Study of the pneumococcal pneumonia of the childrens hospitalized in the pediatrics ward at the University Hospital of the University of São Paulo / Estudo das pneumonias causadas por Streptococcus pneumoniae em crianças internadas na enfermaria de pediatria do Hospital Universitário da Universidade de São Paulo

AUTOR(ES)
DATA DE PUBLICAÇÃO

2009

RESUMO

Introduction: Currently, the annual incidence of the acquired pneumonia in the developing country communities are around 150.7 million cases, among childrens under 5 years of age, and 11 to 20 million (7-13%) of those require hospitalization due to their gravity. In general, the treatments used to be empirical, however, it is important to be noted that Streptococcus pneumoniae is far the major bacterial etiologic agent. It is necessary to keep monitoring the serotypes and the pattern of resistance in order to improve the therapy guidance. Methodology: Retrospective cohort study with inclusion of the 107 childrens with clinical and radiological diagnosis of the pneumonia, and the isolation of Streptococcus pneumoniae in the blood and/or pleural fluid during the period of January 2003 to October 2008. It was performed determination of the minimum inhibitory concentration (MIC) related to the penicillin and other antibiotics. The sensitivity analysis to the penicillin was based on Clinical and Laboratory Standards Institute (CLSI), 2008, recommendations. They were performed serotyping in 96 pneumococcal strains (89.7%) and they were analyzed datas referred to the considered population and their clinical course. Results: About 47.5% of admissions in the ward were caused by pneumonia or bronchopneumonia, and the average positive occurrences in the pneumococcal (blood and / or pleural) culture were 2.5%. It was noted a clear seasonality phenomena of the pneumococcal pneumonia. About 70% of the cases occurred during months of June to October. The median age was 23 months (82.2%<5 years); with predominance of males (58.9%); in the 23,4% of the cases the antibiotic therapy was used during two months prior to the admission; the daycare frequency of the childs less than 2 years were 36.4%; only one case with complete vaccination heptavalent; associated disease was detected in the 44.9% of the cases and the most frequent was wheezing (77.1%); time of fever and respiratory symptoms before admission were 4 days; the need for noninvasive oxygen therapy occurred in 70.1% being 4 days of the average time of the use; the need for mechanical ventilation occurred in 19.6%; the median period of stay were 9 days. In 62% of the cases there were the most frequent complications: empyema (53%) and non-complicated pleural effusion (42%). The childrens with empyema had more necrotizing pneumonia, lung abscess, sepsis, pneumothorax, need for decortication, and even higher mortality (all with p<0.05). The childrens with complications had more days of respiratory symptoms before admission (3x5days), more time of the fever after initiation with antibiotic (1x4, 5days), they need noninvasive oxygen therapy (58,5 x77, 3%) and mechanical ventilation (7 , 3x27, 3%) for more time and remained hospitalized during longer period(5x12 days). Among 107 pneumococcal strains, 100 (93.5%) were susceptible to penicillin and 7 (6.5%) presented intermediate sensitivity. All strains tested were sensitive to rifampicin and vancomycin, and they maintained good sensitivity to clindamycin, chloramphenicol, ceftriaxone, erythromycin and levofloxacin. Five strains were multi-resistant. It was noted that the geometric mean of minimum inhibitory concentrations (GMC) to penicillin were higher in children with complications. The most frequent serotypes were: 14 (36.5%), 1 (16.7%), 5 (14.6%) and 6B (6.3%). The serotype 14 presented the highest GMC for penicillin and it was verified a progressive increase during the years of the study. The coverage of serotypes by the heptavalent vaccine would be cover 53.1% and this less coverage is represented by serotype 1 and 5, which corresponds to 31.3% of the cases. The coverage of serotypes associated with resistance would be 94.2%. The coverage of the 10-valent vaccine would be 86.5% and for 13-valent would be 96.9%. Three cases that carried to died (2.8%) had median age of 18 months, all they male, all they with minimum inhibitory concentration for penicillin <= 1g/mL, all they progressed to empyema and sepsis. Two of them were serotype 5 and one of them was serotype 14. Conclusions: Approximately 2.5% of children were admitted with diagnosis of pneumonia were diagnosed as pneumococcal pneumonia. It was verified a clear seasonality phenomena. They were observed complications in 62% of the cases. The most frequent were: empyema and non-complicated pleural effusion cases. It was confirmed a higher GMC for penicillin in children with complications compared to the children without complications. The most frequent serotypes were 14, 1, 5 and 6B and the serotypes 1 and 5 accounted 31.3%. The coverage of heptavalent vaccine for the isolated serotypes would be 53.1%. The sensitivity to the penicillin of the isolated pneumococcal was 93.5%. Therefore, the therapy option remains being the penicillin.

ASSUNