LD groups. We found differences in median leptin levels (P g/mL) at 48 weeks of follow-up (LD vs. N-LD: 754.6 vs. 139.0; P = 0.016) and in median adiponectin/leptin ratio (at 36 weeks: LD vs. N-LD: 20,166.1 vs. 158,934.4; P = 0.015; at 48 weeks: 25,560.1 vs. 398,444.7; P = 0.043).

Conclusions: Increase in leptin concentration in the LD group could be associated to insulin resistance, reflected in the trend of insulin and HOMA that increased steadily during follow-up. Whether this represents a significant increase could be determined in the future with a longer follow-up.

P262

HOW DO CHILDREN WITH HIV PRESENT IN NORTHWEST ENGLAND?

A. Riordan,* A. Tan,† P. McMaster,‡ R. O'Connor,§ and N. Laycock,¶ *Paediatric Infectious DIseases, Alder Hey Children's NHS Foundation Trust, Liverpool; †Paediatrics, Pennine Acute Trusts, Manchester; ‡Paediatrics, University Hospital North Staffs, Stoke; §Paediatrics, Lancashire Teaching Hospitals, Preston; and ¶Paediatrics, Blackpool Hospital, Blackpool, UK.

Background and Aims: Increasing numbers of HIV infected children are being seen in the UK. We wanted to review how children with HIV were diagnosed in the Northwest of England.

Methods: A case note audit was performed of HIV infected children who had been seen in the Northwest Paediatric and Perinatal HIV Network (NWPPHN). Information was obtained on age at diagnosis, year of diagnosis, main reason for HIV testing and who had arranged the test.

Results: 121 HIV infected children had been seen in the NWPPHN between 1993–2008; 48 were born in the UK. Most children were of African origin (n = 83). Median age at diagnosis was 4yrs (range 1 month-16yrs). Maternal HIV infection was the main reason for HIV testing (n= 52; 43%). 47 (40%) children were HIV tested because of clinical features; pneumocystis/ CMV pneumonitis (17), recurrent respiratory infections (9), FTT/diarrhoea (5), lymphadenopathy/hepatosplenomegaly (5), parotid swelling (3), raised IgG (2), severe chickenpox (2), TB (1). Children who were diagnosed because of maternal infection were significant older (6yrs vs 1yr; P = 0.006), more likely to be diagnosed by an HIV team (62% vs 29%; P = 0.0009) and more likely to present after 2003 (60% vs 27% P = 0.003).

Conclusion: Children with HIV can present at any age. Half are tested because of their mothers HIV status. Many of these children are asymptomatic; highlighting the importance of testing all children born to HIV infected women. However 40% of HIV infected children present with clinical features suggesting HIV and are often diagnosed by non-HIV specialists.

P263

LUPUS ERYTHEMATOSUS DUE TO VORICONAZOLE IN AN IMMUNODEFICENCY INNFANT

M. Rivera Cuello,* D. Moreno Pérez,* A. Vera Casaño,† and F.J. García Martín,* *Pediatric Infectology and Immunodeficiency Unit. Department of Pediatric, Carlos Haya Children Hospital; and †Dermatology Department, Carlos Haya Hospital, Málaga, Spain.

Introduction: Voriconazole is now the first therapeutic option for invasive aspergillosis, but is no currently licensed for patients less than two years. A wide variety of dermatologic manifestations adverse effects are described. Eritematous lupus is a rare reaction (0.01–0.1%). We present a patient with chronic granulomatous disease who developed a lupus-like lesions after the start of voriconazole because a thoracic aspergillosis.

Case: An eight-month infant was diagnosed of thoracic aspergillosis, after the development of a thoracic mass appeared two weeks before. MR demonstrated a large thoracic mass envolved thoracic wall. Culture showed Aspergillus nidulans. The oxidative capacity of neutrophils was decreased (52% of control sample). Intravenous voriconazole was administered at higher dose recommended for these cases (8 mg/kg/12hs) during 39 days, following oral route. After 76 days of therapy, a lupus-like erythema appeared in cheeks and forehead. Biopsy of these lesions confirmed a lupus erythematosus reaction, with depot of IgM and C3 in the basal membrane with the immufluorescence study. Anti-Ro, anti-La and antinuclear antibodies were negatives and the complement was normal. Topic tacrolimus monohydrate, photo-protectors and oral itraconazole were started, and oral voriconazole was stopped. Facial lesions resolved after four weeks, without relapse.

Comentaries: For our knowledge, only a few cases of lupus-like reaction were associated to voriconazole use, but no cases were described in pediatric population. There is no evidence if the immunologic disorder, the short age of our patient or the high dose of voriconazole used predisposed for this rare skin side effect of this drug.

P264

HIV POSITIVE TEENAGER WITH A MEDIASTINAL MASS

M. Sandu,* R. Costa,† L. Negrutiu,* M. Curt,* and M. Gafencu,‡ *Ist Clinic of Infectious Diseases, Clinical Hospital for Infectious Diseases ’Victor Babes'; †IIIrd Clinic of Pediatrics, Emergency Clinical Hospital for Children ‘Louis Turcanu’ Timisoara; and ‡IIIrd Clinic of Pediatrics, University of Medicine and Pharmacy ’Victor Babes’ Timisoara, Timisoara, Romania.

Background and Aims: We present a case with HIV infection which developed a mediastinal mass that we proved to be a tuberculosis lymphadenopathy.

Methods: We are taking the case of a 19 years old female, diagnosed with HIV infection since 2001, admitted in April- May 2008 with family history of cancer.

Results: The patient was admitted for prolonged fever and weight loss. The immunologic profile of HIV infection showed stage B2 with CD4 414/mm3 and undetectable viral load. Chest radiography showed a mediastinal enlargement in the middle and superior area with a multilobulated outline. CT scan indicated several mediastinal lymphadenopathy masses and an apical opacity in the right superior lobe and also hepatosplenomegaly with perisplenic adenopathy. The serology was positive for chronic infection with EBV, CMV and Toxoplasma gondii. The smears and cultures from sputum were negative for M. tuberculosis. It was performed a surgical biopsy of the mediastinal mass and the histopathology exam showed specific findings for tuberculosis. She started DOTS with isoniazid, pyrazinamide, ethambutol and streptomycin, because she was under treatment with 3TC+AZT and LPV/r, for 2 months, and then 3/7 HZE for 10 months.

Conclusion: The evolution was good. ARV treatment and DOTS led to good results and a new chest x-ray showed that the opacity in the apical area of right superior lobe has been reduced, without mediastinal lymphadenopathy.

P265

ASPERGILLOSIS PRESENTING AS OSTEOARTHRITIS IN A CHILD TREATED WITH VORICONAZOLE

G. Sensoy,* M. Elmali,† N. Belet,* C. Kara,‡ M.B. Selçuk,† A. Top,§ and A. Yildiran,¶ *Pediatric Infectious Diseases; †Radiology; ‡Pediatric Endocrinology; §Pediatrics; and ¶Pediatric Immunology, Ondokuz Mayis University, Samsun, Turkey.

Backgrounds and Aim: Aspergillosis predominantly occurs as an opportunistic infection in immunocompromised hosts and the lung and the brain are the most common involved areas. Bone involvement and especially articular aspergillosis are exceedingly rare. Due to its rare occurrence, there is no standard treatment for patients with aspergillus osteoarticular infections. Here we report a child with aspergillus osteoarticular infection treated with voriconazole.

Case Report: A six-year-old boy presented with painful swelling of the right ankle for one week. Past history revealed that he had been hospitalized 3 years ago due to primary peritonitis. Periton fluid culture had yielded Staphylococcus aureus and the patient had been healed with antibiotic treatment. He also had left posterior cervical lymphadenitis 4 months ago and an abscess was drained. Magnetic resonance imaging (MRI) of the right ankle was consistent with osteomyelitis and artritis. The synovial fluid culture grew Aspergillus fumigatus. Chest X-ray revealed consolidation on the right lung. Although, the phagoburst test could not be performed, the patient was diagnosed chronic granulomatous disease clinically. Voriconazole was given to the patient 4 weeks by intravenous and then by oral route. At the sixth month of the therapy physical examination and chest-X ray findings were normal and repeated MRI of the right ankle revealed a marked regression of the arthritis and osteomyelitis findings.

Conclusions: Aspergillus osteoarthritis can be occure especially in immunologically compromised patients and voriconazole is an effective treatment.

P266

INTRAVENOUS PALIVIZUMAB FOR THE TREATMENT OF RESPIRATORY SYNCYTIAL VIRUS IN PEDIATRIC HEMATO-ONCOLOGY PATIENS

Y. Shachor-Meyouhas,* Z. Kra-Oz,† R. Elhasid,‡ N. Arad-Cohen,‡ D. Bakri,‡ and I. Kassis,* *Pediatric Infectious Disease Unit, Meyer Children's Hopital, Rambam Health Care Campuse; †Virology Laboratory, Rambam Health Care Campuse; and ‡Pediatric Hemato-Oncology Department, Meyer Children's Hopital, Rambam Health Care Campuse, Haifa, Israel.

Background and Aims: Children with cancer are at increased risk for serious complications from Respiratory Syncytial Virus (RSV). Treatment options are limited, with no consensus or guidelines. Palivizumab is approved for prevention of RSV in specific populations, but not for treatment. Few studies demonstrated successful treatment with Palivizumab. We describe our experience with Intravenous (IV) Palivizumab treatment for children infected with RSV, in our pediatric Hemato-oncology department.

Methods: Symptomatic patients are routinely tested for common respiratory viruses. Following a case with severe fatal RSV pneumonia in a 2 years (y) old child with AML, patients were actively screened twice weekly regardless of symptoms. Respiratory samples were tested for RSV using rapid ELISA test, Immunofluorescence or RT- PCR. A single dose of Palivizumab (15 mg/kg) was offered to RSV+ children ≤3y old.

Results: During a 6 weeks period (1/1/2008-12/2/2008) 12 patients were RSV+. Seven patients (4 months–3y) were treated with Palivizumab. Five patients (including index case) had respiratory symptoms, 2 children were asymptomatic. The index case was in respiratory failure when treated and died a month later. No adverse events attributed to palivizumab were recorded. Patients who were treated immediately had no complications attributed to RSV.

Conclusions: Containment of outbreak due to RSV among high risk children is difficult. Active screening with RT-PCR, early recognition of mildly symptomatic or asymptomatic children and use of IV Palivizumab may be effective in preventing complications of RSV infection among high risk patients.

P267

AN OUTBREAK OF MYCOBACTERIUM MUCOGENICUM BACTEREMIA IN HEMATO-ONCOLOGY UNIT

Y. Shachor-Meyouhas,* H. Sprecher,† R. Elhasid,‡ A. Ben-Barak‡ S. Postovsky,‡ and I. Kassis,* *Pediatric Infectious Disease Unit, Meyer Children's Hopital, Rambam Health Care Campuse; †Microbiology Laboratory, Rambam Health Care Campuse; and ‡Pediatric Hemato-Oncology Department, Meyer Children's Hopital, Rambam Health Care Campuse, Haifa, Israel.

Background and Aims: Mycobacterium Mucogenicum (MM) is a rapidly growing non-tuberculous mycobacterium (NTM) that is commonly identified in tap water. MM rarely may cause bacteremia. We describe an outbreak of MM bacteremia among pediatric Hemato-oncology patients.

Methods: Charts of children with MM bacteremia were retrospectively reviewed. Demographic data, underlying conditions, Central Venous Catheter (CVC) type, duration of bacteremia, and treatment were retrieved. Epidemiological investigation was conducted during the outbreak including environmental sampling.

Results: During a 6 month period (September 2005-March 2006), 8 patients aged 1.5–17y had MM bacteremia.. Seven patients had underlying malignancy and one with Thalassemia major after Bone Marrow Transplantation. Mean number of positive blood culture was 4.2 (1–11) per patient. Two patients received antibiotic treatment in addition to removal of CVC. One patient had pathological chest Computered Tomography (CT). All patients were cured. Almost 60 environmental samples were obtained from, surfaces, ice and municipal water supply. All were negative and no source was documented. Infection control measures included emphasis on guidelines for prevention of CVC-associated infections. No cases occurred before and after this outbreak.

Conclusions: Mycobacterium mucogenicum is a rare agent of CVC associated bacteremia. Removal of CVC may be sufficient for the management of bacteremia. In the absence of definite source identification, reinforcement of standard infection control measures may be successful in containing outbreaks.

P268

PREVALENCE OF HIV INFECTION IN PREGNANT WOMEN IN MUMBAI, INDIA

I. Shah, B.J.Wadia Hospital for Children, Mumbai, India.

Abstract: Prevalence of HIV among pregnant women in India is of great concern especially to prevent HIV in children. Mother to child transmission of HIV is the commonest cause of transmission of HIV in children. Thus estimating prevalence of HIV in pregnant women would aid in developing and prioritizing prevention of parent to child transmission of HIV (PPTCT) programmes. Prevalence of HIV infection in pregnant women in India has ranged from 0.7–1.2%. All pregnant women referred to the antenatal clinic from 1993 onwards were tested for HIV infection by ELISA test after pretest counseling. A woman was diagnosed to be HIV infected if she tested positive on more than 2 HIV ELISA tests. Prevalence of HIV infection in them was calculated and also whether there was an increasing trend was determined. A total of 123439 pregnant women were tested for HIV from 1993 to 2004 of which 1767 women were HIV infected. Prevalence rate was found to be 1.4%. However, this prevalence has not shown an increasing trend (P = 0.443) over period of 12 years.

Table 1: Prevalence ...
Table 1: Prevalence ...
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P269

KNOWLEDGE AND RISKY BEHAVIOR OF CHILDREN ACCOMMODATED IN INSTITUTIONS FOR CHILDREN WITHOUT PARENTAL CARE IN SERBIA

S. Sipetic-Grujicic,* H. Vlajinac,* M. Bjekic,† M. Paunic,‡ I. Ratkov,* J. Maksimovic,* and T. Knezevic,§ *Institute of Epidemiology, School of Medicine; †City Department for Skin Diseases; ‡Institute for Students Health; and §Institute of Public Health of Serbia, Belgrade, Serbia.

Background and Aims: The aim of this study was to analyze difference in knowledge and behavior of children aged 12–14 and 15–19 years, accommodated in institutions for children without parental care, in relation to risk of HIV infection.

Methods: The research was performed in Serbia in period of November to May, 2007. By the use of random sampling procedure in this cross-sectional study were included 483 children 12–19 years old (78% of all children without parents in Serbia) who were accommodated, at least one month before interview, in the 16 of the 22 institutions for children without parental care. Data were gathered from all respondents by a closed-type structured questionnaire. In the statistical analysis chi square test was used.

Results: Among 483 children without parental care 30.6% were less than 14 years. The mean age at first sexual intercourse was 11.8 for children aged 12–14 and 14.9 for children aged 15–19 years. The use of condom at last sexual intercourse with irregular sexual partner was reported by 70.8% of children 15–19 years old during the last year. Only two of younger children had irregular sexual partners in the last year and no one of them used condom. The difference between these two age groups was significant. Correct answers to 5 questions about HIV transmission were significantly more frequent among children 15–19 years old (34.6%) than among younger children (15.5%).

Conclusions: It can be concluded that HIV/AIDS preventive programs are especially necessary for children without parents aged 12 to 14 years.

P270

PREVALENCE OF HIV INFECTION IN B-THALASSEMIC PATIENTS IN JAHROM, 2008

A. Sotoodeh Jahromi, A. Makarem, and M.Y. Karami, Immunology, Jahrom University of Medical Sciences, Jahrom, Iran.

Background and Aims: Thalassemic patients are high risk group to humanimmunodeficiency virus (HIV) infection due to repeated transfusions. To determine the incidence of HIV infection in thalassemic patients of Jahrom.

Methods: This study was carried out on all 109 thalassemic patients of Jahrom referring to thalassemia center of Jahrom, on May 2007.

Results: No cases of HIV were found. The prevalence of HIV infection in the thalassemic patients of Jahrom was 0%.

Conclusions: It seems that the prevalence of HIV infection in thalassemic patients of Jahrom is lesser than the prevalence of HIV infection in the in thalassemic patients in the most of other cities of IRAN and in other countries.

P271

MYOSITIS DUE TO MICROSPORIDIUM PLEISTOPHORA HOMINIS IN A HIV-INFECTED CHILD WITH SEVERE IMMUNODEPRESSION

T.A. Tran,* C. Roze,* S. Eyssette-Guerreau,* P. Bouree,† O. Lortholary,‡ I. Kone-Paut,* C. Lacroix,§ and C. Goujard,¶ *Pediatrics; †Parasitology and Mycology, Bicêtre University Hospital, Le Kremlin-Bicêtre; ‡Infectious and Tropical Diseases, Necker Enfants Malades University Hospital, Paris; §Histopathology; and ¶Internal Medicine, Bicêtre University Hospital, Le Kremlin-Bicêtre, France.

Introduction: Microsporidia are ubiquitous intracellular protozoa and are important pathogens in HIV-1 infected individuals. Digestive tract is the most frequent organ involved. Myositis was only reported in 3 adults. We report here the first pediatric case of a generalized myositis in a HIV infected child with severe immuno depression.

Case Description: A Nigerian 10 year-old boy was admitted in emergency for fever, dyspnea with hypoxemia. Investigations showed an alveolo-interstitial pneumonia due to pneumocystis Jirovecii and CMV. HIV-1 testing was positive. HIV viral load was high (5.64 log10 copies/ml) and CD4 cell count was low (15/mm3).The child was treated with cotrimoxazole, valganciclovir, corticosteroids and triple antiretroviral therapy. Three weeks later, while the pulmonary symptoms improved, the patient experienced polymyalgia in his limbs with muscular nodules, decreased muscular strength, tendinous retractation and elevated serum creatine phosphokinase. Total body MRI concluded to generalized multi-nodular polymyositis. Biopsy showed multiple muscular necrosis lesions containing microsporidian spores. Ultramicroscopic analysis concluded to Microsporidium Pleistophora hominis. The patient was treated with albendazole for a month with a rapid clinical response. Three months later, the patient presented an immune reconstitution inflammatory syndrome with Mycobacterium scrofulaceum infection and relapsing polymyositis. Albendazole was re-initiated with complete recovery of the symptoms.

Discussion and Conclusion: This is the fourth case reported of myositis due to Microsporidium Pleistophora hominis in AIDS patients. The Microsporidium Pleistophora hominis appears as a microsporidia species preferentially associated with myositis. In AIDS patients who experience polymyositis, muscle biopsy should be performed to rule out atypical or rare microorganisms.

P272

HUMAN HERPES VIRUS 7 (HHV-7) INFECTION IN A 6 YEAR OLD BOY WITH BURKITT LYMPHOMA

V. Tsotoulidou,* Z. Pana,* A. Tragiannidis,* A. Papa,† M. Al-Kassis,* T. Papageorgiou,* and F. Athanassiadou,* *2nd Pediatric Department; and †Microbiology Laboratory, Aristotle University of Thessaloniki, Thessaloníki, Greece.

Abstract: We present the case of a 6 year old boy diagnosed of Burkitt's lymphoma who underwent treatment according to BFM-NHL 90 protocol. On day 10 after initiation of treatment, the boy presented a macular rash on his back, which spread to the trunk and the inner surface of the thighs. On day 11, the rash became hemorrhagic and pruritic and the patient became febrile. Laboratory testing revealed severe neutropenia, anaemia, thrombocytopenia and increased CRP and ESR values. Blood cultures and serologic tests for viruses and parasites were negative. Antibiotic treatment was immediately initiated. Moreover, he was put on antihistaminic and antifungal treatment. Despite medication, fever and rash persisted. Based on the rash, strong suspicion of a herpes virus infection was aroused and the patient was put on acyclovir treatment. HHV-7 was detected by PCR in blood. Within the next twelve days the patient's condition was improved. He became afebrile and the rash subsided with exfoliation. The boy received acyclovir intravenously for a total of 14 days. Two months later, during a lumbar puncture because of persistent headache, HHV-7 was detected by PCR in CSF. He was administered acyclovir orally for 21 consecutive days.

HHV-7 is a T-lymphotropic virus, infecting CD4+ and CD8+ lymphocytes. Primary HHV-7 infection occurs in early childhood and is generally considered to be a benign and self-limited disease. After primary infection, HHV-7 persists in the host in a latent state, and can act as an opportunistic agent after reactivation during immunosuppression as in our patient.

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GASTROINTESTINAL INFECTIONS

P273

EFFECT OF HELICOBACTER PYLORI INFECTION ON STUNTING IN VARIOUS AGE GROUPS OF PAKISTANI CHILDREN

T. Ahmad,* R. Bilal,* M. Mukhtar,† and A. Khanum,† *Life Sciences Group, IAD, PINSTECH, Nilore, Islamabd; and †;Department of Biochemistry, PMAS Arid Agriculture University Rawalpindi, Rawalpindi, Pakistan.

Background and Aims: Helicobacter pylori infection leads to gastrointestinal disorders irrespective of age and sex. There have been few prevalence studies of H. pylori among Pakistani population and our recent reports revealed an overall incidence of 84.6% among Pakistani adult population manifesting dyspepsia [Ahmad et al. (2009) FEMS Immunol Med Microbiol 55(1):34–38]. As such the major aim of our study was to evaluate H. pylori infection-associated stunting in various groups of Pakistani children taking into consideration confounders like socio-economic status and several others.

Methods: A total of 400 children were enrolled from three schools in the suburb of Pakistan capital city Islamabad in accordance with approved protocol from the University Research Board. Upon signing consent/assent forms, each child underwent non-invasive 13C urea breath test to confirm H. pylori infection and anthropometric data recorded.

Results: Our analysis revealed that 72.3% of children without gastric symptoms were harboring H. pylori bacterium whereas this trend varied in different ages, i.e. 69.3% in 3–6, 71.4% in 7–8, 78.6% in 9–10, 76% in 11–12 and 55% among 13–16 years age groups. A lower occurrence of H. pylori in adolescence (13–16 years) is intriguing and needs further longitudinal studies. H. pylori-associated stunting was well pronounced in male children when compared with female group (An Odds ratio 3.46 vs. 2.24). We did not see any association between H. pylori positivity and wasting in either group.

Conclusions: Based on our data we conclude that a strong association exists between early child growth and H. pylori infection.

P274

ROTAVIRUS INFECTION BURDEN IN CHILDREN IN UKRAINE

L. Chernyshova,* Y. Kharchenko,† O. Yukhimenko,* I. Yurchenko,† I. Demchishina,‡ and L. Kotlik,§ *National Academy Postgraduate Medical Education, Kiev; †Medical University, Odessa; ‡Central SES, Kiev; and §Regional SES, Odessa, Ukraine.

Background and aims: Diarrhea disease in children in Ukraine is one of actual medical problems. It has the 3-rd place in children morbidity. 60–70% of annual hospitalizations of children to infectious departments are connected with diarrhea disease. Our previous data on rotavirus infection surveillance in 2 hospitals since December 2006 till November 2007 showed the high incidence of this infection. In this report we show data on the 2-nd year of observation.

Methods: Hospital-bases sentinel surveillance (Kiev, Odessa) was held since December 2007 till November 2008.

Results: Number of hospitalized children with diarrhea was 1071 in Odessa and 614 in Kiev. Number of children, from whom samples were taken was 911 (85%) and 568 (92.5%) respectively. Proportion of diarrheas caused by rotavirus was 43.8% and 62.2% respectively. Season fluctuations - increased incidence in cold seasons 72% in January in Odessa and 84% in February in Kiev was marked. Vomiting, dehydratation of 2-nd degree and fever were significantly more frequent in rotavirus-positive diarrhea than in rotavirus-negative one.

Conclusions: Rotavirus infection burden in children is still high in Ukraine. Received data might be used for solution of question of application of rotavirus vaccine in Ukraine.

Acknowledgements: Study was technically and financially supported by European branch of World Health Organization (WHO/EURO), PATH and CDC.

P275

ROTAVIRUS GENOTYPES DIVERSITY IN DIARRHEAL CHILDREN AT THE FRENCH PEDIATRIC EMERGENCY DEPARTMENTS BETWEEN 2006 AND 2008

A. de Rougemont,* J. Kaplon,* P. Lebon,† M. Lorrot,‡ E. Bingen,‡ A. Gagneur,§ A. Minoui-Tran,§ J.-L. Stephan,¶ S. Pillet,¶ B. Pozzetto,¶ M. Rodière,∥ V. Foulongne,∥ D. Floret,** B. Lina,** D. Oriot,†† G. Agius,†† L. Fourcade,‡‡ S. Alain,‡‡ A. Martinot,§§ F. Huet,¶¶ D. Gendrel,†† and P. Pothier,** *National Reference Centre for Enteric Viruses, University Hospital of Dijon, Dijon; †Saint-Vincent-de-Paul Hospital; ‡Robert-Debré Hospital, Assistance Publique Hôpitaux de Paris, Paris; §University Hospital of Brest, Brest; ∥University Hospital of Saint-Etienne, Saint-Étienne; ∥∥University Hospital of Montpellier, Montpellier; **Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, Bron; ††University Hospital of Poitiers, Poitiers; ‡‡University Hospital of Limoges, Limoges; §§University Hospital of Lille, Lille; and ∥∥University Hospital of Dijon, Dijon, France.

Background and Aims: Rotaviruses are the major cause of acute gastroenteritis (AGE) in young children, and require a careful surveillance, especially in the context of vaccine introduction. This study was designed to evaluate the strains circulation and to detect the emergence of potentially epidemic strains in France.

Methods: This prospective study was conducted from 2006 to 2008 in children under 5 years old consulting for acute diarrhea at the pediatric emergency units of 11 University Hospitals across France. Rotaviruses were detected in stools by rapid tests and genotyped by RT-PCR on the basis of their outer capsid proteins VP4 (P type) and VP7 (G type).

Results: The genotyping of 1084 rotaviruses showed that G1 strains (56.8%) were predominant, followed by G9 (28.2%), G2 (6.8%) and G3 (2.5%). Most strains were associated with P[8] (90.8%). Mixed infections, mostly G1/G9 associations, were found in 4.0% of stool samples. The distribution of genotypes was heterogeneous, regional frequencies regarding G1 and G9 ranged from 35.8% to 79.7% and 12.0% to 69.2%, respectively. Finally, 18 atypical reassortant strains were detected of which several G8 and G12 rotaviruses.

Conclusions: The G1P[8] and G9P[8] strains are the main rotaviruses circulating in France and account for 84% of AGE. The surveillance of rotavirus infections should be maintained to document strains distribution and their clinical expression, and to assess the emergence of new reassortants that may be likely to cause severe gastroenteritis and not respond to current rotavirus vaccines.

P276

NOROVIRUS AND ROTAVIRUS INFECTION IN CHILDREN WITH ACUTE GASTROENTERITIS

I. Dodi, D. Vignali, M.A. Bandello, S. Cesari, R. Cerchio, and M. Sommi, G.C. Izzi, Pediatric Infectious Disease—Pediatric Department, Parma University Hospital, Parma, Italy.

Abstract: In Northern Italy viruses represent the main cause of acute gastroenteritis in children.

The aim of our study was to evaluate the etiology, number of cases, severity of clinical manifestations, and seasonal distribution of acute gastroenteritis in children over a one period.

Between October 1st 2007 and September 30th 2008, 473 children (225 M, 218 F) between the ages of 16 days and 16 years and 2 months (mean age 3 yrs and 7 months) were recovered in the Pediatric Department of the University Hospital of Parma with acute symptoms which included fever, vomiting and diarrhea. Stool samples were collected from all subjects. Patients with bloody diarrhea or bacteric diarrhea were excluded from the study. Diagnosis was based on standard electronic microscopy and later confirmed through latex agglutination test or polyacrylamide gel electrophoresis (Rotavirus) or Nested RT-PCR (Norovirus).

182 cases:

* 4 (46,2%) Rotavirus

* 2. 7 (42,3%) Norovirus

* 3. 9 (10,4%) Rotavirus-Norovirus coinfection

* 4. 2 (1,1%) Norovirus-Adenovirus coinfection

The peak incidence of Norovirus infection was between November and December (29 cases) and between December and March (71 cases) for Rotavirus infection.

Modified Ruuska and Vesikari clinical score:

* otavirus: 3–16; mean score: 11,61

* Norovirus: 0–17; mean score: 9,19

In the province of Parma, Rotavirus and Norovirus infections represent the main cause of hospitalisation for acute gastroenteritis in children.

Modern virological diagnostic technology demonstrates that Noroviruses play an epidemiological role that is similar to that of Rotaviruses.

The duration and severity of clinical manifestations were greater in Rotavirus infections.

P277

CLINICAL PREDICTIVE FACTORS IN ACUTE BACTERIAL DIARRHEA

S. Dumitra,* I. Sabau,† D. Stanescu,‡ D. Oprea,§ S. Morgovan,¶ L. Precup, and * D. Lazar,* *Paediatrics, Vasile Goldis Western University, Arad; †Paediatrics; ‡Infectious Diseases, Medical University of Timisoara, Timisoara; §Infectious Diseases, Vasile Goldis Western University; and ¶Paediatrics, Arad Emergency Hospital, Arad, Romania.

Aim: To determine the clinical predictive factors of bacterial or viral etiology in acute diarrrhea in children.

Methods: 453 children with infectious acute diarrhea, from Arad and Timisoara, Romania, participated in this study. They were divided in two groups: bacterial and viral. The bacterial group included 387 children with diarrhea produced by Shigella, Salmonella, Campylobacter and E. Coli. The viral group included 66 children with Norovirus and Rotavirus infections.

The following parameters were monitored: fever, abdominal pain, vomiting, colic point and stools (frequency, duration, presence of pathologic elements).

The data were introduced in an Excel database and analysed with statistical methods in SPSS 10.

Results: The following results were obtained for the bacterial and the viral group: onset fever (84.2%, respectively 37.3%, P < 0.01), abdominal pain (15.8%/10.6%, P = 0.278), vomiting (40.3% / 81.8%, P < 0.01), vomiting preceding diarrhea (12.1%/80.3%, P < 0,01), colic point (37.7%/0%, P < 0,01), watery stools (41.4%/96.5%, P < 0,01), mucus stools (50%/ 0%, P < 0,01), blood stools (98.3% / 1.5%, P < 0,01).

The average number of stools was 5.57 ± 2.69 (P < 0.01) versus 4.65 ± 1.66 (P = 0.009) in the first day and 4.59 ± 2.39 versus 3.7 ± 1.66 (P = 0.003) in the second day; the duration of stools was 6.39 ± 2.56 and 4.29 ± 1.39, respectively (P < 0.01).

Conclusions: The high fever at onset, the colic point, the stools with mucus and blood, the frequency of stools >5/ day and the prolonged duration of the diarrhea are highly significant for the bacterial etiology.

The vomiting preceding diarrhea and the watery stools are frequently associated with the viral etiology.

P278

PREVALENCE OF SALMONELLA INFECTION IN CHILDREN AND INFANTS WITH GASTROENTERITIS ADMITTED TO A SECONDARY CARE HOSPITAL

S. Fernandes Paupério, A. Leitão, J. Dinis, Á. Sousa, Paediatrics, Centro Hospitalar do Médio Ave-Unidade de Santo Tirso, Santo Tirso, Portugal.

Background: Diarrheal disease continues to be one of the most common causes of admittance to a children′s hospital.

Salmonella infections are recognized as major causes of childhood diarrheal illness.

In addition to the effect of antibiotic use in animal feeds, the relationship of Salmonella infections to prior antibiotic use among children in the previous month is well recognized.

Materials and Methods: The aim of this review was to analyse the prevalence and epidemiologic characteristics of Salmonella.

From January 2005 to July 2008, we analysed the stool samples for Salmonella of 198 children with diarrheal disease admitted in our hospital.

Results: Salmonella was detected in 60 cases, more often during summer months, particularly in children aged between 4 and 9 years.

In majority of cases, the transmission source was unknown. Curiously, our rural population has an exotic habit-drink water of the well.

The two most severe cases had co-morbilities. In 36 cases, children had taken antibiotic six weeks before.

Conclusions: Our review revealed the most typical characteristics of Salmonella infections and a particular transmission source in our population.

P279

FOLIC ACID, VITAMIN B12 AND IRON LEVEL IN THE 6–12 YEARS OLD PATIENTS INFECTED WITH GIARDIA LAMBLIA IN SOUTH TEHRAN

F. Ghaffarifar,* F. Askari,† and A. Dalimi Asl,* *Parasitology, Tarbiat Modares University; and †Tehran University of Medical Sciences, Tehran, Iran.

Abstract: Giardia lamblia is a factor in creating diarrhea for human and other mammaliam through the world. Sometime such unicellular caused transfer diarrhea through food which is circulated too much over developed country and caused extending of infection within a part of world. Contamination of water to Giardia cyst is a common reason of existence of that among tourist and passengers. The feature of cyst is in conic form by length in 8–12 and width in 7–10 micron this parasite is a single host and needs not to mediate. Over this research three times faces of 3000 patient aging 6–15 years old referred to healthy and treatment center at south of Tehran considered in view of parasitic infection by two direct method (moisture) then was taken blood from 30 people whom were affected to giardia immunoassay B12 vitamin host and full and by application the ferene method the amount of iron was measured. Based on the obtained conclusion the ratio and Vitamin B12 among the affected people compare to under controlled patient to be reduced while the acid folic rate not change among those people in comparison with under controlled patient.

P280

GASTROENTERITIS REVIEW AT SHAIKH KHALIFA MEDICAL CITY (SKMC) IN THE UNITED ARAB EMIRATES

M. Howidi, A. Shalash, and O. Amin, Pediatrics, Shaikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.

Background: Acute gastroenteritis (AGE) in children carries significant mortality and morbidity. Rotavirus is a leading causative pathogen. Currently there is a vaccine to prevent the severe forms of this infection. Studying the epidemiology of the infection can help in implementing the vaccine.

Objectives: To evaluate the epidemiology and clinical course of AGE cases presented to SKMC. To identify the percentage of AGE caused by rotavirus in young children.

Methods: We conducted a retrospective case review of children < 6 years admitted to SKMC with AGE including both rotavirus positive and negative over the period Jan. 2003–May 2004.

Results: There were 204 cases of AGE, which accounted for 12.93% of total admissions. There was seasonal distribution, more infections occurred in the months Dec.-Feb. The rate of AGE varied among different age groups. In those ≤ 1 year of age there was a total of 39 cases (19.1%), ≤ 18 months a total of 90 cases (44.1%), ≤ 2 years a total of 117 cases (57.4%), and ≤ 3 years a total of 163 cases (79.9%). Rotavirus testing was done in 150 (73.5%) patients; rotavirus was positive in 39.3% and negative in 60.6%. The mean length of hospital stay (LOS) was 2.1 (0.3–16) days.

Conclusion: AGE accounted for significant number of hospital admissions. Rotavirus is a leading causative pathogen. A vaccine implementation will clearly reduce a significant number of hospitalizations. An economic impact analysis is needed to show the efficacy of vaccination.

P281

THE PARASITIC INFECTIONS. A CASE SERIES

S.I. Iurian,* S. Iurian,† B. Neamtu,* and M. Neamtu,* *Pediatric Clinic, Pediatric Hospital, Lucian Blaga University; and †Clinical Laboratory, Pediatric Hospital, Sibiu, Romania.

Background and Aims: According to World Health Organization, the helminths infect more than a quarter of the world′s population. The authors emphasize the clinical particularities regarding parasitic infections.

Methods: The authors present 3 cases of children with anemia and growth impairment. The 1st case was suspected by kidney malformation because of repeated urinary tract infections. The 2nd case was admitted for further investigations regarding a chronic allergic conjunctivitis. The 3rd case was admitted in the context of recurrent wheezing episodes.

Results: In the 1st case, the parasitological stool exam was negative but adhesive tape test has identified an infection with Enterobius vermicularis. In the 2nd case has been identified an infection with Hymenolepis nana associated with Giardia intestinalis and in the 3rd case the parasitological exam has shown a massive infection with Ascaris lumbricoides and Trichiuris trichiura. We have reconsidered the diagnosis for all 3 cases and the specific therapy was initiated with good clinical evolution regarding growth impairment and the associated pathologies.

Conclusions:

1. All 3 cases have presented impairment nutritional status and were admitted for different reasons;

2. The combined parasitic infections suggest a poor hygiene;

3. Even though the parasitic infections are frequent, they are generally underdiagnosed because the symptoms could be so variable.

P282

SEVERE COMPLICATIONS IN HOSPITALIZED CHILDREN WITH GASTROENTERITIS DUE TO ROTAVIRUS VS. GASTROENTERITIS OF OTHER CAUSES

P. Kaiser,* M. Borte,† G. Kliemann,‡ K.-P. Zimmer,‡ and H.-I. Huppertz,* *Prof.-Hess-Kinderklinik, Klinikum Bremen-Mitte, Bremen; †Kinderklinik, St. Georg Leipzig, Leipzig; and ‡Kinderklinik, Universitätsklinik Giessen, Giessen, Germany.

Introduction: Rotavirus gastroenteritis (RV-GE) affects every child up to school age; hospitalisation rates are high, mortality is high in developing countries. Little is known on morbidity and eventually specific complications of severe RV-GE. Little is known on morbidity and eventually specific complications of severe RV-GE. In the light of 2 available RV vaccines evidence on morbidity for vaccine recommendations is needed.

Material and Methods: In 3 large pediatric hospitals files of all hospitalised children ≤6 years from 10/2002–5/2008 with any ICD-10 Code for infectious GE (A00-A09) were retrospectively analysed with a predefined protocol.

Results: 7235 cases were included in the study, 55,6% male; children were on average 1,4 years old and spent 6,56 days in hospital, median 4 days.

1. 20,8% of all children had an underlying disease.

2. In 2178/7235 (30,1%) cases RV was found.

3. 7/7235 children died, one premature newborn with NEC in the context with RV infection.

In 45,5% of RV cases vs 56,3% of other GE cases another diagnosis or complication was present (P < 0,01). Neurological symptoms and trauma were diagnosed more frequently among children with non-RV GE.

Hypertonic dehydration (sodium >150 mmol/l) occurred in 79 cases, 63,3% cases were RV positive, in 17,7% RV was not searched for, in 19% RV was excluded. In severe hypertonic dehydration (sodium >160 mmol/l) RV was found in 15/21 cases (all P < 0,01).

Conclusion: Hypertonic dehydration is a complication specific for RV-GE putting children at risk for CNS damage.

P283

ROTAVIRUS GENOTYPING IN HOSPITALIZED CHILDREN. EXPERIENCE FROM A SINGLE CENTER IN ATHENS, GREECE DURING 2007–2008 REVEALED ABSENCE OF G9 STRAIN

I. Koutsoumbari,* F. Aladin,† E. Alexopoulou,* N. Paleologou,‡ M. Iturriza,† E. Lebessi,‡ J. Gray,† A. Konstantopoulos,* and V. Papaevangelou,* *Second Department of Pediatrics, University of Athens School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece; †Enteric Virus Unit, Health Protection Agency Centre for Infections, London, UK; and ‡Microbiology Department, P. and A. Kyriakou Children's Hospital, Athínai, Greece.

Background and Aims: Paediatric Rotavirus Gastroenteritis (PRG) is the most frequent and severe cause of acute gastroenteritis (AGE) in young children worldwide. Rotavirus genotype distribution varies between seasons and among countries and regions. Studies from European centres report G1P[8], G2P[4], G9P[8] G3P[8] and G4P[8] as their most frequently identified genotypes. In this prospective study the prevalence of rotavirus genotypes in hospitalized children with PRG was evaluated.

Methods: During the 2007–2008 season 385 children were hospitalized for acute gastroenteritis. Rotavirus was detected in stool specimens of 76 (19.7%) children admitted with acute diarrhoea using rapid antigen detection tests. Forty four rotavirus-positive samples were G and P types by RT-PCR.

Results: Genotyping revealed that G2P[4] genotype was the predominant type (30/44, 68.2%) followed by G1P[9] (25%) and G4P[4] (6.8%), and 2 mixed infections were detected. Interestingly we did not identify any G9 strains in the study samples period.

Conclusions: Although the number of children in this study is very limited, our results are in accordance with those reported from other European centres over the 2007–2008 season.

P284

PREVALENCE OF ROTAVIRUS INFECTION IN CHILDREN AND INFANTS WITH GASTROENTERITIS ADMITTED TO A SECONDARY CARE HOSPITAL

A. Leitão, S. Fernandes Paupério, J. Guimarães Dinis, and Á. Sousa, Paediatrics, Centro Hospitalar do Médio Ave-Unidade de Santo Tirso, Santo Tirso, Portugal.

Background and Aims: Since its discovery in 1973 by Bishop, Rotavirus has emerged as the single most important etiologic agent of diarrhea in infants and young children.

Rotavirus and other gastroenteritis viruses not only are major causes of paediatric mortality but also lead to significant morbidity.

The infection typically begins after an incubation period of 48 hour with mild to moderate fever as well as vomiting followed by the onset of frequent, watery stools.

The aim of this review was to determine the prevalence and epidemiological characteristics of rotavirus infection.

Methods: In a 12 month survey (2008) of infants and children with gastroenteritis admitted to our hospital, Rotavirus was detected in stool specimens by enzyme-linked immuno sorbent assays (ELISAs).

Results: Rotavirus was detected in 32 cases – 48.5% (total of gastroenteritis–66), more often during winter months, particularly in children aged between 6 months and 2 years, with a mean hospital stay of 4.1 days.

Routine bacterial and viral studies revealed that bacterial pathogens and common enteric viruses were associated with relatively few cases of gastroenteritis.

The most frequent clinical manifestations were fever and diarrhea.

The disease was most severe in patients 3–12 months of age.

Only one patient was vaccinated against Rotavirus and in that case the disease was mild.

Conclusions: This study confirmed that Rotavirus is the most important etiologic agent of paediatric acute gastroenteritis in our hospital, although the small sample size.

P285

EFFECT OF ZINC SUPPLEMENTATION ON CLINICAL COURSE OF ACUTE DIARRHEA

K. Mahlouji, and B. Azari, Medical Sciences University of Iran, Tehran, Iran.

Introduction: Zinc Sulfate is a medication used in acute diarrhea for reduction of its duration. Recently several studies have conducted in many countries to confirm the value of zinc sulfate in reduction of diarrhea duration and WHO recommended it was a usual treatment for acute diarrhea.

Method and Material: We conducted an interventional Study (Clinical trial). In patient who admitted in Ali_Asghar children hospital with one episode of acute diarrhea. The patients was divided in 2 groups (cases = 75 and control = 75). In the case group zinc sulfate was added as supplement and in control group no supplement was added to usual treatments. The Zinc prescribed as zinc sulfates syrup; 10 mg for children less than 6 months and 20mg for children greater than 6 months.

Results: Mean duration time of diarrhea in control group without Zinc Sulfate was 5.63 days and for that of case group using zinc sulfate was 3.21 days. Data was analyzed by SPSS-13 software using T-test and Chi-square Test, there was a significant difference between 2 groups in duration of diarrhea (P value = 0.001).

Conclusion: In our study prescription of Zinc sulfate in acute diarrhea similar to other studies reduced the duration of acute diarrhea. Therefore Zinc Sulfate has an important role in treatment of acute diarrhea and should be considered as a supplement in all cases of diarrhea.

P286

CHOLERA AMONG HOSPITALIZED AFGHAN CHILDREN WITH WATERY DIARRHEA

M. Metanat, B. Sharifi-Mood, S.-M. Hashemi-Shahri, and R. Alavi-Naini, Research Center for Infectious Diseases & Tropical Medicine, Zahedan University of Medical Sciences, Zahedan, Iran.

Background: Cholera continues to be an major public health problem among many poorer communties. A recent outbreak of watery diarrhea occurred in Afghan refugee population in Southeastern Iran. This study was performed to determine the characteristics of 9 Afghan children hospitalized for suspected cholera.

Methods: We evaluated all cholera patients that had an age < 19 years. All patients were admitted to Boo-Ali hospital (Zahedan, Southeastern Iran) in September 2008. The results of the clinical manifestations, demographic and stool cultures. Faecal culture was done in TCBS media and serotyping and antibiogram of bacterial strains was performed.

Results: Among 62 cases with cholera 9 cases had an age less than 19 years and all patients were admitted to our hospital for watery diarrhea. Significant risk factor was drinking from a contaminated water source in the vicinity of the frontier of Iran. The range age of patients was 12–19 years. All patients were male. The cases had watery diarrhea and 2 patients had abdominal pain. Vomiting and nausea was associated with diarrhea in two cases. The results of stool culture were positive for cholera O1 El-Tor biotype with Inaba serotype. Susceptibility to antimicrobial agents revealed that the O1 strians were resistant to ampicillin, co-trimoxazole, nalidixic acid but were sensitive to tetracycline, ciprofloxacine, doxycycline and erythromycine. There was no case fatality.

Conclusion: The priorities for cholera control remain public health interventions through improved water and sanitation, improved surveillance and further development of appropriate vaccines.

Keywords: Children, cholera, watery diarrhea.

P287

ACUTE ROTAVIRUS GASTROENTERITIS IN CHILDREN IN UKRAINE

A. Nadraga,* I. Dziublyk,† O. Obertinskaya,† I. Kostenko,‡ and H. Lytvyn,* *Pediatric Infection Diseases, Lviv National Medical University, Lviv; †Virusology, National Academy Postgraduate Medical Education; and ‡Central Military Clinical Hospital, Kiev, Ukraine.

Background and Aims: Pediatric rotavirus gastroenteritis is the most frequent cause of acute gastroenteritis in children up to 5 years old worldwide. The aim of this study was to examine rotavirus epidemiology in Ukraine.

Methods: 647 children less than 3 years old with acute gastroenteritis were investigated. None of that child received rotavirus vaccine. The study was conducted between December 2006–March 2007 at the pediatric infection diseases departments located in 5 Ukrainian cities - Kiev, Odessa, Lviv, Charkiv, and Sumy; the all Ukrainian regions–West, East, South, North and Center were presented. All children had gastroenteritis symptoms during their hospitalizations. Stool specimens were frozen and tested later for rotavirus with enzyme immunoassays. Rotavirus-positive stool specimens were subjected to G typing. All tests were made at the Department of Virology National Medical Academy Postgraduate Education.

Results: The mean rotavirus antigen detection rate was 35,7%, but distribution rotavirus gastroenteritis in different regions was nonuniform. Rotavires was most common cause infant's gastroenteritis in West and East regions, where rotavirus was detected on 44,5% and 45,4%. Several times less rotavirus gastroenteritis were observed in North and East Ukrainian regions (7,1% & 10%). The most prevalent G type among rotavirus isolates in Kiev (Center reg.) was G4, in Odessa (South reg.) was G1. Types G3, G2,G9,G12 being identified less frequently.

Conclusions: We observed the nonuniform distribution pediatric rotavirus gastroenteritis of Ukraine. In some Ukrainian regions rotavirus is the most commonly encountered viral pathogen.

P288

ROTAVIRUS GASTROENTERITIS AMONG CHILDREN UNDER FIVE YEARS IN KARAK JORDAN

O. Nafi, Pediatrics, Mutah Faculty of Medicine, Amman, Jordan.

Objective: Is to Estimate the incidence and compare clinical presentation between Gastro entireties due to Rota virus and non Rota virus.

Design: Prospective clinical comparative hospital based study.

Setting: Was conducted in paediatric department At Al Karak General teaching hospital for the period 1-5-2007 to 30-4-2008.

Patient and Methods: Patient selected with strict inclusion and exclusion criteria Stool samples were taken from all patient(s) matching the selective criteria ELISA method done for all samples.

Results:

- Total no of cases 148

- Mean age 12.41 (±) 11.15 months

- Positive ELISA test for Rota in 59 samples (39.9%)

- Age, seasonal variation and fever were the most significant variables.

Conclusions:

- Rota virus infection is a major cause for diarrhoea hospitalization

- Age is younger in Rota group compared to non Rota group

- Most cases occurred in Autumn followed by summer & spring, the least number occurred in winter

- There is marginal significant association between fever & Rota virus infection but it is significant with the younger age.

P289

ABDOMINAL TUBERCULOSIS DUE TO MYCOBACTERIUM BOVIS: THREE CASES REPORT

E. Nuñez Cuadros,* D. Moreno-Pérez,* P. Bermúdez,† and F.J. Garcia Martín,* *Pediatric Infectology and Immunodeficiency Unit. Department of Pediatric. Carlos Haya Children Hospital; and †Microbiology Laboratory. Carlos Haya Hospital, Málaga, Spain.

Background and Aims: The pathology of the Mycobcterium Bovis (MB) is rare in our country. However it's more frequent in undeveloped countries where the way to become infected is usually by raw milk consumption.

Methods: We describe the epidemiologic, clinical and therapeutic characteristics of 3 patients with abdominal tuberculosis due to MB.

Results: Three male children emanating from Morocco with ages between 2 and 6 years, all of them had fever, abdominal pain and constitutional syndrome. Two of them used to drink raw goat's milk. One case was diagnosed with major histocompatibility complex class II molecules deficiency. Tuberculin skin test showed 0 mm in all three. One case had intestinal occlusion which needed surgery in his origin hospital and it was appreciated estercoraceus fistula throughout the cicatrix. Later he needed a new surgery and MB in the peritoneal biopsy culture was positive. In the other 2 cases, we decided medical treatment and abdominal lymphadenopathy biopsy with laparoscopy. In both the biopsy revealed PCR positive to MB.Treatment with isoniazid and rifampicin in the 3 cases was indicated and, during first month, 2 cases with streptomycin and one case with amikacin. We kept this medication during 6 months except for the inmunocompromised child. The cases with medical treatment presented bacterial peritonitis and abdominal abscess because of laparoscopy.

Conclusions: The treatment for the abdominal tuberculosis must be medical. Surgery should be used only in serious complications. When we suspect infection due to MB should avoid using pyrazinamide.

P290

NOROVIRUS AND ROTAVIRUS—TWO MAJOR CAUSATIVE AGENTS OF SPORADIC VIRAL GASTROENTERITIS IN HOSPITALIZED POLISH CHILDREN

E. Oldak, A. Sulik, D. Rozkiewicz, and N. Liwoch-Nienartowicz, Department of Pediatric Infectious Diseases, Medical University of Bialystok, Bialystok, Poland.

Background and Aims: In Poland, the cause of the majority of viral gastroenteritis cases remains undetermined. We aimed to establish the etiologic agents of acute gastroenteritis in children below 5 years of age, hospitalized during spring/summer 2008 and to assess the severity of disease.

Methods: From April to September 2008, fecal specimens were obtained from 181 children (100 males, 81 females) with acute gastroenteritis. Immunochromatographic test for simultaneous detection of rotavirus and adenovirus were performed soon after the fecal specimens were collected. Then samples were frozen and stored for future testing with IDEA Norovirus. Severity of disease was determined by 20-point score system.

Results: A viral agent was detected in 109 of 181 (60.2%) samples tested. Dual viral pathogens (rotavirus and norovirus) were found in 3 of 181 (1.7%) samples. Rotavirus was the most frequent pathogen (86/181; 47.5%), followed by norovirus (19/181; 10.5%) and adenoviruses (3/181; 1.7%). Approximately 60% of gastroenteritis episodes occurring in children less than 5 years of age were accounted for by infection due to rotavirus and norovirus. Rotavirus infections were leading cause of gastroenteritis in spring months whereas norovirus infections during summer time. Norovirus cases were clinically indistinguishable from those of rotavirus origin, in children aged less than 2 years whereas they were slightly milder in older group of patients.

Conclusions: There is a need to apply molecular diagnostic tools to determine the circulating strains of enteric viruses in Poland.

P291

DIARRHEA IN CHILDREN: EPIDEMIOLOGY AND CLINICAL ASPECTS

E. Palumbo, G. Boscarelli, L. Gori, C. Biondi, S. Giacoma, M. Branchi, and G. Pellegrini, Department of Pediatric, Hospital of Sondrio, Sondrio, Italy.

Aim: To determine the etiology of diarrhea in children with an age < 5 years hospitalised for acute enteritis and to evidence the prevalent clinical aspects in correlation of different etiology agents.

Patients and Methods: A total of 402 children with acute diarrhea were examined between February 2003 and December 2007 in the Paediatric Department, Hospital of Sondrio. Fecal samples were collected and processed by routine microbiological and biochemical tests. For all patients the clinical signs and symptoms at the admission were evidenced.

Results: The major part of patients (310/402, 77.1%) resulted infected by rotavirus, while among the remain 82 (22.9%) 40 resulted infected by salmonella species and in 42 any bacterial agent was evidenced by microbiological tests. Clinical signs of mild dehydration were observed in 13 children during the hospital stay (all infected by rotavirus), while any case of metabolic acidosis, hypoglycaemia and hypovolemic shock was documented. Elevated serum levels of uric acid were evidenced in 13/302 (4.3%) of patients with rotavirus infection, while only 1/82 (1.2%) children rotavirus negative presented a minimal increase of serum uric acid level.

Conclusion: Our retrospective study confirms the major epidemiological and clinical importance of rotavirus, as the principal etiologic agent in hospitalised children affected by acute diarrhea with an age < 5 years. Also, we have evidenced a possible correlation between rotavirus infection and hyperuricemia, probably connected with dehydration.

P292

IS THE SERUM PROCALCITONIN LEVEL USEFUL AS INFLAMATORY BOWEL DISEASE ACTIVITY MARKER IN CHILDREN?

K. Plata-Nazar, A. Jankowska, G. Luczak, A. Borkowska, M. Szumera, B. Kaminska, Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Medical University of Gdansk, Gdansk, Poland.

Background and Aims: Procalcitonin is known as an important protein in diagnosis, treatment and prognosis in different inflammatory states. Its clinical significance has not been fully established yet. Aim of the study was to determine clinical usefulness of serum procalcitonin measurement as an activity marker in inflammatory bowel diseases in children.Patients and methods. The studied group comprised of 82 children, including 27 girls (32.9%) and 55 boys (67.1%), aged from 1.4 to 18.0 years (mean 13.9 ± 4.1 [SD], mediane 15.4). The patients suffered from inflammatory bowel disease: Crohn's disease and ulcerative colitis, with different disease activity estimated on Pediatric Crohn's Disease Activity Index and Trulove-Witts score, respectively. There were 23 children with mild, 9 with moderate and 2 with severe Crohn's disease activity, and 30 children with mild, 12 with moderate, and 6 with severe ulcerative colitis activity. Serum procalcitonin level was measured by immunoluminometric method using the commercial kit (LIA PCT; BRAHMS). This quantitative assay uses two monoclonal antibodies which captivate procalcitonin molecules. One of them is labeled with luminescent agent and emits light which intensity is proportional to procalcitonin concentration in analyzed probe.

Results: In majority of patients with inflammatory bowel disease procalcitonin level is normal. Only 4 out of 82 ill children from studied group (0.05%) had procalcitonin values elevated (above 0.5 ng/ml). In one of these four it was higher than 5 ng/ml.

Conclusions: Serum procalcitonin measurement seems to have no clinical value as a marker of inflammatory bowel disease activity in children.

P293

ACUTE GASTROENTERITIS WITH ROTAVIRUS IN CHILDREN UNDER 5 YEARS IN A PAEDIATRIC DEPARTMENT

D.A. Plesca,* V. Hurduc,* O. Parvescu,† C. Gheonea,‡ I. Stancea,* M. Plesca,§ and E. Buzoianu,† *Pediatric Department, University of Medicine and Pharmacy Carol Davila; †Pediatric Department, Victor Gomoiu Pediatric Clinic Hospital; ‡Pediatric Department, University of Medicine and Pharmacy Craiova; and §TMS, University of Politehnica Bucharest, Bucharest, Romania.

Background and Aims: Rotavirus (RV) infection is a major cause of infectious gastroenteritis in children worldwide, requiring hospitalization in most of the cases. The aim of the study was the analysis of rotavirus gastroenteritis incidence and clinical characteristics in children aged under 5 years in a Paediatric Department.

Methods: A prospective study of all cases of acute gastroenteritis presenting to Victor Gomoiu Clinical Pediatric Hospital, Bucharest, from January 2008 to December 2008. There were studied: viral etiology, age and sex of children, clinical aspects, biochemical parameters, stool aspects.

Results: During the 12 months of study, a total of 1313 children with acute gastroenteritis were observed in our Emergency Service and 379 (28.8%) were admitted to the Pediatric Department representing 5.2% of all children hospitalisations. Admitted children had median age 13.25 months. All the children had abdominal pain at admittion. Other common symptoms were: fever (90.2%), nausea and vomiting (87.8%) and sings of dehydration (5.8 stool/day, sunken eyes, dry skin, lethargy, decreased urinary output) in 49.4%. Consistency of stools was liquid in 87.5% of cases, with a mean duration of 5–7 days (45%) and 35% presenting more than 7 stools/day. Rotavirus was positive in 114 (30%) cases (Rotastrip). More children had acid-base and metabolic abnormalities, hypoglycemia, urea and creatinine level. The treatments consisted in increased fluid intake (oral rehydration) or intravenous fluid (95%). IV rehydration was given 4.92 days (extremes 1–8 days).

Conclusions: Rotavirus plays an important role in severe viral gastroenteritis in children, causing a large number of hospitalization during winter.

P294

RANDOM? FLUCTUATION OF NON-G1 ROTAVIRUSES AFTER LAUNCH OF ROTAVIRUS VACCINES IN FINLAND

S. Räsänen, S. Lappalainen, A. Halkosalo, M. Salminen, and T. Vesikari, University of Tampere Medical School, Tampere, Finland.

Background: Universal mass vaccination since 2006 with human G1 rotavirus (RV) vaccine (Rotarix®, GSK) in Brazil has been associated with emergence of G2 RVs as predominant cause of RV gastroenteritis (GE) (Gurgel RQ, et al. Emerg Infect Dis 2007;13:1571–1573).

Methods: We conducted a prospective survey of RVGE in hospitalized children over 2 RV epidemic seasons from August 2006 to August 2008. RVs were G-typed by RT-PCR. In Finland Rotarix® was launched in May 2006, and its coverage increased up to 25 % of the birth cohort by August 2008. In addition, RotaTeq® (SP-MSD), which was launched in the beginning of 2007, reached coverage of 4% by the same time.

Results: A total of 152 RV positive cases were found in the first RV epidemic season 2006–2007. G1 RVs accounted for 38%, G2 18%, G3 3%, G4 1% and G9 for 41% of the detections. In the second season 2007–2008, of 293 RV positive cases G1 accounted for 77%, G2 only 3%, G3 6%, G4 13% and G9 had virtually disappeared.

Conclusions: While non-G1 RVs were common: 63% in the first and 22% in the second RV season, there was no regularity in the pattern of emergence. G2 RV did not increase to predominance at the coverage level of 25% for Rotarix® and 29 % for all RV vaccination in the birth cohort of Finland.

P295

A PROSPECTIVE HOSPITAL-BASED SURVEILLANCE TO ESTIMATE DISEASE BURDEN CAUSED BY ROTAVIRUS INFECTIONS AND ITS COMPLICATIONS IN SWEDISH CHILDREN 2007/2008

M. Rinder,* A.N. Tran,† R. Bennet,‡ T. Cassel,§ M. Eriksson,‡ D. Frithiof,¶ L. Gothefors,¶ E. Sjölin,† J. Storsaeter,∥ B. Trollfors,** S. Valdimarsson,** M. Wennerström,** and K. Johansen,† *Sachs′ Children′s Hospital, Stockholm South General Hospital; †Swedish Institute for Infectious Disease Control, Karolinska Institute, Stockholm; ‡Astrid Lindgren Children′s Hospital, Karolinska University Hospital, Stockholm; §Sanofi Pasteur MSD, Stockholm; ¶Department of Clinical Sciences Paediatrics, Umeå University Hospital, Umeå; ∥GlaxoSmithKline, Stockholm; and **Queen Silvia Children′s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.

Background: The aim of this study was to determine burden of severe rotavirus gastroenteritis (RV GE) leading to hospitalization and describe evolving complications in three geographical regions during a 12-month period. Isolated rotavirus strains were genotyped and signs of systemic disease were evaluated.

Methods: The study population was hospitalized children with RV GE. Symptoms and complications were described in a questionnaire. Rotavirus excretion was verified by a rapid-test (Vikia, BioMerieux) or ELISA (Oxoid) and further confirmed by PCR and genotyping. S-ASAT/S-ALAT were analysed with standard methodology and viremia was quantified by real-time PCR.

Results: In total 592 children were included. The peak of the rotavirus season 2007/2008 was seen in February-April in all regions. The incidence for hospitalization ranged in different regions from 300 to 500/100,000 children < 5 years. The median age of hospitalized children was 15 months. Less than 1% of the children were below two months of age, the recommended age for initiation of vaccination. Complications, such as hypertonic dehydration and seizures were observed in < 5% of all children. Signs of systemic disease, measured as S-ASAT/S-ALAT, were noted in 77% and 29% respectively of RV+ children compared to 29% and 10% in RV- children. Genotyping of rotavirus strains revealed that 78% were G1P[8], 3% G2P[4], 4% G3P[8], 6% G4P[8], 8% G9P[8], and < 1% a mix of genotypes.

Conclusion: The incidence of rotavirus infections leading to hospitalization is high in Sweden and the virus causes a large burden on hospital resources.

P296

TRENDS IN INCIDENCE AND GENOTYPES OF ROTAVIRUS (RV) ACUTE GASTROENTERIRIS (AGE) IN COIMBRA, CENTRAL REGION OF PORTUGAL

F. Rodrigues,* M. Iturriza,† G. Gonçalves,‡ M. Costa Alves,* J. Gray, and † L. Januário,* *Hospital Pediátrico de Coimbra, Coimbra, Portugal; †Vírus Reference Department, Health Protection Agency, London, UK; and ‡ICBAS, Universidade do Porto, Porto, Portugal.

Background and Aims: Since 2006 we have conducted surveillance for RV in children seen at our Emergency Service (ES). RV vaccine was introduced in Portugal in 2006 but it is not included in the Immunisation Program. Coverage in 2007 was estimated to be |P515% and in 2008 |P525%.

Methods: During the epidemic season (January to June), between 2006 to 2008, children < 3 years of age, attending the ES with the diagnosis of AGE had their stools tested for RV and positive samples were genotyped.

Results: A total of 1290 children were included and RV was positive in 36,7%: 261 (45%) in 2006, 170 (36%) in 2007 and 60 (22%) in 2008.

Overall G9P[8] went from being the most frequent type in 2006 (90%), to a significant decrease in 2007 (32.6%) and undetected in 2008, accompanied by a significant increase in the proportion of G3P[8] that was the predominant genotype in 2008 (from 3.8 to 40%). The proportion of G1P[8] increased in 2007 (from 4.3 to 18%) and remained at similar levels in 2008. G2P[4], undetected in 2006, was found in a significant proportion in 2007 (21.3%) and 2008 (31%).

Conclusion: RV is a major cause of AGE, although its incidence significantly decreased in 2008. Different RVs co-circulate in the same geographic region and seasonal variation in the strain distribution is found. Overall, G1-G3 and G9 were associated with the majority of infections, but interestingly, G1P[8] has never been the most common strain, in contrast to many other European countries.

P297

CONSERVATIVE MANAGEMENT OF ISOLATED SPLENIC ABSCESS IN CHILDREN

S. Roy Choudhury, R. Chadha, P. R Debnath, A. S Kushwaha, P. Jain, and A. Puri, Pediatric Surgery, Lady Hardinge Medical College & Kalawati Saran Children's Hospital, New Delhi, India.

Background and Aims: Isolated splenic abscesses (SA) are rare in children. The management modality for SA varies from antibiotic therapy only to percutaneous drainage to splenectomy. We report a single centre experience of SA in children with emphasis on its diagnosis, etiology, treatment and outcome.

Methods: Eighteen pediatric patients with SA were managed over a period of 8 years in a tertiary care institution. Their age ranged from 3–16 years, average 9 years, and male to female15:3.

Results: The presenting symptoms included fever, abdominal pain, and anorexia in all patients. Splenomegaly was present in 12(67%), leucocytosis in 9(50%), and thrombocytosis in 12(67%) patients. Associated diseases were thalassemia -1, tuberculosis -1, and typhoid fever in 9 patients. Imaging diagnosis was done with ultrasonography and computerised tomography. Solitary and multiple SA was seen in equal numbers. Blood culture was positive for Salmonella paratyphi A in 1 case. Splenic aspirate culture was positive in 3 cases (Escherichia coli-1, Salmonella paratyphi A-1, Acinatobactor-1). Widal's serology was positive in 9(50%), however HIV test was negative in all cases. Management included intravenous broad spectrum antibiotics (ceftrioxone, amikacin, metronidazol) in all and percutaneous aspiration in 10(56%) cases where abscess size was >3 cm. Average duration of antibiotic therapy was 3 weeks. All patients responded to conservative treatment and none was subjected to splenectomy. Complete resolution was observed during follow-up ranging from 3–6 months.

Conclusion: Isolated SA in children responds favourably to conservative treatment with intravenous broad spectrum antibiotics and percutaneous drainage which obviates the need for splenectomy.

P298

ASSOCIATION BETWEEN ANTRAL NODULARITY, GASTRITIS, POSITIVE CYTOTOXIN ASSOCIATED PROTEIN SEROLOGY, AGE, GENDER, ABO BLOOD GROUP AND HELICOBACTER PYLORI IN CHILDREN

T. Sabbi, and M. Palumbo, Pediatric Unit, Belcolle Hospital, Viterbo, Italy.

Abstract: Helicobacter pylori (Hp) causes one of the most widespread infections worldwide.It is known that blood group antigens are related to the development of peptic ulcer and gastric carcinoma.

To investigate the association between virulence factors of Hp, severe gastritis, age, gender and ABO blood group.

25 patients (15 Male; age range 3–18 years) underwent to esophagogastroduodenoscopy with antral biopsy for a suspicious upper gastrointestinal disease. In all of them serum sample were assayed for IgG antibodies to CagA and ABO blood groups were determined by standard techniques.

19 children (76%) were Hp positive by histopathology and urease rapid test. 15 of these 19 (79%) Hp positive patients were positive for CagA serology, too. At endoscopic examination of the 19 infected children, hyperemia and friability of the gastric antrum was observed in 7 (37%) patients and antral nodularity appearance in 12 (63%) children. The histologic examination of all infected patients showed an active microerosive gastritis and chronic gastritis. The children CagA positive presented an endoscopic finding of more intense hyperemia of gastric antrum, associated to an important lymphoplasmacellular infiltrate and vacuolar lesions of gastric epithelium. In non infected children there weren't histologic signs of gastric inflammation. As expected from previous studies, we found that seropositivity for Hp increased with age and the rate of Hp infection was not significantly different in boys and girls. Similarly, Hp serological status was not significantly different between subjects of different ABO blood groups.

We found no association between Hp infection and ABO blood groups.

P299

ROTAVIRUS IN HOSPITALIZED SPANISH CHILDREN

A. Sánchez-Fauquier,*† V. Montero,*† I. Wilhelmi,† J. Colomina, and † R. Glass,† *Viral Gastroentritis Unit, Centro Nacional de Microbiología, ISCIII., Majadahonda, Madrid; and †Vigess-Net, Madrid, Spain.

Background: In Spain, diarrhoea remains as an important cause of morbidity among children. A surveillance study of children less than 5 years old with acute gastroenteritis was initiated in different regions of Spain by Vigess-net, which is the first national rotavirus study collaboration. It includes 15 collaborating hospitals covering a population of 1.500.000 children under 5 years old. The aim of this study was to conduct a structured surveillance to determine the prevalence of rotavirus in children hospitalized for acute gastroenteritis, as well as to determine the G and P types among infecting rotavirus strains.

Methods: From April 2006 to April 2008, the specimens were collected and sent to the Viral Gastroenteritis Unit at the ISCIII as the reference laboratory. A total of 2208 stool specimens of hospitalized children were tested by Elisa and different PCR and nested PCR protocols used for nucleic acid detection of RV, NoV, adenovirus and HAstV.

Results: Rotavirus was the most frequent (40,6%) etiologic agent followed by norovirus (33.1%) human adenovirus (2.4%), and astrovirus (3.7%). Enteropathogenic bacteria were detected in 0.8% of samples.

The most predominant Rotavirus genotypes were G1 P [8] (56.7%), followed by G9 P[8] (37.2%) and co-circulating with G12, G2, G6, G3, and G4.

Conclusions: Rotavirus was associated with the majority of hospitalizations for acute gastroenteritis in children under 5 years of age.

G1P[8] and G9P[8] were the predominant types co-circulating in Spain. In addition, multiple rotavirus infection was detected in over 12% of the episodes during this period.

P300

CLINICAL PICTURE OF YERSINIOSIS IN CHILDREN

E. Talarek,*† A. Banaszkiewicz,‡ A. Radzikowski,‡ and M. Banasiuk,‡ *Department of Children's Infectious Diseases, Medical University of Warsaw; †Hospital of Infectious Diseases; and ‡Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warszawa, Poland.

Background: In the first half of 2008 in Poland there was an increase in incidence of yersiniosis.

Aim: The aim of the report was to present clinical picture of yersiniosis in hospitalized children.

Material & Methods: From March to June 2008 36 children (19 boys, 17 girls, age 13 months-17 years) were hospitalized with diagnosis of yersiniosis, confirmed by positive stool culture and/or positive result of serological testing (ELISA).

Results: Fever occured in 80,6% of patients. In 7 cases fever was the only symptom. Symptoms from digestive tract occured in 27/36 (80,6%): diarrhoea (10/36), abdominal pains (12/36), diarrhoea with abdominal pains (7/36). Pharyngitis and rash were relatively common features (each in 16,7%). Increased CRP level and leukocytosis were found in 66,6% and 44,4%, respectively. Bacteriemia was not confirmed in any case. Abdominal sonography revealed abnormalities in 24/26 cases: enlargment of mesenteric lymph nodes and/or thickening of terminal ileum wall. Among patients with those features 11 did not complain of abdominal pain. 26/36 patients required antibioticotherapy. All children recovered completely. In 3 cases serological testing suggested infection with Yersinia enterocolitica O:8, uncommon in Europe.

Conclusion: Clinical picture of yersiniosis is not specific. Yersinia infection should be taken into consideration in differential diagnosis in children hospitalized because of abdominal pains, diarrhoea or fever of unknown origin.

P301

THE BURDEN OF ROTAVIRUS GASTROENTERITIS IN CHILDREN PRESENTING TO THE TERTIARY-CARE HOSPITALS IN ESTONIA

E. Tamm,* D. Mägi,† K. Pruudel,† L. Vainomäe,† L. Moosar,† K. Kirss,† K. Zilmer,† S. Torm,* A. Pütsepp,* M. Närska,* H. Nurm,‡ K. Pruunsild,‡ A. Jänes,§ and I. Lutsar,§ *Tartu University Clinics, Childrens Clinic, Tartu; †West Tallinn Central Hospital; and ‡Tallinn Childrens Hospital, Tallinn; § and Tartu University, Department of Microbiology, Tartu, Estonia.

Background and Aims: In most European countries rotaviruses are the major cause of hospitalization for acute gastroenteritis (GE). We aimed to collect detailed data on the burden, management and outcomes of RVGE in hospitalised children aged < 5 years.

Methods: From 01.01.2007 until 30.11.2008 all children aged below 5 years admitted with the laboratory confirmed RVGE into three major paediatric hospitals of Estonia were prospectively enrolled. The severity and duration of clinical symptoms was evaluated using Clark score.

Results: A total of 671 children fulfilled the inclusion criteria and accounted for 5.5% of all admitted patients aged of < 15 years. The mean age was 20.5 ± 12.8 months. A total of 30% of patients were of < 1 year and 71% of < 2 years. Majority (429/565; 76%) of community acquired RVGE (CA-RVGE) were of moderate severity. Intravenous fluids were given to 93.4% of patients. Nosocomial RVGE accounted for 106 cases (15,8%) with the rate of 37/10,000 hospitalisation. In comparison to CA-RVGE there were lower number of severe cases based on the Clark scale (4.8% vs 16.3%; OR 0.2; 96% CI 0.1–0.6 with the score >16). The mean duration of hospitalisation was 3.2 ± 1.9 days for CA-RVGE. The nosocomial RVGE prolonged duration of hospitalisation by 4.2 ± 2.2 days. No deaths or severe disabilities were recorded.

Conclusions: RVGE is far the most common vaccine preventable disease presenting high burden to hospitalisation and acquisition of nosocomial infections. The data provide additional information of the assessment of rotavirus vaccination programme.

P302

DIAGNOSTIC VALUE OF STOOL ANTIGEN AND ANTIBODY TESTS FOR HELICOBACTER PYLORI INFECTION IN CHILDREN WITH UPPER GASTROINTESTINAL COMPLAINTS

Z. Tiryaki,* D. Yilmaz Çiftdoǧan,† and E. Kasirga,‡ *Department of Pediatrics, Celal Bayar University, Faculty of Medicine, Manisa; †Department of Pediatric Infectious Diseases, Ege University, Faculty of Medicine, Izmir; and ‡Department of Pediatric Gastroenterology, Celal Bayar University, Faculty of Medicine, Manisa, Turkey.

Objective: Several noninvasive methods, such as H. pylori stool antigen (HpSA), H. pylori antibody test (HpIgG), have been used to diagnosis of H. pylori infection in children. The aim of this study; to evaluate the diagnostic value of HpSA and serologic tests before and after eradication therapy for H. pylori in children with upper gastrointestinal complaints (UGC) in our region.

Methods: In this study, 87 children with UGC and 95 children without gastrointestinal complaints were enrolled. H. pylori infection was detected by Urea breath test. HpSA and HpIgG tests were applied to all the children. Eradication treatment were given to the 34 H. pylori positive children. These children were re-evaluated after treatment with UBT, HpSA and HpIgG tests.

Results: The UBT was positive for 43 of 87 children (49.4%) with UGC. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), false positivity (FP), false negativity (FN) values of the HpSA in children with UGC were 86%, 84.1%, 86%, 15.9% and 14%, respectively, and those for the HpIgG were 76.7%, 90.9%, 89%, 80%, 9.1% and 23.3% respectively. After eradication therapy the overall HpSA test sensitivity, specificity, PPV, NPV, FP and FN values were detected 88.9%, 84%, 66%, 95%, 16% and 11.1%, respectively, and those for the HpIgG were 77.8%, 36%, 30%, 81%, 64% and 22.2%, respectively.

Conclusion: HpSA test is highly sensitive and specific for the diagnosis of H. pylori and confirming eradication in children with upper gastrointestinal complaints living in Western Anatolia, Manisa region.

P303

MOLECULAR EPIDEMIOLOGY OF NOROVIRUS INFECTION AMONG CHILDREN WITH ACUTE GASTROENTEROLOGY IN SHANGHAI, CHINA (2001–2005)

J. Xu, Y. Yang, and J. Sun, Pediatric Institute, Children's Hospital, Fudan University, Shanghai, China.

Background and Aims: Norovirus is one of the major pathogens leading to sporadic acute gastroenteritis in young children worldwide. Obtaining the local baseline information regarding this virus is important for development and evaluation of vaccination program. The current study was undertaken to understand the age and seasonal distribution and circulating genotypes during a long period.

Methods: Stool specimens were collected from children hospitalized with acute gastroenteritis under 5 years between 2001 and 2005 in Shanghai, China. A total of 484 samples were chosen for molecular epidemiology study of norovirus. Testing for norovirus was carried out using the Mon 431−434 degenerate primers directed at the 3’ end of ORF1. The nucleotide sequence of each PCR product was determined on ABI 3730 sequencer. A multiple sequence alignment of nucleotide sequence of 170 nt was constructed using Clustal W and Phylogenetic trees were constructed using Mega 4.1 software.

Results: Of all 484 detected samples, 45 samples (9.3%) were identified to be norovirus. Over 75% of children with norovirus diarrhea were less than 2 years of age. The monthly distribution of norovirus infection illustrated a seasonal peak from August to November. Among the 37 identified norovirus strains, 2 were GII-3 and 2 belonged to GII-7 and all the other 33 strains were GII-4 genoclusters.

Conclusions: This study demonstrated the importance and epidemiological features of norovirus in children hospitalized with acute gastroenteritis in Shanghai. Our findings about the prevalence and distribution of strains will be helpful for prevention of norovirus diseases in children.

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IMMUNITY AND INFECTIONS

P304

EVALUATION OF INTERLEUKIN-6 FOR EARLY DIAGNOSIS OF NEONATALSEPSIS IN COMPARISON WITH CRP

K.M. Adib,* F. Navaeie,† Z. Bakhshiani,* F. Sahebfosoul,* and V. Ostadi,* *Immunology; and †Pediatrics, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran.

Background: Early diagnosis of neonatal sepsis is essential for successful treatment. Blood culture is a gold standard for diagnosis but the final results are not available until 48–72 hours after culture.

Interleukin-6 (IL-6) as a marker plays a critical role in the induction of C-reactive protein (CRP) synthesis in the liver. It has been hypothesized that this cytokine could be detected in blood earlier than CRP during the course of neonatal sepsis.

Methods: Blood samples were collected upon admission from 50 neonates with suspected sepsis, and 10 healthy neonates. The patients were assigned to two groups according to bacteriological and laboratory results. Group I consisted of 19 newborns with positive blood cultures and clinical signs of sepsis. Group II included 31 neonates with negative blood cultures, but with two or three clinical signs of sepsis. The control group (group III) included 10 healthy neonates with no clinical or biological data of infection. Serum CRP was determined by nephelometry and IL-6 by ELISA method.

Results: Mean CRP level in the group with proven sepsis was 22.18 mg/l which was higher than in other groups (P = 0.005). The sensitivity and specificity of CRP was 57% and 100% respectively. Mean level of IL-6 was 117.49 pg/ml in group one, which was higher than in other groups (P = 0.001), exhibiting a sensitivity of 78% and a specificity of 95%.

Conclusions: Based on our results, measurement of IL-6 is more useful than CRP for early diagnosis of neonatal sepsis; especially within the 24 hours before the onset of sepsis.

P305

INCONTINENTIA PIGMENTI AND CLINICAL MANIFESTATIONS OF IMMUNODEFICIENCY-CASE REPORT

A. Bandeira,* J. Sousa,† A. Costa,‡ M.J. Oliveira,‡ P. Fernandes,‡ G. Franchini,§ and M. Guedes,¶ *Pediatrics, Hospital Santo Antonio; †Centro Genética Médica, Genetics; ‡Pediatrics, Intensive Care; §Imunology; and ¶Pediatrics, Porto, Portugal.

Introduction: Incontinentia pigmenti (IP) is an ectodermal dysplasia that affects the skin, hair, teeth and nails. It is an uncommon X-linked dominant disorder, mapped to Xq28, lethal in uterus in the majority of affected males and variably expressed in females. These differences in expressivity have been attributed to lyonization in females, resulting in functional mosaicism. In girls, abnormalities of the immune system have been reported.

Case Report: The authors report a case of a female patient with the diagnosis of IP.

She was born from healthy non-consanguineous parents, who presented the classical dermatological stages of IP. The skin biopsy confirmed the diagnosis at 3 weeks of age. She was admitted to our Intensive Care Unit hospital because of bilateral pneumonia requiring of mechanical ventilation. It was isolated Pseudomonas aeruginosa from pleural effusion and posteriorly Staphylococcus aureus. The laboratory studies revealed leucocytosis, eosinophilia, lymphopenia with markedly diminished NK cells. She was treated with parenteral antibiotics without clinical improvement. She died after 22 days of internment. DNA extraction was made for molecular diagnosis.

Discussion: Our case describes a female child with IP and clinical manifestations of immunodeficiency. Genetic studies have demonstrated that mutations in the NEMO/IKKg gene result in the IP phenotype. Mutations in NEMO gene in this clinical case were not found. We are waiting for study of gene IKBA (NFKBI) for genetic advisement and prenatal diagnosis.

P306

KAWASAKI DISEASE: ATYPICAL PRESENTATION IN INFANCY

A. Boto, C. Cristovão, A. Macedo, and A. Serrão Neto, Hospital Cuf Descobertas, Lisbon, Portugal.

Abstract: Kawasaki syndrome is a rare childhood disease of unknown aetiology, mostly described between ages two and five. Diagnosis is made based on major and minor clinical criteria in a child with fever and irritability. Prognosis depends on early administration of gamma globulin which may prevent coronary disease.

We describe the clinical case of a 4 months old baby with high fever and irritability for one day. On analysis, high leukocyte count with neutrophilia, high CPR and normal CSF were evident. He was hospitalised with the diagnosis of occult bacteraemia and ceftriaxone was instituted. On D3 of hospitalisation he was observed by the cardiologist because of persistent tachycardia. No abnormalities were detected. On D4, a diffuse erythematous macular rash appeared which persisted until D7, as well as fever and irritability. The appearance of hands and feet oedema on D7 led to re-evaluation by the cardiologist. No other Kawasaki's clinical criteria were present. This time he had mitral insufficiency, pericardial effusion and coronary artery irregularities. He received gamma globulin with a rapid disappearance of symptoms. Cardiac follow up showed an amelioration of the cardiac lesions.

Acute febrile syndrome in a small infant is usually infectious and is treated accordingly. Whenever the evolution is atypical, the diagnosis should be reviewed and if inflammatory signs persist despite antibiotic administration, Kawasaki disease should be thought.

This case points out the need of a high clinical suspicion index that led to a cardiologic re-evaluation even with a previous normal examination.

P307

THE LEVEL OF POSTVACCINATION IMMUNITY TO SAME INFECTIONS IN MOLDOVA, 1991–2008

V. Bucov, G. Hodireva, A. Melnic, and N. Caterinciuc, Ministry of Health, The National Research and Practical Center of Preventive Medicine, Chisinau, Moldova.

Background: The aim of this study was to estimate the population′s immunity in Republic of Moldova against some vaccine-preventable diseases (tetanus, diphtheria, measles, rubella and mumps) and to compare the results of serological testing with the level of reported vaccination coverage in various periods and in conditions of different vaccination programs in 1991−2008.

Methods: The levels of tetanus (N 19 630), diphtheria (N 19 610), measles (N 12 804), rubella (N 1 025) and mumps (N 924) antibodies were investigated in groups aged 2–60 years from rural and urban territories with ELISA and RPGA.

Results: The level of immunity to diphtheria with titers ≥ 0,03 IU/ml was in limits of 89,3–98,7%, ≥ 0,12 IU/ml–74, 9−90,3%, tetanus antitoxin (n = 17.265) ≥ 0,1 IU/ml was in limits of 94,8–98,9%, ≥ 0,8 IU/ml–68,6–94,5%, the immunity to measles 86,4–92,0%, to rubella and mumps in last three years–96,9% and 69,3%, respective. The less level of immunity was in preschool children and adults. The difference between the coverage and serological data is more accentuated for measles and mumps until the introduction of the 2nd dose of MMR.

Conclusions: In the condition of immunization program it is necessary to conduct the serological monitoring of population′s immunity to vaccine-preventable diseases. At the other hand, these data may serve the base of individual immunization schedule, because the majority of persons at the time of ordinary revaccination have a high level of antibodies and not need the booster dose, for example, the DT containing vaccine.

P308

EARLY ONSET AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME (ALPS) IN INFANCY-A DIFFERENTIAL DIAGNOSIS TO HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH)

I. Delgado,* B. Sanchez,† C. Speckmann,‡ I. Obando,* and O. Neth,* *Pediatric Infectious Diseases and Immunology; †Immunology, Hospital Universitario Virgen del Rocio, Sevilla, Spain; and ‡Center of Pediatrics, University of Freiburg, Freiburg im Breisgau, Germany.

Abstract: ALPS is characterized by non-malignant lymphadenopathy, splenomegaly, autoimmune disorders, hypergammaglobulinaemia and lymphocytosis with increased levels of double negative (CD4-/CD8-) T cells (>1% of total lymphocytes). Often a mutation in genes involved in CD95 (FAS) mediated apoptosis is found. In various patients a mutation cannot be identified suggesting alternative pathways of disease pathology.

We present an 8-month old girl, born to non-consanguineous parents with no previous family history of haematological disorder, who presented with a 2-week history of temperature, mild lymphadenopathy, a rash and 4 cm splenomegaly. Full blood count showed pancytopenia with relative lymphocytosis; Hb 7.2 g/l, WCC 5.4 × 109/l (lymphocytes 4.4, neutrophils 0.4), platelets 52 × 109/l; normal coagulation profile. Lymphocyte subsets and stimulation were normal; IgG levels high (27 g/l). LDH and triglycerides were raised (2140 IU/l and 306 mg/dl). CRP 90 mg/l. An infectious cause was not found (including EBV, CMV, adenovirus, parvovirus and HIV). Imaging confirmed splenomegaly only. She was thought to suffer from HLH; however a BMA showed no signs of haemophagocytosis, expression for perforin was normal and genetic analysis for possible perforin or MUNC deficiency (seen in familiar HLH) as well as SH1D2 deficiency (X-linked lymphoproliferative disease) were normal. Expression of CD95 on T cells was normal, however circulating double negative T-cells were raised on two occasions (12% and 1.2%). Results regarding mutations in CD95/CD95L are pending.

In summary we present an infant who fulfils some criteria for ALPS, illustrating the difficulty to diagnose this heterogenous genetic syndrome. She has not suffered from infections nor required any immune modulatory treatment.

P309

ANTIBODY RESPONSE PATTERNS TO BORDETELLA PERTUSSIS ANTIGENS IN VACCINATED (PRIMED) AND UNVACCINATED (UNPRIMED) YOUNG CHILDREN WITH PERTUSSIS

U. Heininger,* and J.D. Cherry,†‡ *Div. of Pediatric Infectious Diseases, University Children's Hospital, Basel, Switzerland; †PID, David Geffen School of Medicine; and ‡PID, Mattel Children's Hospital UCLA, Los Angeles, CA, USA.

Background: It is generally thought that antibody response occurs earlier in primed compared with unprimed persons. However this has not been quantitated in regard to pertussis.

Methods: ELISA (EU/ml) antibody values to B. pertussis antigens PT, FHA, PRN and FIM-2 were analyzed by time of sera collection after onset of illness in 183 children with pertussis who were vaccine (DTaP with PT, FHA, PRN, FIM-2) failures or were previously unvaccinated.

Results: For sera collected 0–15 days after illness onset, the GMTs for all 4 antigens were significantly lower in the unvaccinated group as compared to DTaP recipients. In the unvaccinated group GMT of PT antibody rose rapidly over time and was similar to that of DTaP recipients at the 16−30 day period and at 50 days was higher than the GMT of the DTaP group. FHA antibody rise was less marked than that of PT in the unvaccinated subjects and its peak was lower than that in DTaP recipients. PRN antibody rise in the unvaccinated was less marked than that in DTaP group and peak titer was > 10 fold less. The response to FIM-2 was delayed and minimal in unvaccinated children.

Conclusions: This study does not support the idea that antibody response in primed subjects is quicker than in unprimed. However, the response is more marked in primed subjects and peak titers are lower than in primed subjects. Interestingly the response to PT in the unprimed has a sharp response and final GMT is higher than that in primed children.

P310

OXIDATIVE STRESS MODULATES THE INFLAMMATORY SIGNALING PROGRAM INDUCED BY GROUP B STREPTOCOCCI (GBS) IN PHAGOCYTES

P. Henneke, University Medical Centre Freiburg, Freiburg, Germany.

Background and Aims: In invasive group B streptococcal infections, a potent antimicrobial macrophage response and a limited inflammatory response need to be controlled on the signal cell level in order to prevent potentially deleterious hyperinflammation and multi-organ failure. During uptake and endosomal processing of bacteria, the host-pathogen interface rapidly changes through reciprocal modulation of the two cell types. Mechanisms interrelating these processes with the regulation of inflammatory signaling are poorly understood. Here we examined the role of oxidative stress on the endosomal process, the modification of pathogen-associated molecular patterns and associated signal regulation.

Methods: Primary and immortalized mouse macrophages of various genetic backgrounds (e.g. MyD88 ko, iNOS ko, gp91 ko) were analyzed by complementary methods such as confocal microscopy, luminometry, ELISA.

Results: We found that the nitric oxide (NO) response to GBS depended on both bacterial uptake and Toll-like receptor signaling. Subsequently, NO was crucial for proper lysosomal acidification and the degradation of bacterial DNA, a putative microbial pattern recognized by cytoplasmic DNA sensors. Furthermore, NO was essential for the formation of inflammatory cytokines in response to group B streptococcus. In contrast, the NADPH-oxidase-dependent reactive oxygen species downregulated the transcription of inflammatory genes, however did not influence endosomal maturation.

Conclusions: NO and reactive oxygen species control the inflammatory signaling program in phagocytes processing GBS in a distinct fashion.

P311

DEVELOPMENT OF A BIVALENT FACTOR H BINDING PROTEIN VACCINE TO BROADLY PROTECT AGAINST INVASIVE NEISSERIA MENINGITIDES SEROGROUP B (MNB) DISEASE

K. Jansen,* A.S. Anderson,* T. Jones,* A. Arora,† G.W. Zlotnick,* S.K. Hoiseth,* E. Murphy,* L.K. McNeil,* S.L. Harris,* H. Jiang,* and D. Zhu,* *Early Phase Programs; and †Clinical Research, Wyeth Vaccines Research, Pearl River, NY, USA.

Background and Aims: Invasive meningococcal serogroup B disease (IMDB) though rare is devastating. There is no licensed broadly protective vaccine available. We are conducting clinical trials with a vaccine (rLP2086) composed of two MnB human factor H binding proteins (fHBP). fHBP is a recognized virulence factor associated with immune evasion. Extensive prevalence and sequence analyses of fHBP were conducted on MnB clinical isolates to determine the potential breadth of vaccine coverage.

Methods: fHBP sequence and surface expression levels were determined for IMDB isolates (n = 1,830) from surveillance sites in the US and five European countries. Serum bactericidal antibody (SBA) assays for >100 IMDB isolates were developed and used to assess human immune sera from clinical trials of the fHBP vaccine.

Results: All isolates had fhbp and 197 unique sequence variants segregated into 2 distinct subfamilies (A and B) in all countries surveyed. Human immune sera generated by the rLP2086 vaccine were able to kill a high proportion of IMDB isolates in SBA. Bacterial surface expression of fHBP predicted strain susceptibility to immune sera while fHBP variant sequence, PorA and MLST type did not.

Conclusions: A vaccine that includes fHBP from each subfamily (A and B) elicits antibodies that are broadly bactericidal against epidemiologically diverse IMDB isolates. fHBP can be detected by flow cytometry on >98% of IMDB isolates, and therefore broad protection from the rLP2086 vaccine can be expected.

P312

PNEUMOCOCCAL PERICARDITIS WITH HEMOLYTIC UREMIC SYNDROME: DO WE HAVE TO CONSIDER IMMUNODEFICIENCY?

S. Kenzel,*† H. Fehrenbach,‡ R. Grychtol,* M. Pohl,* and P. Henneke,*† *Centre of Paediatric and Adolescent Medicine; †Centre of Chronic Immunodeficiency (CCI), University Hospital Freiburg, Freiburg im Breisgau; and ‡Children's Hopsital Memmingen, Memmingen, Germany.

Abstract: Streptococcus pneumoniae is the major bacterial cause of otitis media, pneumonia and septicemia in children.

Here, we report on the case of a 20 months old girl, who was transferred to our hospital with hemolytic uremic syndrome (HUS). S. pneumoniae, serotype 14, was isolated from blood culture. Extensive workup revealed purulent pericarditis as the only infectious focus. The past medical history was unremarkable. The vaccination status was complete with the exception of pneumococcal vaccine. Despite adequate intravenous antibiotic therapy with vancomycine and cefotaxime, intermittent hemodialysis and pericardial drainage were required. The pneumolysin PCR of pericardial fluid was positive. The further course was uneventful and the outcome was favorable.

This case demonstrates that invasive pneumococcal disease (IPD) can manifest in virtually any organ system. In HUS, IPD has to be suspected even in the absence of respiratory tract infections. Recent discoveries revealed that monogenetic alterations in Toll-like receptor signaling (e.g. mutations in MyD88, IRAK-4, NEMO) are associated with some cases of invasive pneumococcal infections. However, the population based contribution to IPD is currently unknown. A targeted immunological workup is proposed in unusual or recurrent pneumococcal infections.

P313

THE CONDITION OF THE IMMUNE STATE IN CHILDREN WITH A RECURRENT RESPIRATORY SYNDROME

E. Kondurina and M. Shevchenko, Novosibirsk State Medical University, Novosibirsk, Russia.

The Aim of Investigation is to study the condition of the immune state and the state of flora in nasopharynx in children under 7 going to kindergarten with a recurrent respiratory syndrome.

Methods: 33 children aged 3 to 7 with an acute viral respiratory infection which occurred more than 4 times during a year have been under observation. The immune state have been investigated by the method of flow cytometry. All children were taken a swab from nasopharynx.

Results: The state of the pathogenic microflora in nasopharynx: hemophilic bacillus–28,6%, pneumococcus–54,3%, adenovirus–5,7%.

The lymphocytosis towards the survival rates being accompanied by the B-lymphocytes reduction in 58% was marked in most children (63,4%) after examination. Immunoregulatory index–was normal in 45,5% of cases. The prevalence of CD8+ T-suppressor activity was marked in 30% of cases, CD4+ T-helper orientation of the immune response was seen in 24,2% of cases. The granulocytic phagocytosis rates were normal in 70% of children, and were heightened in 30%, on the contrary the monocytic phagocytosis was reduced practically in all examined children (96,9%). Low rate of genes expression on the surface of immunocompetent cells CD HLA DR was revealed in 54,2% of cases.

Conclusion: Low phagocytic activity of monocytes and the imbalance of cell and humoral component of immune system reveals the tensity of immunoregulatory processes and, more over, produces the inadequacy of anti-infectious defence, that can lead to the frequent respiratory infection reccurences.

P314

ACUTE POLIRADICULONEURITIS OF INFECTIOUS ETIOLOGY IN CHILDREN

M. Luminos, G. Jugulete, M. Vasile, A. Draganescu, R. Mantescu, A. Visan, and R. Matei, Pediatric, Institute of Infectious Diseases Matei Bals, Bucharest, Romania.

Background and Aims: Acute inflammatory demyelinating poliradiculoneuropathy (Guillain -Barre syndrome, GBS), is a disease of peripheral nervous system, that affects the nerves roots and Shafts (demyelinating lesions), with ascending evolution. It is considered to be an immune response to a variety of triggers, most frequently a viral infection, hence the specific treatment, (IV immunoglobulin, plasmapheresis), that tries to block the immune response.

Material and Methods: We present 3 cases of children admitted in the ICU, diagnosed with GBS of infection etiology (influenza, chiken pox and borrelia). The diagnosis was based on clinical, serological and electomyographic criteria. All patients receved IV immunoglobulin.

Results: The treatment was initiated between 1 and 2 week from the neurological onset of the disease. The outcome was favorable, 2 patients have no neurological symptoms and third patint was significantly improved (after 2 weeks of evolution).

Conclusions: The patients diagnosed with GBS of viral etiology had a favorable outcome. Elecromyography performed early in the course of the disease, confirmed the diagnosis. The administration of IV immunoglobulin (in adequate dose), was efficient, with rapid recovery and no significant side effects.

P315

RESPIRATORY INFECTIONS INVOLVING CHILDREN WITH PRIMARY IMMUNODEFICIENCY DISEASES

M.A. Marc,* A. Grama,* and A. Butnar,† *Paediatrics 2; and †Paedriatics 3, University of Medicine and Pharmacy, Cluj-Napoca, Romania.

Introduction: Children with primary immunodeficiency diseases (PID) have a particular evolution of infections depending on the PID type and the nature of the infectious aggression.

Objectives: This study proposes an evaluation of pulmonary disease for children with PID.

Methods: A retrospective study has been done involving all the 96 cases with PID (1998–2008). The study groups have been chosen depending on the PID type.

Results: The PID types were: selective IgA deficit (66 cases), variable PID (15), hypogammaglobulinemia with hyper-IgM (2), mixed PID (3), cellular PID (2), neutrophyle anomalies (4). In 86% of cases, the PID diagnostic was determined in the first 3 years of life, time in which children suffered at least 3 episodes of respiratory tract infections. In the first 5 years of evolution, upper respiratory tract infections were dominating (69%). After 5 years of evolution, 3% of children suffered from chronic respiratory insufficiency determined by pulmonary fibrosys, from which 2 patients have died (ataxia teleangiectasia). The 3 cases suffering from mixed PID, died during their first year from multiple organ infections (sepsis). The etiology was determined in 22% of cases (dominated by Gram negative bacteria and associated with CMV and EBV).

Conclusions: In 86% of cases, the recurrent respiratory infection episodes were helpfull in establishing the PID diagnostic in the first 3 years of life. At all cases that were followed on a long term basics, the PID put their mark onto the unfavourable evolution of the respiratory suffering.

P316

DIAGNOSTIC VALUE OF WHOLE BLOODIFNIMMUNOLOGICAL ASSAY (QUANTIFERON) FOR TB INFECTION IN HOUSE HOLD CONTACTS IN BCG VACCINATED POPULATION

S. Noorbakhsh,* J. Mousavi,† M. Barati,‡ and T. Azardokht,§ *Ped Infectious Disease, Research Center of Pediatric Infectious Diseases, Iran University of Medical Sciences; †Pulmonary Disease; Internal Medicine; Rasul Hospital, Research Center of Pediatric Infectious Diseases; ‡Infectious Diseases, Research Center of Pediatric Infectious Diseases, Iran University of Medical Sciences; and §Research Center of Pediatric Infectious Diseases, Tehran, Iran.

Objective: To detect the agreement between tuberculin skin test and whole-blood IFN- assay in household contact of active pulmonary TB in BCG vaccinated population with intermediate TB burden.

Methods & Materials: A cross-sectional analytic study done in 130 household contact of active pulmonary TB (bacteriologically proven) selected by Convenice sampling. QuantiFERON-TB assay and the TST results compared in all cases.

Results: Mean age 26.2 ± 18.7 years; positive QuantiFERON-TB results seen in 15.8% (19 /120) of cases. 15% (7/47) of young (<20 Years) and 16% (12/73) of adult ones (>20 years) had positive QuantiFERON-TB results without significant difference between two groups. (Fisher′s Exact Test = 1) the positive PPD results detected in 11.7% (14/119) of cases. TST had not significant difference between young and adult cases.

50% (7/14)of TST-positive cases had negative QuantiFERON-TB results. 61% (11/ 18) of cases with positive QuantiFERON-TB results had TST negative results. We found Significant difference between two test (fisher test; 95% CI, P = 0.01). The agreement between TST and QuantiFERON-TB assay in cases was poor (=0.352); PPV for TST = 0.32; NPP = 0.89; Positive Likelihood Ratio+ (LR+ = 3.2); Negative Likelihood Ratio (LR- = 8.5). TST was dependent to age but not for QuantiFERON-TB.

Conclusion: We recommend Quantiferon TB as a basis for the decision on whether to perform subsequent chest X-ray examinations or to start treatment for latent tuberculosis infection. The cost /benefit should be evaluated by Ministry of Health in our country.

P317

THE FEATURES OF NON-CLASSICAL, NON-CALCAEMIC IMMUNE DOWN REGULATIORY EFFECTS OF COMPLETE CLASSICAL RACHITIC OSTEODYSTROPHY IN A 2 YEAR MALE CHILD

E. Onyekwelu, Paediatrics, Royal Victoria Teaching Hospital, Banjul, The Gambia.

Background/Purpose: Severe childhood rickets is getting more indistinct due to a better comprehension of its aetiopathogenesis/ intervention. Where it exists, it follows dysfunctions of metabolic organs, genetic factors and famine. Unlike in adults its pathobiology in children is still elusive. A unified model is unlikely to espouse the perturbations in its causality.

Case/Intervention: A 2 year old male negroid presented with chronic cough, breathing difficulty for six months and progressive weight loss for three months. He had contact with a grandmother who had PTB. He was developmentally delayed. He was severely wasted with widely open AFs and macrocephalic. He had rachitic rosarys, Harrisons sulcation, widening of the epiphysis of the wrist bones, scoliosis, genu varum and features of respiratory difficulties. He was pot-bellied and globally hypotonic, radiographs of the upper limbs showed cupping, fraying and splaying of the radio/ulnar-carpal joints, with a left radial and right ulnar fractures. The serum ALP was high; the serum calcium/phosphates were low. The blood glucose was normal. His TST was negative. The Chest X-rays features were consistent with a central pneumonia with probable paediatric tuberculosis. He was managed effectively with oral vitamin D, calcium, antibiotics, anti TB drugs, nutritional support and orthopaedic referral.

Conclusion/Importance: The classical calcaemic effect and the non-classical humoural/ Immunomodulatory functions of vitamin D were highlighted. The associated malnutrition with its related T-cell/B-cell immunodysfunctions could have propagated/sustained the vicious cycle in this case.

This was a good teaching case and an illustrative model of its natural history. A holistic intervention will be implied in such cases.

P318

A NOVEL AP3B1 MUTATION IN HERMANSKY PUDLAK SYNDROME TYPE 2

D. Pace,* G. Davies,† P. Ancliff,‡ I. Russell-Eggitt,§ M. Benson,¶ G. de Saint Basile,∥ and S. Attard-Montalto,** *Department of Paediatrics, Mater Dei Hospital, Tal-Qroqq, Msida, Malta; †Department of Paediatric Immunology; ‡Department of Haematology/Oncology & Palliative Care; §Department of Clinical and Academic Ophthalmology, Great Ormond Street Hospital, London; ¶St Luke's Hospital, Oxford, UK; ∥Centre d'Etude des Deficits Immunitaires and INSERM U 768, Hôpital Necker Enfants Malades, Paris, France; and **Department of Paediatrics, Mater Dei Hospital, Tal-Qroqq, Msida, Malta.

Background and Aims: Hermansky Pudlak syndrome type 2 (HPS2) is a rare autosomal recessive disorder caused by mutations in the gene encoding the beta-3A subunit of the AP3 complex (AP3B1) resulting in defects in intracellular protein trafficking of lysosome related organelles. HPS2 is characterised by oculocutaneous albinism, congenital neutropenia and platelet dysfunction with a tendency for developing pulmonary fibrosis and granulomatous colitis later on in life. An increased risk of infection is associated with the underlying granulocytopenia.

Methods: We describe a 2-year-old girl, born to healthy unrelated Maltese parents, who presented with oculocutaneous albinism at 2-months of age. Subsequent investigations revealed chronic neutropenia, low serum IgM and impaired platelet aggregation. PHA responses were normal but cytotoxic NK-cell function was reduced. The girl suffered from recurrent upper respiratory tract infections but never sustained any episodes of invasive bacterial or fungal sepsis. She was also found to have bilateral hip dysplasia which was corrected by open reduction.

Results: Mutational analysis revealed a novel homozygous deletion of 624 base pairs including part of intron 18 and exon 19 (g.180117−180740 del) in the AP3B1 gene which led to a premature stop codon. Both parents were heterozygous for the mutation.

Conclusion: Management of children with HPS2 is complex and involves repeated visual assessments, prophylactic antimicrobials, and G-CSF and platelet transfusions prior surgery. In view of the potential risk of haemophagocytic lymphohistiocytosis, secondary to the impaired NK-cell function, a matched bone marrow donor should be sought after diagnosis. Early diagnosis should lead to appropriate genetic counselling.

P319

SUBOPTIMAL PROTECTIVE IMMUNITY OF HEALTHCARE STUDENTS AGAINST VACCINE PREVENTABLE DISEASES

I.D. Pavlopoulou,* G.L. Daikos,† A. Tzivaras,‡ C. Tsoumakas,* E. Bozas,* C. Kosmidis,† and M. Theodoridou,§ *Paediatric Research Laboratory; †First Department of Propedeutic Medicine, Athens University; ‡Blood Transfusion Centre, ‘Aghia Sophia’ Children's Hospital; and §First Department of Pediatrics, Athens University, Athens, Greece.

Background and Aims: Immunity of healthcare students (HCS) against infectious agents in a hospital setting is important, as it prevents their transmission to patients and acquisition of disease. Aim of this study was to evaluate immunization rates of HCS and their serologic immunity against certain vaccine preventable diseases.

Methods: Medical and nursing students during their pediatric clerkship at our institution, were enrolled. Information including demographics, past history of disease and immunization status was obtained through personal interview and available records. In addition, serum IgG antibodies were determined for measles, mumps, rubella, varicella-zoster virus (VZV), hepatitis B surface antigen (HBs) and hepatitis A virus (HAVAb). Seronegative students and those with incomplete immunizations, were referred to local vaccination clinics and compliance was assessed three months later.

Results: From April to November 2007, a total of 187 students (84 medical, 103 nursing) were recruited; mean age was 24 years; median: 23 years (range: 20–45 years). Only 131 (70%) of them provided complete vaccination records since birth. Adequate immunity against diphtheria and tetanus was documented in 37.5% and 49% of the students. Seropositivity against measles, mumps, rubella, VZV, HBs (≥ 10 IU/l), HAVAb (≤0.900 S/CO) was found in 98, 89.5, 97, 92, 84 and 14.6%, respectively. At follow-up, 67% of the nursing and 48% of the medical students had received none of the vaccines indicated.

Conclusions: HCS presented significant immunization gaps, indicating the need of an appropriate prevention strategy. In order to maximize compliance, Faculty has to bear the costs of vaccination.

P320

HIGH MONOCYTE ACTIVATION IN VERY-PRETERM NEONATES AS CAUSE OF THEIR SUSCEPTIBILITY TO INFECTIONS

A. Perez,* J.M. Bellon,* M.D. Gurbindo,† A. Aguaron,‡ and M.A. Muñoz-Fernandez,* *Laboratory of Molecular Immunobiology; †Immunopaediatrics Department; and ‡Ginecology and Obstetrics Department, Hospital Gregorio Marañón, Madrid, Spain.

Background/Aim: Little is known about characteristics of innate immunity that make very-preterm neonates (<30 g.w.) more susceptible to infections. Monocytes belong to the first line of innate response, acting as antigen-presenting cells and recognizing molecular patterns of bacterial components (LPS) through Toll-like receptors. Our aim was to describe the differences of the innate immune response between neonates of different gestation age.

Methods: Cross-sectional study in umbilical-cord-blood monocytes of 64 healthy neonates divided into 3 groups: very-preterm (25−30 weeks), preterm (31–36), full-term (37–41). CD14+ monocytes were isolated by an immunomagnetic-technique and cultured with LPS/LPS+IFNγ. Monocyte-population analysis was performed by flow-cytometry and cytokines quantified in culture supernatants. CD14/TLR4-mRNA expression was measured by qPCR.

Results: We found HLA-DR lower values for very-preterm neonates in unstimulated and LPS-stimulated cells. No differences for CD40+-cell percentages were found. We observed a CD80-percentage increase and a CD86-percentage decrease within each group when stimulated with LPS/LPS+IFNγ. CD69+CD40+ and CD69+HLA-DR+ cells showed lower percentages in preterm and full-term groups. We found higher CD69- and CD25-percentages in very-preterm newborns in unstimulated cells and they increased when cells were LPS-/LPS+IFNγ-stimulated. We found higher production of IL-1β, IL-6, IL-8 and TNFα cytokines and higher expression of CD14/ TLR4 mRNA for unstimulated monocytes in the very-preterm neonates.

Conclusion: Monocytes from very-preterm neonates have a diminished function and a higher basal activation seen at both cellular and molecular levels as compared with preterm or full-term neonates. This could explain the susceptibility of very-preterm neonates to bacterial infections because of an uncontrolled proinflammatory microenvironment.

P321

CHANGING OF SERUM DEFENSINE CONCENTRATION IN ACUTE PERIOD OF TICK-BORNE NEUROINFECTIONS IN CHILDREN

T. Poponnikova,* T. Vakhrameeva,* F. Hufert,† G. Dobler,‡ G. Vavin,§ and G. Galieva,§ *Kemerovo State Medical Academy, Kemerovo, Russia; †Institute of Virology, University Göttingen, Göttingen; ‡Bundeswehr Institute of Microbiology, Munich, Germany; and §Kemerovo Regional Hospital, Kemerovo, Russia.

Abstract: Researching of clinical peculiarities of tick-borne infections–tick-borne encephalitis (TBE), borreliosis (TBB), ehrlichiosis, anaplasmosis) showed the possibility of CNS damage. TBE can be developing as mixed infection. The mechanisms for the different clinical forms and outcome of TBE infection are unclear.

For detecting diagnostic meaning of defensine changing 46 cases of serologically confirmed tick-borne neuroinfections in children (1−15 years of age) were analysed. The sera were tested for TBE virus-IgM and -IgG using ELISA, for B.burgdorferi, E.chafeensis and A.phagocitophila -IgM and -IgG using ELISA. For defensine testing commercial ELISA test systems were used. Among researched clinical cases in 28.2%–TBE, in 6.5 %- TBB, in 65.3%–mixed infection were diagnosed. The results show that the serum defensine concentration in patients with meningeal form of TBE was 80 ± 5.5 ng/ml, in patients with meningeal form of TBB–65 ± 9.3 ng/ml, in mixed infection–110 ± 6.3 ng/ml. During the regress of clinical manifestations the lowering of defensine concentration to normal data (62 ± 8.3 ng/ml in TBE patients and 50 ± 6.8 ng/ml in mixed infection patients) was detected. The serum defensine concentration in patients with TBE meningoecephalitis was 135 ± 7.4 ng/ml, in mixed infection–189 ± 7.4 ng/ml (P < 0.05). The changing of defensine concentration in serum is unspecific in different etiological variants of tick-borne diseases, more manifested in mixed infections and reflects the functional activity of leukocytes in inflammatory reactions. The prolonged high level of defensine concentration in serum during meningitis and meningoencephalitis observed in severe cases can be considered as unfavorable sign.

P322

ROLE OF INNATE IMMUNITY IN MOTHER-TO-CHILD TRANSMISSION OF HIV-1

E. Ricci,* S. Malacrida,* M. Zanchetta,† I. Mosconi,* M. Montagna,† C. Giaquinto,‡ and A. De Rossi,*† *Dept of Oncology and Surgical Sciences, AIDS Reference Center, University of Padova; †Istituto Oncologico Veneto-IRCCS; and ‡Dept of Pediatrics, University of Padova, Padova, Italy.

Background and Aims: Innate immunity may contribute to host-viral interactions and impact the risk of mother-to-child transmission (MTCT) of HIV-1. Defensins and toll-like receptors (TLRs) play a crucial role in the host′s innate immune response. This study focused on evaluating the influence of single nucleotide polymorphisms (SNPs) in the beta-defensin-1 (DEFB1) gene and in the TLR9 gene.

Methods: The study was conducted in 300 children (118 HIV-1-infected and 182 HIV-1-uninfected) born to HIV-1-infected mothers, and in 84 available maternal samples. Genomic DNA was evaluated for −44C/G (rs1800972) and −52G/A (rs1799946) SNPs of the DEFB1 gene and 1635A/G (rs352140) and 1174G/A (rs352139) SNPs of the TLR9 gene by TaqMan allelic discrimination assay. Statistical analysis was performed using SNPStats and Haploview programs.

Results: −52GG genotype and the −44G/−52G haplotype of DEFB1 in children were strongly associated with a low risk of HIV-1 infection (odds ratio (OR) = 0.52, 95% confidence interval (CI) 0.31–0.86, P = 0.03, and OR = 0.50, 95%CI 0.31−0.83, P = 0.01, respectively). Similarly, the −52GG genotype and the −44G/−52G haplotype of DEFB1 in mothers were associated with a low risk of HIV-1 transmission (OR = 0.23, 95%CI 0.06−0.85, P = 0.042, and OR = 0.23, 95%CI 0.08−0.66, P = 0.012, respectively). SNPs of TLR9 were not significantly associated with a risk of HIV-1 infection and transmission. However, the 1174A/1635G haplotype was strongly associated with a low risk of MTCT of HIV-1 (OR = 0.15, 95%CI 0.05−0.48, P = 0.0012).

Conclusions: Our results demonstrate a significant correlation between genetic variants of DEFB1 and TLR9 genes and risk of MTCT of HIV-1,thus confirming the role of innate immunity in perinatal HIV-1 infection.

P323

DIFFERENCES IN THE IMMUNE RESPONSE TO MYCOBACTERIUM BOVIS BACILLE CALMETTE-GUÉRIN IMMUNISATION BETWEEN CHILDREN AND ADULTS

N. Ritz,*† M. Strach,* C. Yau,* B. Dutta,† M. Tebruegge,*† T. Connell,*† and N. Curtis,*† *Department of Pediatrics, University of Melbourne; and †Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, Australia.

Abstract: BCG vaccine is the most commonly administered vaccine worldwide. It has proven efficacy in preventing severe and disseminated forms of TB in children. In contrast, the reported efficacy of the vaccine for preventing TB in adults is variable. Data comparing the immune response following BCG immunisation in children and adults are scarce. Investigating differences in the immune response to BCG immunisation between children and adults is important to understand differences in protective efficacy.

Healthy, BCG-unimmunised children and adults were administered BCG after exclusion of previous TB exposure. Blood was collected prior to BCG immunisation and at 6 and/or 10 weeks after. Proportions of antigen-specific Th1 cytokine-producing CD4 and CD8 cells were compared in a 12-hour intracellular cytokine assay using multicolour flow cytometry.

Results were available for 13 children (median (range) age 0.9 (0.1–2.0) years) and 16 medical students (median (range) age 24.0 (20.9–32.4) years). A significant increase in the proportion of cytokine-producing CD4 and CD8 cells was seen in both children and adults. Following immunisation, compared to adults, children had smaller increases in the proportions of INF-γ-producing CD4 and CD8 cells, but greater increases in IL-2- and TNF-producing CD4 cells. In contrast to adults, children had significant increases in all double positive (INF-γ+IL−2+; INF-γ+TNF+; IL−2+TNF+) and triple positive (INF-γ+IL−2+TNF+) CD4 cell populations.

The immune response to BCG immunisation in children and adults differs both quantitatively and qualitatively. Antigen-specific T cells capable of producing multiple Th1 cytokines are more effectively induced by immunisation in childhood.

P324

INVASIVE PNEUMOCOCCAL INFECTION IN A VACCINATED CHILD REVEALING COMPLEMENT DEFICIENCY

M. Sabbe,* F. Haerynck,† L. Desimpel,‡ and P. Schelstraete,† *Epidemiology, Scientific Institute of Public Health, Brussels; †Department of Pediatric Pulmonology and Immunology, Ghent University Hospital, Ghent; and ‡Department of Pediatrics, General Hospital St Rembert, Torhout, Belgium.

Background: Streptococcus pneumoniae causes a wide spectrum of diseases such as upper respiratory tract infections, meningitis, bacteremia and pneumonia. The primary risk factor of invasive infections is related to age and deficiency of protective antibodies.

Methods: We present a case of meningitis caused by a vaccine serotype of S. pneumoniae in a child previously vaccinated with PCV7.

Results: In November 2007 a 3 year-old boy was diagnosed with meningitis causing general seizures. His medical history was marked by recurrent upper respiratory tract infections. He had received immunizations consistent with the recommended childhood immunization schedule and received two doses of PCV7 at the age of 14 months and 18 months and additionally one dose of varicella vaccine. Culture of the cerebrospinal fluid grew S. pneumoniae and the isolate was serotyped as 18 C, a strain included in PCV7. Results of immunoglobulins, lymphocyte subsets, neutrophil count and neutrophil oxidative burst were normal but the total complement function (CH50) values were 21–34% (nl 80–120%) and C2 concentrations were undetectable. Specific IgG response to polysaccharide vaccination against S.pneumoniae was normal. Upon treatment the child recovered and remained seizure free, but suffered from hearing loss. Prophylactic antibiotics were administered.

Conclusions: Although complement C2 deficiency has been detected in asymptomatic individuals, patients usually present with either autoimmune disease or recurrent pyogenic infection, particularly due to encapsulated bacteria. Evaluation for immunodeficiency was indicated in this vaccinated patient with an S.pneumoniae infection due to a vaccine strain.

P325

KAWASAKI DESEASE: EVEN MORE ATYPICAL

F. Salvini, A. Ruscitto, C. Bettiga, F. Farina, and M. Giovannini, Paediatric Department, University of Milan, Milan, Italy.

Background and Aims: Kawasaki disease (KD) is an acute systemic vasculitis that preferentially affects coronary arteries and is the most common cause of aquired cardiopathy in children in developed countries. Clinical presentation may occur with atypical and incomplete patterns.

Methods: incidence and presentation patterns of atypical/incomplete KD cases admitted at our hospital were registered during the last five years (2003–2008).

Results: 12 cases of KD were diagnosed; 4/12 (33%) can be considered atypical or incomplete. In the first case a 4-years old patient showed Rotavirus gastroenteritis and then developed anasharcatic status with edema of face, hands and feet, ascitis, bilateral pleural and pericardial effusion. In the second case a 4 months-old infant began with chicken-pox and persistent fever lasting over 5 days and associated with right hip-pain without arthritis. In both cases, notwithstanding intravenous immunoglobulins (IGIV 2 gr/Kg) and aspirin (ASA 100 mg/Kg) treatment, coronaropathy appeared. Two further cases of incomplete KD occurred in 2 infants. Both started with persistent fever lasting over 5 days. In one child (4 months of age) fever was concomitant to sepsis (serum EBV-CMV IgM positive) and severe anaemia (Hb 6.6 g/dL); in the other infant (3 months of age) fever was accompanied by a skin rash. Both cases were refractory to IGIV infusions, but no coronaropathy was observed at follow-up.

Discussion: Incidence of atypical KD cases in our Paediatric Clinic was high, presented with unusual signs such as anasharca, never described before in literature as a sign of KD, and often were refractory to IGIV theraphy.

P326

EVALUATION OF IMMUNE RESPONSE TO PNEUMOCOCCAL VACCINE IN VACCINATED SPLENECTOMIZED B-THALASSEMIC CHILDREN

A. Sotoodeh Jahromi,* M.R. Farjam,† M. Pourahmad,‡ and O.R. Zakavat,§ *Immunology; †Biochemistry; ‡Infectious Disease; and §Pediatrics, Jahrom University of Medical Sciences, Jahrom, Iran.

Background and Aims: Splenectomy is accompanied by a life-long risk of overwhelming postsplenectomy infection, mainly caused by polysaccharide (PS) encapsulated bacteria such as Streptococcus pneumoniae. The mortality rate in those infected patients remains high. Therefore pneumococcal polysaccharide vaccine has been recommended. To obtain information on the immunity levels of pneumococcal antibody, in splenectomised beta-thalassemic patients in Jahrom.

Methods: This descriptive and cross sectional study was carried out on all splenectomised beta-thalassemic patients in Jahrom, Nov. 2007–March 2008. Total anti-pneumococcal vaccine antibody concentrations were measured by the enzyme-linked immunosorbent assay method. The parients were divided to two groups based on antibody concentrations: Group 1: Immune patients or good responder with 1.0 μg/ml antibody concentrations and group 2: Non-immune patients or poor responder with less than 1.0 μg/ml antibody concentrations.

Results: The results showed that 57.10% and 42.90% of the patients were immune and non-immune to pneumococcal infections, respectively. There was a negative significant between Immunity level with the period after pneumococcal vaccination (r = −0.573, P < 0.001).

Conclusions: These results suggest that high percentage splenectomised beta-thalassemic patients are poor responders to pneumococcal vaccination. Therefore evaluations immunity levels to pneumococcal vaccine are recommended in these patients.

P327

DETERMINATION OF ANTI-HEPATITIS B SURFACE ANTIBODY TITER IN HBV VACCINATED B-THALASSEMIC CHILDREN

A. Sotoodeh Jahromi,* M. Pourahmad,† and A. Mohtashami,‡ *Immunology; †Infectious Disease, Jahrom University of Medical Sciences; and ‡Blood Transfusion, Blood Transfusion Center, Jahrom, Iran.

Background and Aims: Thalassemia patients are more susceptible to hepatitis than the normal population due to the frequent blood transfusions. To determine the immune response of children with major -thalassemia, by measuring anti-hepatitis B surface antibody (anti-HBs Ab) following the last HBV vaccine injection.

Methods: This study was carried out on all (110) thalassemic patients of Jahrom 15.34 ± 5.99 year, who received three standard intramuscular recombinant HBV vaccines- 2006. Based on the serum levels of anti-HBs antibody, subjects were categorized as: good responders (anti-HBs >100 IU/Lit), low responders (anti-HBs 10–100 IU/Lit) and non-responders (anti-HBs < 10 IU/Lit).

Results: In females, the mean antibody level was 133.69 ± 107.647 and in males it was 158.02 ± 109.640 IU/Lit (P = 0.243). Out of 110 thalassemic patients of Jahrom 66 (60%) were good responders, 21 (19.1%) low responders and 23 (20.9%) non-responders.

Conclusions: Standard HBV vaccination in thalassemic patients results in an immune response in about 60% of the subjects. Therefore, annually assessment of anti-HBs antibody level, after the last vaccination (booster), is recommended.

P328

COMPARISON OF CYTOKINE GENE POLYMORPHISMS AMONG GREEK PATIENTS WITH MENINGOCOCCAL OR VIRAL MENINGITIS

C.J. Titmarsh,*†‡§ S.M. Moscovis,*†‡§ S. Hall,*‡§ G. Tzanakaki,¶ J. Kremastinou,¶ R.J. Scott,†‡§ and C.C. Blackwell,‡§ *Immunology; †Molecular Genetics, Hunter Area Pathology Service; ‡School of Biomedical Science, University of Newcastle; §Hunter Medical Research Institute, Newcastle, Australia; and ¶National Meningitis Research Laboratory, National School of Public Health, Athens, Greece.

Background and Aims: Inflammatory responses play a significant role in the pathogenesis of viral and meningococcal meningitis (VM and MM); white blood cells in cerebrospinal fluid differ, neutrophils predominantly with MM and lymphocytes with VM. We compared single nucleotide polymorphisms (SNPs) in pro- and anti-inflammatory cytokine genes among patients with VM or MM, particularly interleukin-8, a powerful attractant for neutrophils.

Methods: Ethical permission was obtained from Hunter New England Research Ethics Committee. Patient DNA samples were prepared by the National Meningitis Reference Laboratory in Athens: MM = 98; VM = 53. Results were compared with data published for healthy Greek control data. SNPs were assessed by real-time PCR. IL6 G-174C, IL1B C-511T, IL1RN T+2018C, IL10 G-1082A, IL8 A-251T and TNF G-308A were assessed. Fisher's exact test was used for analysis.

Results: Compared with controls (31%), the genotype for high IL-6 was predominant among MM (51%, P = 0.0008) and VM (74.5%, P < 0.0001). The genotype associated with high TNFα was 5% among controls, lower for MM (1.1%, P = 0.0014) and VM (0%, P = 0.052). There was no difference between distribution of IL-8 SNPs between controls and MM (P = 0.162), but was significant for VM (P = 0.0025). Distribution of IL-6 and IL-8 SNPs between MM and VM groups differed, IL-6 = 0.024, IL-8 = 0.00004.

Conclusions: Reports on associations between the IL-8 SNP and cytokine responses differ. Because of its role in neutrophil attraction, differences in the frequency of the IL-8 SNP between the MM and VM groups require further investigation.

P329

SERUM BACTERICIDAL ACTIVITY IN CHILDHOOD AND ADOLESCENCE 3–6 YEARS AFTER VACCINATION WITH SEROGROUP C MENINGOCOCCAL CONJUGATE VACCINE

G. Tzanakaki,* I.-I. Sakou,† M. Sioumala,* A. Barbouni,* M. Kyprianou,* V. Papaevangelou,† A. Tsitsika,‡ D. Kafetzis,† J. Kremastinou,* and M. Tsolia,† *National Meningitis Reference Laboratory, National School of Public Health; †Second Department of Pediatrics; and ‡Adolescent Health Unit, Second Department of Pediatrics, University of Athens School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece.

Background and Aims: Serogroup C meningococcal conjugate vaccines were introduced in Greece since 2001 and contributed to the decrease in disease incidence in the following years. Although no cases of serogroup C disease were recorded in 2004, a steady increase was observed since 2005. This study aimed to examine the duration of protective immune responses to the vaccine in children immunized at different ages.

Methods: Serum bactericidal activity (with rabbit complement) and geometric mean titers of specific IgG antibody (with ELISA method) were assessed in 269 children and adolescents (135 males) immunized with a single vaccine dose (at ≥12 months of age) at a mean time of about 5 years after vaccination.

Results: In total 79/269 (29.4%) children had serum bactericidal antibody titres ≥1:8. Non-protective antibody titers were observed in most children vaccinated at age <6 years (85.9%), followed by those between 6 and 10 years (62.2%), while this percentage was considerably lower in adolescents vaccinated at an age >10 years (37.8%) (P < 0.01). Geometric mean titres of serum IgG antibodies against serogroup C showed a similar variation.

Conclusion: These results indicate that serum bactericidal antibody titers significantly correlate with age of vaccination; most children do not have protective antibody titers few years after immunization in infancy and childhood whereas most adolescents maintain sustained protection. A booster dose of conjugate vaccine in adolescents may provide further protection to them as well as indirect protection to younger children.

P330

CIRCULATING B CELL MEMORY AFTER MEASLES AND MUMPS VACCINATION

C. Vandermeulen,* L. Verhoye,† F. Clement,† K. Hoppenbrouwers,* and G. Leroux-Roels,† *Centre for Youth Health Care, K.U. Leuven, Leuven; and †Center for Vaccinology, Ghent University, Ghent, Belgium.

Background and Aims: To evaluate the presence of circulating measles- and mumps-specific memory B-cells using a Human-PBL-SCID-mouse model in which PBMC were transferred of donors with either low or high antibody titers against measles and mumps.

Methods: PBMC's of 6 donors (3 subjects with low and 3 with high antibody titers against measles and mumps) were injected in the spleen of conditioned NOD-SCID-mice (3 per subject). In vivo production of human antibodies against measles and mumps was evaluated in mouse plasma on days 7, 10 and 13 with a commercial ELISA (Enzygnost measles and mumps, Behring).

Results: For mumps, 3 donors had undetectable antibody titers and 3 had very high antibody titers, whereas for measles 2 donors had undetectable antibodies, 1 donor had a very low antibody titer and 3 donors had high antibody titers. None of the mice injected with PBMC from subjects with undetectable antibody titers for measles and mumps developed detectable human antibody titers for either virus. All mice injected with PBMC from subjects with high(er) antibody titers against mumps and/or measles, also showed detectable antibody titers for measles and/or mumps in the animal plasma.

Conclusions: In vaccinees without detectable serum antibodies against mumps and/or measles viruses, no or a very limited number of circulating memory B-cells against these viruses could be detected. These findings further add to the existing evidence suggesting that individuals without circulating antibodies are at risk of developing either measles or mumps disease upon encounter with wild-type virus.

P331

SEVERE GROUP A STREPTOCOCCAL INFECTIONS IN THE PAEDIATRIC INTENSIVE CARE UNIT—CASE SERIES AND ROLE OF INTRAVENOUS IMMUNOGLOBULIN

E. Woodrow, D. Ellis, and A. Turner, Paediatric Intensive Care Unit, Royal Hospital for Sick Children, Yorkhill, Glasgow, UK.

Background and Aims: We have experienced a significant increase in severe Group A streptococcal infection (GAS) presenting to paediatric intensive care (PICU). Our aim is to describe our experience in the management of these patients. Our secondary aim is to review the current literature regarding the use of intravenous immunoglobulin (IVIG) in severe GAS infections.

Setting: Tertiary paediatric intensive care unit.

Patients: Children < 18 years of age presenting over a one year period to 2008.

Methods: Retrospective case note review. Data extracted from computerised information system database. Accompanying Medline literature review to 2008.

Results: 11 children were included. Mean age: 5.04 years (range 0.16–12.32). 3 had co-morbid pathology. Duration of admission range: 8–257 hours (mean 103). Nine children required ventilation, range 57–186 hours (mean 87). Six patients required inotropes. One child required VA ECMO for cardiorespiratory failure. GAS was isolated from the following: Pleural fluid 3; Throat swab 4; Bronchoalveolar lavage 2; Joint aspirate & Blood Culture 1; Skin lesion 1. All patients received antibiotics (cefotaxime, clindamycin). Two patients fulfilling STSS criteria received IVIG. Ten of eleven children survived to PICU discharge. One patient died of cardiorespiratory failure. Literature review reveals 2 conflicting randomised controlled trials in the use of IVIG. One Cochrane meta-analysis was inconclusive. Current guidelines suggest that IVIG may be useful.

Conclusions: Serious GAS infection frequently requires PICU intervention. Cardiorespiratory failure is common although usually responds to conventional intensive care therapy. Mortality is low. Evidence supporting the use of IVIG is inconclusive.

P332

INTRANASAL IMMUNIZATION WITH GBS SURFACE PROTEIN SIP AND SCPB INDUCES SPECIFIC MUCOSAL AND SYSTEMIC IMMUNE RESPONSES IN MICE

G. Xue, S. Li, and X. Shen, Microbiology, Capital Medical University of China, Beijing, China.

Abstract: Sip and ScpB are highly conserved among all strains of Group B streptococcus (GBS). Thus, the two proteins are attractive antigens for inclusion in a vaccine against GBS. In this study, we constructed and expressed the two proteins, investigated their specific mucosal immune responses against GBS induced by intranasal immunization with cholera toxin (CT) and CpG-ODN as adjuvant. Intranasal immunization with different doses of recombinant Sip and ScpB all elicited specific antibodies in serum and [ct1] vagina of mice. A mixture of rSip and rScpB with either CT or CpG-ODN elicited specific antibodies in serum and vagina. Sera from the mice group intranasally immunized with rSip +CT, rScpB +CT, and a mixture of rSip+rScpB +CT also showed bactericidal activity compared with the serum of the control group; the serum of rSip+rScpB mixture group had the highest phagocytic index. The current findings suggested that

(1) rSip and rScpB would be useful antigens as the components of the vaccine to induce protective immune responses against GBS, and

(2) CpG-ODN could be used as a very effective mucosal adjuvant in inducing a good mucosal immune response.

“The use of an intranasal vaccine composed of the different surface protein antigens is an attractive strategy for the development of a vaccine against GBS.

Keywords: Group B streptococcus; surface protein; rSip; rScpB; intranasal immunization.

P333

HUMORAL IMMUNITY TO HEPATITIS A IN BONE MARROW TRANSPLANTED PATIENTS

S.S. Yalcin, M. Kondolot, Y. Karacan, M. Cetin, S. Aksu, I. Tezcan, H. Göker, and D. Uçkan, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Background and Aims: Bone marrow transplant (BMT) recipients lose immune memory of exposure to infectious agents accumulated through a lifetime and therefore need to be revaccinated. We conducted a prospective study to evaluate the

hepatitis A seroprevalence in pre-bone marrow transplant cases and the loss of anti-hepatitis A virus (anti-HAV) immunoglobulin-G antibodies following BMT, in intermediate endemic region, Turkey.

Methods: Between 2002 and 2007, candidates for BMT at our institution were tested for anti-HAV IgG prior to transplantation. Seropositive patients were retested at 12 months of BMT, then once or twice yearly until they became seronegative.

Results: Bone marrow transplanted ninety one patients whose age range was 2–57 years old were evaluated. Sixty eight of them (74.7 % in overall group, 61.1% in children, 94.6% in adults) were seropositive before BMT. There was no history of hepatitis A virus vaccination before BMT reflecting natural infection. Loss of anti-HAV IgG was observed at a mean of 46.9 mo after transplantation with survival analysis.

Conclusions: BMT recipients should have serological screening before hepatitis A virus vaccination.

P334

IMMUNOLOGICAL DERANGEMENT AGAINST CAUSATIVE PATHOGENS IN OTITIS-PRONE CHILDREN

N. Yamanaka,* M. Hotomi,* and R. Sugita,† *Otolaryngology, Wakayama Medical University, Wakayama; and †Otolaryngology, Sugita ENT Clinic, Chiba, Japan.

Abstract: Otitis media is the most common disease seen in childhood. Streptcoccous pneumoniae(SP), nontypeable Haemophilus influenzae (NTHI), and Moraxella catarrhalis(MC) are the most frequent pathogens and are isolated 35−40%, 30−35%, and 10−15%, respectively, in all episodes. Protection against the disease due to these pathogens may depend on pathogen-specific antibody. The pathogen-specific antibodies may be directed against surface protein antigens.

In this study, we studied the causative pathogen specific immune responses among otitis-prone children. We evaluated specific IgG levels against pneumococcal surface protein A (PspA) for SP, outer membrane protein P4 and P6 for NTHI, and ubiquitous surface protein (UspA) for MC in sera of both otitis-prone children and healthy children. Antibody levels to PspA, P4, P6, and UspA in otitis-prone children was measured and specific IgG antibodies against these proteins were defined if the concentration was lower than 2 SD below the mean of age in healthy children. Against SP, 46.1 to 57.1% of otitis-prone children showed subnormal levels of anti-PspA IgG. Against NTHI, 45.0% and 54.0% of otitis-prone children showed subnormal levels of anti-P4 and P6 IgG, respectively. Against MC, 18.1% to 45.5% of otitis-prone children showed subnormal levels of anti-UspA IgG. These results strongly suggested that selective immunologic derangements in otitis-prone children might be wider than previously believed. Moreover, the results raise the possibility that otitis-prone children may not respond adequately to immunization with these protein-based vaccines. Effective active immunoprophylaxis against otitis media will be possible only when the mechanism of immunologic defects in otitis-prone children is understood.

P335

DIFFERENTIAL EXPRESSION OF TOLL-LIKE RECEPTOR SIGNALING GENES IN LEUKOCYTES: NEWBORN COMPARED TO ADULT IN RESPONSE TO LIPOPOLYSACCHARIDE STIMULATION IN VITRO

Y. Yang, and M. Jiang, Children's Hospital, Fudan University, Shanghai, China.

Background and Aims: Compared with adults, newborn infants have developmentally immature immune systems and increased susceptibility to invasive microbial infections. Toll-like receptors (TLRs) are critical components of innate immunity. This study was designed to evaluate differential expression of genes for TLR signaling pathway in leukocytes from cord blood compared with those from adult peripheral blood in response to lipopolysaccharide stimulation in vitro.

Methods: Blood samples were obtained from three health term newborns and three health adult donors. Whole blood cells culture in vitro and lipopolysaccharide was added. After 2, 4, 6, 8, 12, 24 hours of cultured, leukocytes were isolated and total RNA was extracted. The Oligo GEArray Human TLR Signaling Pathway Microarrays, representing 117 genes, were used in this study. Gene expression levels were determined using ScanAlyze and GEArray Analyzer software.

Results: A total 101 differential express (more than twofold) genes were found. Among them 40 genes, mostly associated with positive accommodation of TLR signaling, were down-regulated, and 11 genes, mostly associated with negative accommodation of TLR signaling, were up-regulated in the cord blood leukocytes compared with those in the adult leukocytes at all time points of cell cultured with lipopolysaccharide. The other 50 genes were up or down regulated trade-offs between newborn and adult at different time points of lipopolysaccharide stimulation.

Conclusions: The suppressed TLR response to bacterial endotoxin appear to be part of the functional immaturity of the neonatal immune system and might predispose them to bacterial infection.

P336

INCIDENCE AND ETIOLOGY OF INFECTIOUS COMPLICATIONS DURING TREATMENT FOR HEMATO-ONCOLOGIC DISORDERS AT HIGH RISK FOR INVASIVE INFECTIONS

A.M. Zwitserloot,* A.M.C. Mavinkurve-Groothuis,* J.M. Galama,†‡ P.E. Verweij,†‡ P.M. Hoogerbrugge,* and A. Warris,‡§ *Paediatric Haematology and Oncology; †Medical Microbiology; ‡Nijmegen Institute for Infection, Immunity and Inflammation; and §Department of Paediatric Infectious Diseases, UMC St Radboud, Nijmegen, The Netherlands.

Introduction: Prolonged neutropaenia in patients with severe aplastic anaemia (SAA), myelodysplastic syndrome (MDS), acute myeloid leukaemia (AML), relapsed acute lymphoblastic leukaemia (rALL) and after bone marrow transplantation (BMT), is a well-known risk factor for infectious complications. Few data are available about the incidence and etiology of infections during the total treatment period associated with a decreased T-cell function, in children diagnosed with these conditions.

Methods: Paediatric patients diagnosed with SAA, MDS, AML, rALL and post-BMT between 1 January 2000 and 31 December 2005 in our centre were included in our study. A retrospective review of medical, laboratory, microbiology, and pathology records was performed to describe the incidence and etiology of the infectious complications and the associated morbidity and mortality.

Results: We included 138 patients in our study. 68% of 180 microbiological proven infections were diagnosed during neutropaenia; 83% bacterial (98% blood stream infections), 6% fungal and 11% viral infections. 54% occurred in patients with AML, 37% after BMT. In the period without neutropaenia, 58 (32%) microbiological proven infections were diagnosed; 37% bacterial (85% bloodstream infections), 3% fungal and 60% viral. 86% of micro-biological proven infections occurred in patients after BMT. Infection related mortality was 4.3%. Four patients died during neutropaenia (fungal infections), two patients in the period without neutropaenia (systemic adenovirus infection).

Conclusion: Bacterial infections were most frequently seen during neutropaenia, especially in AML patients. Fungal infections are associated with a high mortality. Viral infections were most frequently seen in the period without neutropaenia, mainly in post BMT-patients.

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INFECTION CONTROL IN HOSPITAL AND IN THE COMMUNITY

P337

MRSA INFECTION AND COLONIZATION—A NEW CHALLENGE IN PEDIATRICS

A. Beyersdorff,* R. Bruns,* G. Schröder,† and R.-D. Stenger,* *University Children's Hospital; and †Department of Microbiology, Greifswald, Germany.

Introduction: Colonization and infection by MRSA has increased in adult patients throughout the years in Germany. As well in pediatric institutions cases have been reported.

Patients and Methods: We have seen 8 patients with positive results for MRSA within 18 month. All patients were isolated and treated by standardized hygienic protocol. All patients were treated for eradication.

Results: Mostly colonization with MRSA was seen at different localizations (nose, perineum, gastro stoma). In 3 cases an infection was found. 5 patients were chronically ill. 1 premature infant, 1 term born and 1 older infant were found positive for MRSA during time of hospitalization. 4 parents were as well found positive for MRSA. In 7 patients MRSA could be eradicated. 3 chronically ill patients were later on again positive for MRSA. MRSA elimination has not been possible at all parents’ homes.

Discussion: Chronically ill patients (living in care facility, multiple hospitalizations) have to be seen as risk patients for acquiring MRSA even at young age. At each time of hospital admission (readmission or known MRSA in history) these patients should be isolated until negative results for MRSA are found. Eradication of MRSA is required. For family members with close contact there is no obligation for treatment by law at the moment.

Conclusion: Within the next years an increasing number of MRSA colonization has to be faced. Medical employees should therefore familiarize with this problem and protective care and eradication should start at an early stage including maternity clinics and pediatric wards.

P338

EPIDEMIOLOGY AND MANAGEMENT OF A NOSOCOMIAL NOROVIRUS OUTBREAK IN A PEDIATRIC HOSPITAL

M. Campins,* R. Bartolome,† F. Coll,‡ M. Alonso,§ I. Albero,* V. Balasso,* V. Rodriguez,† and L.M. Vilca,* *Preventive Medicine; †Microbiology; ‡Pediatrics; and §Occupational Health, Hospital Universitario Vall d'Hebron, Barcelona, Spain.

Background and Aims: Norovirus are a frequent cause of gastroenteritis worldwide. Nosocomial outbreaks by norovirus are well documented, being difficult to control because of their stability in the environment and efficient transmission. We describe a norovirus outbreak and its control in a paediatric tertiary hospital in Spain during October-November 2008.

Methods: Hospital Vall d'Hebron is a 1396-bed tertiary hospital in Barcelona. Paediatric area is an independent 364-bed center. Patients and HCWs met the case definition if they had new onset of vomiting and/or diarrhea after 24 hours from admission and during the outbreak period. Selected stool samples were tested for norovirus by RT-PCR.

Results: We identified 32 cases that affected 17 patients and 15 HCWs that were clustered in two general paediatric wards. Laboratory confirmation was available in 4 patients and 2 HCWS. Attack rates were 7,6% (17/224) for patients and 16,7% (15/90) for HCWs. No hospitalizations were required for HCWs. Epidemiological investigation revealed that the index case was a child admitted for an acute gastroenteritis whose mother also was affected. Aggressive infection-control measures, including contact precautions isolation of patients with symptoms, cohorting patients and HCWs, intensive environment disinfection and instructing HCW not to go to work if they suffer for suspected symptoms, were required to terminate the outbreak.

Conclusions: The significant disruption of patient care of this single nosocomial outbreak, as it occurs in other similar outbreaks, support aggressive efforts to prevent transmission of norovirus in health care setting.

P339

COMPARISON OF NOSOCOMIAL INFECTION IN A NEONATAL INTENSIVE CARE UNIT BEFORE AND AFTER MOVING INTO A NEW BUILDING

F.-L. Huang,* Y.-C. Chen,† H.-M. Chang,† and P.-Y. Chen,* *Department of Paediatrics; and †Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan R.O.C.

Introduction: The purpose of this comparative study was to investigate changes in nosocomial infection rates, infection sites, bacterial species, and discussed the related factors in a Neonatal Intensive Care Unit (ICU) before and after moving into a new building at a medical center in central Taiwan.

Method: Data were collected on 30 premature infants who matched inclusion criteria (including spending time in the old ICU) and 31 infants who spent time in the new facility. Nosocomial infection rates, infection sites and changes in bacterial species were included in a descriptive analysis.

Result: Data were collected 6 months before moving and 6 months after moving. We moved from old building into a new building on 5 July 2003. The results show that the nosocomial infection rate decreased from 12.99‰ to 8.81‰ (statistically significant at P <.05). The lower respiratory tract was the most common infection site in both buildings, and Methicillin-resistant Staphylococcus aureus was the most common infection species in both buildings. We analyzed the potential effects of several related factors, including changes in environment; encouraged staff members to wash hands more frequently, and the use of higher quality isolation facilities.

Conclusion: The findings suggest that change in environment and convenient hand washing facilities can promote hand washing rate of health care workers, in the other word, it may reduce nosocomial infection rate.

P340

A VANCOMYCIN-RESISTANT ENTEROCOCCUS (VRE) OUTBREAK IN A NEONATAL UNIT (NU): CONTROL THROUGH SURVEILLANCE AND INTERVENTION

E. Iosifidis,* J. Evdoridou,† K. Karakoula,‡ E. Protonotariou,‡ E. Chochliourou,† E. Agakidou,† J. Stathis,§ D. Sofianou,‡ and E. Roilides,*§ *3rd Pediatric Department; †1st Department of Neonatology, Aristotle University of Thessaloniki, Thessaloníki; ‡Microbiology Department, Hippokration Hospital, Thessaloniki; and §Infection Control Committee, Hippokration Hospital, Thessaloníki, Greece.

Background and Aims: VRE has become an important cause of nosocomial infections. Detection and control of VRE colonization is important to prevent patient-to-patient transmission and subsequent development of infection. The aim of this study was to use both active surveillance and enhanced infection control measures to combat high incidence of VRE colonization.

Methods: In a 44-bed NU (15-bed NICU), an active surveillance study of VRE colonization was conducted, after a VRE ventriculoperitoneal shunt infection occurred. During a 12-wk period stool samples were collected weekly from all neonates that were hospitalized ≥ 5 d. Enterococci were isolated on selective media and tested for susceptibility to vancomycin. Van resistance genes were detected by PCR. Other interventions included daily written reporting of VRE colonization status and enhanced infection control measures.

Results: A total of 319 stool cultures were obtained. Among 151 neonates screened, 59 (39%) were colonized with VRE. Active surveillance during the first 4 wks yielded a maximum of 85% daily prevalence of VRE colonization and a rate of 10−14 new cases weekly. During the following wks prevalence of VRE colonization significantly decreased to 32% (8th wk) and finally to 13% (12th wk), P < 0.05. In the last 3 wks there were no new cases of VRE colonization. Besides, there was no case of VRE infection during active surveillance. All VRE isolates tested were Enterococcus faecium harbouring VanA gene.

Conclusion: Both active surveillance cultures and enhanced infection control measures are important to combat high incidence of VRE colonization in the NU setting.

P341

MEASURES TO CONTROL A VANCOMYCIN-RESISTANT ENTEROCOCCUS (VRE) OUTBREAK IN A PEDIATRIC ONCOLOGY DEPARTMENT (PONCO)

E. Iosifidis,* K. Karakoula,† E. Protonotariou,† M. Kaperoni,‡ E. Matapa,‡ D. Koliouskas,‡ J. Stathis,§ D. Sofianou,† and E. Roilides,*§ *3rd Pediatric Department, Aristotle University of Thessaloniki, Thessaloníki; †Microbiology Department, Hippokration Hospital, Thessaloniki; ‡Pediatric Oncology Department; and §Infection Control Committee, Hippokration Hospital, Thessaloníki, Greece.

Background and Aims: VRE can cause serious and treatment-refractory infections in immunocompromised children. Detection and control of VRE colonization is important to prevent patient-to-patient transmission. The aim of this study was to evaluate the role of active surveillance and infection control measures to combat an outbreak of VRE colonization in PONCO.

Methods: In a 16-bed PONCO, an active surveillance of VRE colonization was conducted after two VRE bloodstream infections occurred. During a 12-wk period stool cultures were taken every 14d from all inpatients. Enterococci were isolated using selective media and tested for susceptibility to vancomycin. Van resistance genes were detected by PCR. Other interventions included enhanced infection control measures and closure of the unit to all new admissions for 3 mos.

Results: A total of 26 patients (median age 6 yrs, 13 patients with leukemia) were screened during the study period. Eleven (42%) patients were colonized with VRE based on the first screening during the 1st mo of the study. Among the remaining 15 patients, in whom the first culture did not detect VRE, 7 patients acquired VRE before the end of the 2nd mo. During the 3rd mo there were no new VRE acquisitions. Daily prevalence of VRE colonization among inpatients ranged from 40 to 75%. There were no other cases of VRE infection during the study period. All VRE isolates tested were Enterococcus faecium carrying VanA gene.

Conclusion: Active surveillance cultures and strict adherence to infection control policies are needed to eliminate transmission of VRE among PONCO patients.

P342

RISK FACTORS FOR HOSPITAL INFECTIONS FOLLOWING CARDIAC SURGERY IN CHILDREN

N. Jashiashvili, and A. Nanuashvili, APUA–Georgian Chapter, Alliance for the Prudent Use of Antibiotics, Tbilisi, Georgia.

Background and Aims: Hospital infections are a major cause of morbidity and mortality. The aim of our study was to determine the main risk factors for hospital infections following cardiac surgery.

Methods: We studied 427 patients. The age of the patients varied from 1 day to 15 years.

Results: Postoperative infections occurred in 15,7%. The rate of hospital infection following primary operations was 12,1%, after the reoperations–33,3%. After the planned operations hospital infections were developed in 14,0% and after the emergency operations in 32,5%. From patients with cardiopulmonary bypass time ≤120 min, the rate of hospital infection was 9,3%, whereas from patients with cardiopulmonary bypass time >120 min 31,7% cases were complicated with hospital infection. From patients with aortic cross clamp time ≤60 min hospital infection developed in 10,8%, whereas from patients with aortic cross clamp time > 60 min in 30,5% cases. Patients developing hospital infection had longer duration of surgery–4,12 ± 0,26 h, compared to patients without infection–3,18 ± 0,19h. Similarly the duration of hospitalization before surgery was longer among infected patients–6,74 ± 1,25 day, compared to patients without infection–4,32 ± 0,25 days. The rate of hospital infections were more in patients under 1 year.

Conclusions: The main risk factors for hospital infections were: age, emergency operation, reoperation, longer duration of cardiopulmonary bypass, aortic cross clamp time, prolonged hospitalization before surgery, longer duration of surgery.

P343

SCREENING FOR METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) IN A DISTRICT HOSPITAL

M. Kubwalo, Paediatrics, Wirral Hospital NHS Trust, Liverpool, UK.

Background and Aims: MRSA is now endemic in many hospitals. Colonization with this organism is a risk factor for eventual MRSA clinical infection which is associated with poor clinical outcomes, prolonged hospital stay and high cost. There is conflicting evidence on universal screening to reduce the risk for clinically important MRSA. In our unit, screening for MRSA was carried out in all paediatric elective and urgent admissions over a 9 month period. The main aims were to quantify the burden of MRSA colonisation in our setting, to identify carriers and offer decolonisation treatment.

Methods: Swabs were taken from all children admitted to the paediatric wards within 24 hours of admission during March-Dec 2008. Swabs were taken from the nose, groin and any areas with accessible medical devices (e.g. gastrostomy, tracheostomy, central venous line site) Children who had positive results were offered decolonisation treatment via either their general practitioner or the paediatric team for those who were still in the ward when results were available.

Results: Approximately 4000 children were admitted to the wards and 11 grew MRSA (median age 66 m). 9 represented colonisation (nose 5, groin 8, and perineum 1) and 2 represented skin infections. Risk factors included recent antibiotic treatment, recent contact with healthcare facility and admission to hospice.

Conclusion: MRSA colonisation and infection is rare in children admitted to a district hospital with acute illness or electively admitted for minor surgical procedures.

P344

THE BURDEN OF POLYPARASITISM AMONG PRIMARY SCHOOLCHILDREN IN RURAL AND FARMING AREAS IN ZIMBABWE

T. Mduluza,* N. Midzi,† S. Zinyowera,‡ D. Sangweme,§ M. Mapingure,* K. Brouwer,¶ J. Mudzori,∥ A. Munatsi,† F. Mutapi,** G. Woelk,* and N. Kumar,§ *University of Zimbabwe; †National Institute of Health Research; ‡University of Jordan, Harare, Zimbabwe; §Johns Hopkins School of Public Health, Baltimore, MD; ¶University of California, CA, USA; ∥National Microbiology Reference Centre, Harare, Zimbabwe; and **University of Edinburgh, Edinburgh, UK.

Abstract: A cross-sectional study was conducted in Zimbabwe among 1303 primary schoolchildren from a rural (53.3%) and a commercial farming area (46.7%) to determine the prevalence of co-infection by helminths and Plasmodium falciparum. Urine was examined on three successive days using the filtration method. Two stool specimens were processed using the Kato-Katz method and a third specimen was processed using the sedimentation method. Plasmodium falciparum was diagnosed from thick blood films. The prevalence of Schistosoma haematobium in the rural and farming areas was 66.8% and 52.3%, respectively, and for S. mansoni the prevalence was 12.4% and 22.7%, respectively. Plasmodium falciparum, hookworms, Ascaris lumbricoides and Trichuris trichiura occurred only in the farming area, with a prevalence of 27.9%, 23.7%, 2.1%, 2.3%, respectively. Co-infection and triple infection with schistosomes, P. falciparum and soil-transmitted helminths occurred in the commercial farming area only. Hookworm and S. mansoni infections were associated with P. falciparum malaria (P < 0.001, OR = 2.48, 95% CI 1.56−3.93 and P = 0.005, OR = 1.85, 95% CI 1.20–2.87, respectively). Overlap of helminths with malaria is a concern among primary schoolchildren and incorporating helminth control in programmes aiming to control malaria will improve funding and increase the efficiency of control for neglected tropical diseases in identified co-endemic settings.

P345

10 YEARS EXPERIENCE OF MRSA IN CHILDREN: INFORMING A SCREENING PROGRAMME

U. Nusgen, M. Patel, and J. Gray, Department of Microbiology, Birmingham Childrens Hospital, Birmingham, UK.

Background and Aims: Screening of hospital admissions, with decolonisation of carriers, is increasingly advocated. In England paediatric guidance is ambiguous. We report using 10 years experience of MRSA to inform a screening programme.

Methods: Analysis of prospective data on 405 consecutive in-patients with MRSA between April 1998 and March 2008.

Results: 210 patients presented with infection; 195 had asymptomatic colonisation. Surgical, Cardiac and PICU specialties accounted for 80.5% of colonised and 79.0% of infected patients. 62 MRSA bacteraemias occurred in 53 patients. 22 (41.5%) and 27 (50.9%) of first bacteraemias presented within three and seven days of MRSA being first detected.

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Conclusions: Most in-patients with MRSA were unrecognised before developing infection. Half of bacteraemias presented before conventional culture could have detected colonisation. Screening of three high-risk specialties would have identified 80% of colonised children, but rapid molecular methods would have been required to to prevent infections in these patients.

P346

EVALUATING PCR FOR DETECTION OF MRSA FROM NASAL SWABS IN A PAEDIATRIC ICU

M. Patel, U. Nusgen, J. Gray, H.L. Turner, and J. Room, Department of Microbiology, Birmingham Children's Hospital, Birmingham, UK.

Background and Aim: To evaluate PCR for detection of MRSA in paediatric ICU patients.

Methods: A pair of nasal swabs was collected at the time of admission. The first swab was used for PCR (GeneXpert, Cepheid). The second swab was cultured using MRSA selective medium and enrichment broth. The accuracy of PCR was determined by comparing PCR results with direct and enrichment culture or any other clinical specimen growing MRSA at the same time. PCR was also used to investigate contacts of a hospital acquired MRSA case.

Results: Over a 15-week-period, 286 nasal swabs were processed from 249 patients. Ten out of 249 patients (4%) were MRSA positive by culture. Fifteen of 286 swabs were found to be positive by either PCR or culture. The sensitivity, specificity, PPV, NPV and accuracy of PCR when compared with culture results of nasal or other clinical specimens was 91%, 98.5%, 71.4%, 99.6% and 98.3%, respectively. We reviewed four PCR positive and culture negative cases. Two were admitted to PICU from home with no known risk factors for MRSA. The other two were long-term in-patients who were found to be positive when investigating a hospital acquired culture confirmed MRSA case on the unit.

Conclusion: Our preliminary data suggest that PCR may be more sensitive than culture. Further work is required to fully evaluate the usefulness of PCR as a rapid and specific detection method for MRSA in PICU setting.

P347

OUTBREAK OF ENTEROBACTER CLOACAE ISOLATES OVERPRODUCING AMPC B-LACTAMASE IN A NEONATAL INTENSIVE CARE UNIT

N. Pestourie,* F. Garnier,* O. Barraud,* F. Compain,† S. Ketterer,† F. Denis,* M.-C. Ploy,* and M. Mounier,* *Laboratoire de Bactériologie-Virologie-Hygiène, CHU Dupuytren, Limoges Cedex; and †Service de Réanimation de Néo-natalogie, CHU Dupuytren, Limoges, France.

Abstract: E. cloacae is a growing problem in Neonatal Intensive Care Unit (NICU). Indeed, many outbreaks by cross-transmission via health-care workers and material have been reported. Here we report the investigation of an outbreak of E. cloacae isolates overproducing AmpC b-lactamase (ECOAC) in a NICU in a French teaching hospital.

At the end of October, 4 ECOAC strains were isolated from three 3-weeks old babies (twins sisters and a boy), 3 from anus and 1 from bronchial aspirate. Another E. cloacae strain was isolated from the twin mother's milk but this strain did not overproduced the AmpC b-lactamase. All these five strains were analyzed by pulsed-field gel electrophoresis (PFGE) and belonged to a same pattern, suggesting that a same clone has spread in the NICU. The twins were treated by antibiotics (amoxicillin, cefotaxime and gentamicin) since their birth. We thus suggest that this treatment has selected the mutant ECOAC from the susceptible milk strain. The ECOAC strain could have been transferred to the boy by hands or environment. Two weeks later, a fourth case was detected in the NICU, an ECOAC strain being isolated from an anus sample from a girl at birth. Surface and material samples were carried out in the unit. ECOAC was found on a glove box and on the thermometer used for the fourth case. The PFGE analysis of the last strain showed that it belonged to the same clone.

We concluded to a contamination involving mother's milk, use of antibiotics and care practices.

P348

DEVELOPING A PAEDIATRIC DEFINED DAILY DOSE (DDD) METHODOLOGY TO ALLOW COMPARISON OF ANTIBIOTIC EXPOSURE BETWEEN EUROPEAN COUNTRIES

A. Porta,* S. Esposito,* N. Principi,* and M. Sharland,† *Department of Maternal and Infantile Sciences, University of Milan, Fondazione IRCCS ‘Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena’ Via Commenda 9, Milan, Italy; and †Paediatric Infectious Diseases Unit, St George's Hospital, Blackshaw Road, London, UK.

Background and Aims: At a European level DDD is used for adult antimicrobial comparative data, but there are few prospective studies in children. Aim of this pilot study was to evaluate the daily dose variability for the antibiotics prescribed in both paediatric wards and Neonatal Intensive Care Unit (NICU) of a large hospital in London.

Methods: In a 5 day prospective observational study, 73 children were exposed to 19 antibiotics in a 154 prescriptions. The data shown is for the three main drugs prescribed: amoxicillin+clavulanate (24 prescriptions/21 patients, only paediatric wards), benzylpenicillin (21 prescriptions/18 patients, both paediatric wards and NICU) and amikacin (18 prescriptions/18 patients, only NICU).

Results: The mean amoxicillin+clavulanate oral daily dose was 896.6 mg (220–1875 mg), and the mean intravenous dose was 1711 mg (525–4000 mg). The mean iv benzylpenicillin daily dose for paediatric wards was 2155.4 mg (174–5300 mg), while in NICU it was 414 mg (178–1000 mg). For intravenous amikacin, the mean total daily dose was 30 mg (7.8–60 mg). The adults WHO DDDs are respectively 1 g for oral and 3 g for parenteral amoxicillin+clavulanate, 3.6 g for parenteral benzylpenicillin and 1 g for parenteral amikacin.

Conclusions: There are difficulties with the current adult based DDD system to analyze paediatric antimicrobial consumption because of the wide dose variability and the weight and age dependence of paediatric daily doses. A proposed new method is discussed to compare antimicrobial exposure between paediatric units in Europe.

P349

NOSOCOMIAL INFECTIONS IN HIGH-RISK NEWBORNS

I. Sampaio, M. Abrantes, J. Costa, and C. Moniz, Unidade de Cuidados Especiais ao Recém-Nascido, Departamento da Criança e da Família, Hospital de Santa Maria, CHLN, Lisboa, Portugal.

Background and Aims: Nosocomial infections (NI) result in considerable mortality and morbility. Newborns in neonatal intensive care units (NICU) are at high risk due to their immature immune system and the need for invasive procedures and treatment.

We evaluated the frequency, characteristics and risk factors for NI in a NICU of a tertiary care hospital, using data from our National NICU nosocomial infection surveillance system. We used German NEO-KISS protocol definition of NI.

Results: We included 408 newborns admitted from January to December 2008, corresponding to 5819 days of stay. Average birth weight (BW) was 2433 g (6,6% with BW < 1000 g) and average gestational-age was 35 weeks (range:24–41 weeks).

A total of 31 NI were diagnosed in 23 newborns, corresponding to 5,3 NI per 1000 patient-days. Newborns with BW < 1000 g were most affected (11,2 NI/1000 patient-days). The most frequent location was septicaemia (80,6%) and coagulase-negative Staphylococci were the most commonly isolated pathogens (47%) followed by Enterobacteriaceae (31,5%).

Invasive-ventilation utilization ratios for all BW groups were below percentile(p) 10 according to NNIS system-report 2004 (0,21 days-of-invasive-ventilation/days-of-stay in BW < 1000 g). The central-venous-catheter utilization ratio was below p50 for BW < 1000 g (0,39 catheter-days/1000 days-of-stay), but in P75-90 in other BW groups.

Conclusions: The epidemiology of NI is characteristic of a NICU. NI rates are acceptable and similar to national rates. Greatly contributing to this were the institution of proper hand-washing-policies, compliance with catheter care guidelines and low invasive-ventilation rates in our unit. It is important to reduce central venous catheters indwelling times especially in higher BW group newborns.

P350

EUROPEAN GUIDANCE ON EXCLUSION OF CHILDREN WITH COMMUNICABLE DISEASES FROM SCHOOLS AND DAY CARE CENTRES: AN EVIDENCE-BASED APPROACH

A. Sharma,* M.A. Anjay,† J. Hawker,‡ M. Sharland,§ M. Richardson,¶ T. Endericks,∥ H. Bedford,** L. Craig,* D. Elliman,†† D. Lévy-Bruhl,‡‡ P. Bonanni,§§ Z. Mészner,¶¶ M. Tsolia,∥∥ and V. Usonis,*** *Immunisation Department, Health Protection Agency (HPA) Centre for Infections, London; †Paediatrics, James Paget University Hospital NHS Trust, Great Yarmouth; ‡Public Health, Health Protection Agency; §Paediatric Infectious Diseases, St George's Hospital, London; ¶Paediatrics, Peterborough District Hospital, Peterborough; ∥Health Protection Agency; **Institute of Child Health, UCL; ††Community Child Health, Great Ormond Street Hospital, London, UK; ‡‡Institut de Veille Sanitaire, St Maurice, France; §§Public Health, University of Florence, Florence, Italy; ¶¶National Institute of Child Health, Szent László” Hospital for Infectious Diseases, Budapest, Hungary; ∥∥Second Department of Paediatrics, School of Medicine, University of Athens, Athens, Greece; and ***Center of Pediatrics, Vilnius University, Vilnius, Lithuania.

Background and Aims: International recommendations on exclusion from schools for communicable diseases vary widely and are often not evidence based. A new collaborative project was set up, funded by the European Centre for Disease Prevention and Control (ECDC) which aimed to update previously published evidence-based guidelines (Richardson et al, 2001), and to make recommendations which would be applicable to the whole of Europe.

Methods: The following primary parameters were studied for 39 communicable diseases: mode of transmission, incubation period, risk of transmission, period of infectivity, duration of shedding and serial interval. For each of these variables, the best available evidence was obtained by systematic searches of the medical literature. The evidence was critically reviewed and categorised into high, moderate or low quality and was then peer reviewed by experts. A UK steering group and a European expert panel considered the evidence as well as other relevant factors including public health importance of the disease and effectiveness of exclusion. Consensus recommendations were made for each disease which were categorised into ‘strong’ or ‘weak’.

Results: High quality evidence was not available for many of the diseases. The final guidance for 39 diseases was presented to the ECDC scientific advisory forum. European consensus was achieved on all diseases except typhoid fever and will be presented.

Conclusion: The best available evidence for the relevant epidemiologic parameters of 39 communicable diseases was collected and European guidance for school exclusion policies were produced based on the same.

P351

MANAGEMENT OF A CRYPTOSPORIDIOSIS OUTBREAK IN A DAY-CARE CENTER

O. Vandenberg,*† F. Robberecht,‡ N. Dauby,* F. Derouin,§ A. Dediste,* C. Moens,* T. van Gool,¶ and J. Levy,‡ *Department of Microbiology, Saint-Pierre University Hospital; †Infectious Diseases Epidemiological Unit, Public Health School, Université Libre de Bruxelles; ‡Department of Paediatrics, Saint-Pierre University Hospital, Brussels, Belgium; §Laboratory of Parasitology-Mycology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; and ¶Dept Medical Microbiology, Section Parasitology, Academic Medical Center, Amsterdam, The Netherlands.

Background and Aims: Cryptosporidium outbreaks in day cares centres (DCC) are commonly occurring. Controlling spread of infection in these settings is difficult however and data about effectiveness of different control strategies are sparse.

In this study, a cryptosporidium outbreak in a large DCC is described with evaluation of hygienic and therapeutic interventions.

Methods and Results: In a 3 week period in a 130–children DCC located in Brussels, 43 developed enteric symptoms. From 120/130 children stools were examined for microbial pathogens, with in 34/120 Cryptosporidium oocysts being diagnosed. Twenty eight of them were symptomatic (82%), 6 asymptomatic. Strict hygienic measurements were installed in the first week after the start of outbreak. After 4 weeks, 27/34 children (79%) were still symptomatic and cryptosporidium positive. Because of fear of further spread of infection and symptomatology, all 27 children were treated with paromomycin. Two weeks afterwards, 6 weeks after the start of outbreak, 18/27 children were asymptomatic and negative for cryptosporidium. The remaining 9 children, still symptomatic and cryptosporidium positive were treated with nitazoxanide. Three weeks afterwards, week 9 after the start of outbreak, all 34 children involved in the outbreak were asymptomatic and cryptosporidium negative. No other children developed cryptosporidiosis after the three weeks after start of the outbreak.

Conclusion: Our study underscores the need to exclude Cryptosporidium aetiology in cases of diarrhoeal outbreak in a DCC. Regarding to our results, direct instalment of specific hygienic measurements most likely halted spread of infection, possibly with some additional effect of specific treatment.

P352

8 CASES OF PAEDIATRIC TB IN ONE FAMILY FOLLOWING AN ADULT PULMONARY TB DIAGNOSIS- THE IMPORTANCE OF TIMELY CONTACT TRACING

E. Whittaker,*† and A. Williams,† *Department of Paediatrics, Imperial College; and †Department of Paediatrics, Northwick Park Hospital in Association with Imperial College, London, UK.

Case History: 10 children from 2 related Somalian families presented to TB clinic in September 2008. Their maternal Aunt had been diagnosed with smear positive pulmonary TB in June 2008. In the preceding months, she had lived with her two sisters, sometimes sharing a room with their children. Three months following her diagnosis, her 15 year old niece presented with respiratory symptoms and a diagnosis of culture positive TB was made. Subsequent contact tracing of her siblings and cousins revealed that all had enlarged TST responses (>15 mm). 8 children were commenced on 6 months treatment for active TB, including 4 year old twins. 2 were treated for Latent TB infection.

Discussion: It is well recognised that children contract TB infection from household contacts. They are more susceptible to TB infection and more likely to develop primary and disseminated TB/TB meningitis than adults. Diagnosis is also a challenge due to the paucibacillary nature of paediatric TB. Early diagnosis and immediate initiation of treatment are essential for an effective TB control program, but even more important in the paediatric population. Becerra described the TB prevalence detected through combined active and passive case finding was 0.91%, much higher than with passive case finding alone (0.18%). 21% of TB cases in London occur in Somalian patients. This case series highlights the importance of early, effective contact tracing following adult TB diagnosis. This is more difficult with mobile large families, and with a language barrier. These issues need to be addressed for effective case finding.

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NEONATAL INFECTIONS

P353

IL-6-174, IL-10-1082 GENETIC POLYMORPHISMS AND OUTCOME OF FULL-TERM NEONATES WITH BLOOD STREAM INFECTIONS

H. Abdel-Hady,* M. Al-Naggar,† G. Al-Maghawry,† R. Badr,† and M. El-Daker,† *Pediatrics, Mansoura University Children's Hospital; and †Medical Microbiology and Immunology, Mansoura Faculty of Medicine, Mansoura, Egypt.

Background: Genetically determined variation in the magnitude of inflammatory response may play a role in determining the risk of developing neonatal sepsis, as well as its outcome.

Objective: To test the hypothesis that IL-6-174, IL-10-1082 genetic polymorphisms are associated with the risk of sepsis and clinical outcomes in full-term neonates with blood stream infections.

Methods: A total of 54 full-term neonates with blood stream infections and 70 matched controls were included in this case/control study. DNA amplification using PCR with sequence- specific primers was done for detection of promotor single nucleotide polymorphism of IL-6-174 G/C, IL-10-1082 G/A genes in blood samples from all infants enrolled in the study.

Results: The IL-6-174 and IL-10-1082 genotypes were not significantly different in neonates with blood stream infections compared to controls. Whereas; IL-6-174CC and IL-10-1082GG genotypes were associated with increased risk for mortality [Odds ratio (95% confidence intervals): 6.17 (1.34−28.41), p= 0.02 and 12.19 (0.26−228.34), P = 0.01, respectively]. Moreover, IL-6 174CC and IL-10-1082GG genotypes were significantly higher in neonates who required inotropic support and those who developed disseminated intravascular coagulopathy.

Conclusion: The IL-6 -174 CC and IL-10 -1082 GG genotypes were associated with increased risk for mortality, need for inotropic support and development of disseminated intravascular coagulopathy in full-term neonates with blood stream infections. These findings suggest that the genetic composition of the IL-6 and IL-10 promoter areas play a significant role in the pathogenesis of neonatal sepsis.

P354

PROCALCITONIN AS A USEFUL MARKER FOR DIAGNOSING OF NEONATAL SEPSIS

F. Alesahebfosoul,* M. Adib,* F. Navaei,† and Z. Bakhshiani,* *Immunology, Isfahan University of Medical Sciences; and †Pediatric, Isfahan University, Isfahan, Iran.

Abstract: Neonatal sepsis cause significant neonatal mortality and morbidity in spite of appropriate antibiotic therapy. Therefore Early diagnosis of neonatal sepsis is essential for the successful treatment. Blood culture is a gold standard but the final result is not available until up to 48−72 hours after collection. Since Procalcitonin concentration is raised in the serum of patients with infection diseases, we attempt to measurment procalcitonin as an early marker of neonatal sepsis.

Methods: Blood samples were collected at admission from 69 neonates with suspected sepsis. Patients were included in 2 different groups according to bacteriological and laboratory results: Group 1 consisted of 20 newborns with positive blood cultures. Group II, 49 neonates with negative blood cultures but had two or three of clinical signs of sepsis. The control group (group 3) included 18 healthy neonates with no clinical and biological data of sepsis. PCT measured by Immunoluminometric assay.

Results: Mean levels of PCT were 5.7 ng/ml in proved sepsis group which was higher than those other two groups (P value < 0.05). Sensitivity, specificity and negative predictive value of PCT were 70% and 80% and 75% respectively.

Discussion: Procalcitonin is a useful additional tool for the diagnosis of bacterial disease in neonates and children.

Keywords: Procalcitonin, C Reactive Protein, Neonatal sepsis.

P355

AN 11 YEAR STUDY OF CAUSES OF NEONATAL BACTERIAL MENINGITIS IN EMAM KHOMAINI HOSPITAL IN AHVAZ, IRAN (1997–2007)

S.M.H. Aletayeb, A. Farajzadeh Sheikh, and M. Dehdashtian, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

Introduction: Bacterial meningitis is a devastating infection with high mortality rate especially in neonates. The aim of this study was to recognize the etiological agents of the bacterial meningitis in Khuzestan province (south west region) of Iran.

Methods: A descriptive cross-sectional study was carried out between 1997 and 2007 at the neonatal ward of A university teaching hospital in Ahvaz, South West region of Iran. All infants less than 29 days who suffered from meningitis were included; laboratory tests included Gram stain and culture. Cases were defined as meningitis if the cerebral spinal fluid (CSF) was positive by aerobic bacterial culture.

Results: Based on cerebrospinal fluid (CSF) cultures, 31 cases were identified as bacterial meningitis, of which 11(35.5%) were Klebsiella pneumoniae, 9(29%) Enterobacter spp, 3(9.6%) E.coli, 3(9.6%) Entercoccus, 2(6.4%) Acinetobacter, and Staphylococcus aureus. Pseudomonas aeroginosa, and nontypeble Haemophilus influenzae each were seen in one cases (3.2%). The male: female ratio was 2/1 (67.7% / female). Birth weights of 20 (64.5%) cases were under 2500 grand 11(35.4 %) cases had normal birth weight. Considering the type of the infection, 13(42%) were in early onset and 18(58%) in late onset. More than r half of the cases (54.8%) had acquired the infection from hospital. Blood cultures were positive in 18(58%) of the patients. Thirty two percent of cases were died in spite treatment.

Conclusion: The Klebsiella and Enterobacter were two main etiological agents of neonatal bacterial meningitis, and nosocomial meningitis was the most common type.

Keywords: Enterobacter, Klebsiella, Newborn, Nosocomial meningitis.

P356

TREAT OR NOT TO TREAT (CONGENITAL CYTOMEGALOVIRUS INFECTION) CASE REPORT AND REVIEW OF THE LITERATURE

S. Amin, Frenchay Hospital, NHS UK, Bristol, UK.

Background: Cytomegalovirus is a ubiquitous virus that commonly infects people across the spectrum of all ages, races, and ethnic groups, and those from a variety of socioeconomic, cultural, and geographic backgrounds. Although most CMV infections are asymptomatic or cause mild disease, the virus can cause serious disease in newborns and immunocompromised children. All treated infants reported in literature presented with symptomatic CMV infection and only one RCT showed clinically meaningful beneficial effect of ganciclovir on hearing deterioration. Potential harms include haematological abnormalities, central line related problems and animal experiments with high doses of ganciclovir showed that short term exposure Induces testicular damage, affect sperm variables and may have carcinogenic effects.

Case: We report a case of neonatal CMV, a premature infant born with emergency C/S for fetal distress and in poor condition at birth, head US scan on D1 showed intracranial calcification, full septic screen done on D1, CSF protein was1.8 gm/d, CXR showed right sided consolidation and was shown to have positive urine, blood and CSF CMV. After consultation with infectious disease specialists, she was started on intravenous ganciclovir. The central line problems especially had a major negative impact on the mother's emotional wellbeing. Treatment, alongside the trauma of diagnosis and possible outcomes, has caused considerable distress to all the family. The dilemma is, taking into consideration all factors, do you treat or not?

P357

UNUSUAL ORGANISMS IN NEONATAL CONJUNCTIVITIS: LESSONS FROM A CASE SERIES

M.A. Anjay,* V. Palanivel,† R. Chaudhary,* and M.A. Hegarty,‡ *Paediatrics, James Paget University Hospital NHS Trust, Great Yarmouth; †Paediatrics, Addenbrookes Hospital, Cambridge, MA; and ‡Microbiology, James Paget University Hospital NHS Trust, Great Yarmouth, UK.

Background and Aims: Infection with unusual organisms can complicate the clinical picture in neonatal conjunctivitis and might lead to treatment failure. We aimed to identify the prevalence of these organisms in a large geographical area in the United Kingdom (UK) and discuss the management issues raised.

Methods: A large case series on neonatal conjunctivitis previously reported from the UK was reanalysed for unusual or uncommon organisms. For the purpose of this study ‘uncommon’ was defined as organisms accounting for less than 1 in 100 of all positive eye swabs.

Results: Of 255 positive swabs in a five year period, the following organisms were identified as ‘uncommon': Serratia marcescens, Acinetobacter, Morganella morgagni, Neissiria meningitidis and Haemophilus parainfluenzae. The clinical and microbiologic features were reviewed.

Although the baby who grew Serratia made an uneventful recovery, infection control measures were considered in view of the risk of nosocomial spread. Acinetobacter although known to be a commensal, has occasionally caused serious infections. Morganella species has never been reported before as a cause of neonatal conjunctivitis although it has been implicated in sepsis. Neisseria meningitidis was associated with carriage in nose and throat. This necessitated systemic therapy for decolonisation and prophylaxis for all contacts including all staff. Interestingly, all the organisms were sensitive to chloramphenicol.

Conclusions: All the ‘uncommon’ organisms were gram negative species. They posed interesting management dilemmas. Chloramphenicol proved to be effective against all the isolates. Clinicians encountering unusual organisms should consider the wider implications and seek specialist advice.

P358

NEONATAL SEPSIS WITH UNUSUAL PATHOGENS IN THE NEONATAL UNIT AT NORTH MIDDLESEX HOSPITAL IN THE YEAR 2008

P. Arora,* A.-M. Buckley,* S. Mohandas,† and S. Raman,* *Paediatrics, North Middlesex University Hospital in Partnerships with Great Ormond St Hospital, London; and †Paediatrics, St John's Hospital, Chelmsford, Essex, UK.

Background and Aims: With the widespread use of antibiotics in neonatal units there has been an emergence of unusual and resistant organisms. Our aim was to analyse the factors associated with infection with unusual organisms.

Methods:

* Retrospective analysis of all positive blood cultures in year 2008 in the neonatal unit at the North Middlesex Hospital

* List of all positive blood cultures was obtained from the Microbiology department.

* Case notes for the neonates with unusual organisms were reviewed to gather information regarding the factors associated with infection with unusual organisms.

Results: 36 positive blood cultures were obtained.

Most common organism isolated were coagulase negative Staphylococcus. Other organisms included GBS, Micrococcus.

The unusual organisms causing sepsis were:

E. coli gentamicin resistant: 2

MRSA 1

Staph aureus 1

Staph haemolyticus 1

Enterococcus 1

Lactococcus 2

Diptheroids 1

Retrospective analysis of the notes of these 9 babies revealed:

9 out of 9 babies were premature.

6 out of 9 babies were one of twins/triplets

6 out of 9 babies were born by C. section

Mortality was 2 out of 9 babies.

Conclusion: Our study shows that prematurity, prior treatment with antibiotics, invasive procedures and a long stay in the neonatal unit predisposes to infection with unusual organisms.

We recommend hand washing, strict aseptic precautions while carrying out procedures and judicious use of antibiotics.

Further larger studies are needed to study the increased risk of infections with unusual organisms in babies born by C-section and multiple pregnancies.

P359

IDENTIFICATION OF FACTORS AFFECTING INCIDENCE AND OUTCOME OF CANDIDEMIA IN A NEONATAL INTENSIVE CARE UNIT FOR DEVELOPING PROPHYLAXIS STRATEGIES

N. Ashouri, J. Singh, O. Vargas-Shiraishi, and A. Arrieta, Infectious Diseases, Children's Hospital of Orange County, Orange, CA, USA.

Background: Candidemia is a major cause of morbidity and mortality in premature infants. Epidemiological, clinical and outcome data will help us identify better target sub-populations for antifungal prophylaxis.

Methods: Retrospective chart review of all neonates hospitalized at our neonatal intensive care unit (NICU) between June 1, 2002-December 31 2008 with blood culture positive for Candida spp.

Results: We identified 34 subjects (5.2% of NICU admissions); 21 (61.8%) < 1000 g birth weight (BW). Mean day of life at infection was 44.8 days (range 6−145), 73.5% occurring in the first 6 weeks of life. History of gastrointestinal (GI) pathology, including necrotizing enterocolitis (NEC) was present in 17 subjects (50%). Complications included endovasculitis and meningitis (4 and 2 patients respectively). Candida albicans (15) and C parapsilosis (15) were equally represented. There were 5 deaths (3 albicans, 2 parapsilosis), all in < 1000 g BW, 4 (80%) of deaths had history of NEC. The average age at time of death was 32 days (median 13; range 6−93 days). One patient died within 24 hours of infection, 4 deaths occurred > 7 days from infection (mean 12.25 d, median 11.5 d). Mortality in infants < 1000 g BW that survived > 72 hours of life, was higher in candidemic patients (5/21; 23.8% Vs 45/377; 11.9%; OR 2.31; CI 0.8057−6.5976).

Conclusion: Candidemia in our NICU occurred most often in the first 6 weeks of life. BW < 1000 g and those with history of GI pathology are at higher risk for candidemia and mortality. These groups may be appropriate targets for fungal prophylaxis.

P360

COMMUNITY-AQUIRIED STAPHYLOCOCCUS AUREUS INFECTION IN PREVIOUSLY HEALTHY NEONATES

G. Berberian, G. Castro, A. Monaco, H. Lopardo, C. Hernandez, and M.T. Rosanova, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina.

Abstract: Community-Aquired S aureus (CA-Sa) resistance are changing in the last ten years inArgentina, increasing methicillin-resistant S aureus (MRSA) strains. First case in ourneonatal unit was diagnosed in 2006.

Objectives: Identify clinical features, risk factors, sensibility and outcome of neonate withCA-Sa infection.

Material and Methods: Prospective observational study. We included previously healthypatients ≤ 30 days of age admitted to the neonatal unit with CA-Sa infection from 2006 to2008. We defined CA-Sa infection based on CDC guidelines.

Results: We included 7 healthy newborn with CA-Sa infection. The labor was vaginal delivery in 6/7. Mean gestational age 39 weeks, weight 3197 grs, and < 3 birth hospital days. Of 7 S aureus infections, 4 (57%) were MRSA. Six of 7 were male. Median age at symptoms onset was 11 days (r:9−18). All infection involved skin and soft tissue (7/7) with pustulosis, omphalitis, mastitis, chest, facial/neck, and goin abscesses. Invasive manifestations were sepsis, ostheoarticular infection, orbital cellulitis and necrothizing pneumonia. Culture positive were form softt tissue in 6, and 3 from blood cultures. All recived sistemic antibiotics. Three of 4 and 2/3 MRSA and MSSA infections respectively required surgical drainage. One patient died because of sepsisMaternal skin/soft tissue infection history occured with 3/4 MRSA versus none of MSSA infections.

Conclusion: Epidemiology of CA-Sa infection is changing even in the newborn period, with increasing MRSA strains. Male neonates 9–18 days of life were affected more often, Maternal infection has a strong association with MRSA.

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RISK OF SERIOUS BACTERIAL INFECTIONS IN HOSPITALIZED INFANTS ≤3 MONTHS WITH FEVER BY HISTORY ONLY VERSUS DOCUMENTED FEVER

H. Bilavsky, E. Bilavsky, J. Amir, S. Ashkenazi, and G. Livni, Schneider Children's Medical Center of Israel, Petah Tiqwa, Israel.

Objective: To assess the risk of serious bacterial infections (SBI) in hospitalized infants with fever by history only and to compare it to infants with documented fever.

Patients and Methods: The study group consisted of all infants ≤3 months hospitalized at our center for fever evaluation from September 2006 to December 2008. Data were collected prospectively regarding the presence of fever during hospitalization and diagnosis of SBI.

Results: A total of 1229 infants met the inclusion criteria, 229 (18.6%) had fever by history only and 1000 (81.4%) had documented fever. SBI was detected in 23 of the 229 infants with fever by history only (10%) (UTI in 20, bacteremia in 1, pneumonia in 1 and enteritis in one) compared to 108 of 1000 infants with documented fever (10.8%) (UTI in 79, urosepsis in 6, bacteremia in 8, bacterial meningitis in 1, pneumonia in 12 and enteritis in two). This difference was not statistically significant (P = 0.813).

Conclusion: The risk of SBI in hospitalized infants≤3 months with fever by history only does not differ from infants with documented fever. Thus, we believe similar sepsis evaluation is warranted regardless documentation of fever in this age group.

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PRELIMINARY STUDY OF PRO-VASOACTIVE PEPTIDE FOR EARLY DIAGNOSIS IN SEVERE NEONATAL INFECTION

Y. Cao,* Y. Yang,† Q. Xia,* C. Chen,* and T. Qian,* *Neonatal Department; and †Pediatric Institute, Children's Hospital, Fudan University, Shanghai, China.

Abstract: The purpose is to assay the concentration of proadrenomedullin (pro-ADM), pro-atrial natriuretic peptide (pro-ANP), pro-endothelin1 (pro-ET) and copeptin in neonates, and explore the correlation between the level of pro-vasoactive peptide and the gestational age, birth weight, age and the severity of infection; the diagnostic efficiency of pro-vasoactive peptide in the neonate with severe infection; the correlation between the level of pro-vasoactive peptide and the severity and the prognosis of the neonates. Three hundred fifty six neonates (169 preterm,187 full-term infants) were divided into three groups: non-infection group (160), mild infection group (114) and severe infection group (82). The severe infection group were subdivided into two groups: critical group and non-critical group. Serum level of pro-ADM, pro-ANP, pro-ET and pro-AVP were determined.

The infection is the independent influencing factor for the variation of the level of pro-ADM, pro-ANP and pro-ET. There were positive correlation between the level of pro-ADM, pro-ANP and pro-ET and the severity of infection (P < 0.0001). There was no correlation between the level of copeptin and infection. The pro-ET, pro-ADM and pro-ANP had good diagnostic efficiency for neonatal infection. Among them pro-ADM had highest diagnostic efficiency and the sensitivity and specificity was 82.65% and 61.25% respectively. The positive predictive value and negative predictive value were 68.08% and 77.93%, respectively. The level of pro-ADM in critical patient (2.498 ± 1.140 nmol/L) was significantly higher than that of non-critical patient (1.810 ± 1.162 nmol/L) (P < 0.05). The concentration of pro-ANP was significantly higher in non-survivors (1680.93 ± 712.88 pmol/L) than that of survivors (1185.85 ± 767.09 pmol/L) (P < 0.05).

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A PROSPECTIVE STUDY OF NOSOCOMIAL INFECTIONS IN A CHINESE NEONATAL INTENSIVE CARE UNIT

Y. Cao,* X. Cai,* C. Chen,* Y. Yang,† Q. Yang,* C. Wang,† and L. Zhang,* *Neonatal Department; and †Pediatric Institute, Children's Hospital, Fudan University, Shanghai, China.

Abstract: This study aimed to determine the epidemiologic profile of NIs, including rates, main infection sites, common microorganisms and risk factors, in a Chinese NICU.

A prospective study was conducted during 1 year from February 2006 to February 2007 in the NICU at a university hospital. The National Nosocomial Infection Surveillance (NNIS) definitions of Centers for Disease Control and Prevention for NIs were applied with modifications to neonate.

During the study period a total of 1159 patients were admitted, and 135 patients had a total of 169 NIs. The cumulative incidence rate for NIs was 14.58%. The incidence of NIs was 19.52 per 1000 patient-days. Respiratory infection (54.44%), conjunctivitis (21.89%), bloodstream infection (14.20%) and gastrointestinal infection (7.10%) were the most frequent NIs observed.

The ventilator-associated pneumonia (VAP) rate was 29.56 per 1000 mechanical ventilation days. Major microorganisms isolated for VAP were Gram-negative rods, including Acinetobacter species (56.52%) and Klebsiella species (23.91%). Coagulase-negative staphylococci (40%) and Escherichia coli (30%) were the most common organisms isolated for bloodstream infection. The durations of hospitalization for patients with and without infection were 12 and 5 days, respectively (P < 0.001). The stepwise logistic regression analysis showed that risk factors associated with NIs was birth-weight less than 1500 g, low Apgar score at birth, delayed oral feeding and treatment of ibuprofen.

P364

ROLE FOR EYE PROPHYLAXIS IN NEONATAL CONJUNCTIVITIS

R. Castelo,* G. Marrão,† and J. Agro,* *Serviço de Pediatria; and †Serviço de Patologia Clínica, Hospital de Santo André, Leiria, Portugal.

Background and Aims: The effectiveness of prophylaxis for bacterial conjunctivitis is a matter of debate. A study was designed to compare topical oxitetraciclin versus no prophylaxis, followed by a surveillance period.

Methods: In our hospital, a randomized clinical trial was designed, divided in Phase I (08/2006−07/2007) which included all newborn, randomized in two groups: group A with prophylaxis (oxitetraciclin) and group B without. Newborn were controlled up to their 28th day postnatal age. During phase II (02/2008−01/2009), prophylaxis was discontinued, but newborn were still controlled as in phase I. Data was compared after completion of phase I and at the end of phase II.

Results: We included 2181 newborns in phase I. Demographic data, delivery, postconceptional age and infectious risk were without statistical difference between both phase I groups. About 108 developed conjunctivitis, 27 with identifiable germen. In the 108 newborns with conjunctivitis, 51 had done previous eye prophylaxis; from the 81 without identifiable germen 33% had prophylaxis and in the 27 with identified germen 55% had previous prophylaxis. There was no statistical significance in the outcome (conjunctivitis) between phase I groups. During phase II, from a total of 2292 births, 105 newborn were reported with conjunctivitis. A germen was identified in 33: S. aureus (14); E. coli (8); S epidermidis (3); other (8).

Conclusions: In our study, prophylaxis with oxitetraciclin did not prove superior to no prophylaxis in phase I. Phase II surveillance confirmed this assumption.

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BIOFILM-FORMING CAPACITY OF CANDIDA BLOODSTREAM ISOLATES FROM NEONATES WITH CANDIDEMIA

A. Chatzimoschou,* J. Dotis,* J. Evdoridou,† M. Simitsopoulou,* E. Georgiadou,* C. Antachopoulos,* V. Drosou-Agakidou,† and E. Roilides,* *3rd Department of Pediatrics; and †1st Neonatology Department, Hippokration Hospital, Aristotle University, Thessaloníki, Greece.

Backround: Candida species constitute an important nosocomial pathogen in the NICU. Little is known about the capacity of Candida species to produce biofilm (BF) in neonates with candidemia. Our aim was to investigate and quantify BF production of bloodstream Candida isolates from NICU patients.

Methods: 5 × 105 planktonic cells/mL from each of bloodstream Candida isolates were grown in YNB medium. For BF formation, 106 cells/mL were grown on silicone disks placed in 96-well plates with RPMI-1640 under shaking. BF production was evaluated by XTT metabolic assay, safranin staining and light microscopy (LM). Documented BF producer isolates were used as positive controls. Isolates that a) showed XTT conversion ≥ 80% of positive controls, b) stained with safranin and c) produced a microscopically visible fungal network were considered high-BF producers. Isolates with XTT conversion of < 80% were considered non-BF producers, whereas those with conversion ≥ 80% but inconsistent safranin staining and LM findings were considered low-BF producers.

Results: Among 45 neonates (21 male) with candidemia an equal number of Candida strains was isolated; 51% were Candida albicans, 29% Candida parapsilosis, 4% each Candida lusitaniae and Candida guilliermondii and 12% other non-albicans Candida species. 18/23(78%) of C.albicans were BF-producers vs. 9/22(41%) of non-albicans Candida isolates (P < 0.05). However, while all 9 BF-producing non-albicans Candida isolates were high-BF producers, only 11/18(61%) of BF-producing C.albicans isolates were high-BF producers (P = 0.059).

Conclusions: BF-forming capacity is a frequent characteristic among neonatal bloodstream Candida isolates, especially C.albicans. High-BF production tended to be observed more frequently among non-albicans Candida BF-producing isolates.

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CLINICAL SPECTRUM OF “NEONATAL“ PICORNAVIRUS CNS-INFECTIONS

J. Christoph, and E. Kattner, Neonatology, Kinderkrankenhaus auf der Bult, Hannover, Germany.

Methods: Between July 2001 and October 2008 we treated 23 infants below the age of 3 months, out of these 11 were neonates, who suffered from a clinically severe picornavirus infection not infrequently.

Results: In 13 cases we succeeded to prove the virus by the PCR, 10 times the cell culture was positive (Coxsackievirus N = 4; Echovirus N = 6, among these twice type 6 and 30 respectively, and once type 13 and type 25 resp.). In 15 cases the agent was found in the CSF, in 8 cases in the throat swab, in the tracheal secretions and / or in the faeces. The infections occurred nearly all over the year with the exception of January and May. Clinically some infants appeared to be septic; others were comatose with central respiratory insufficiency, resembling an intoxication. In 3 infants ventilation was necessary. In some cases CSF findings were suggestive of a bacterial infection (i.e. leucocytes > 1000/μl and interleukin 6 > 1000 pg/ml).

Conclusions: After detection of the virus by the PCR the antibiotic and antiviral herpes-therapy usually was discontinued, however in single cases double infections were also observed (concomitant bacterial sepsis). Infections with picornavirus are not rare illnesses in neonates and young infants. The proof of the virus allows the diagnosis of initially unclear illnesses and mostly also a shortening of the antibiotic therapy. In addition a surveillance is necessary to exclude a poliovirus infection.

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PAEDIATRIC GROUP B STREPTOCOCCAL INFECTION IN NORTH COUNTY DUBLIN–A FIVE YEAR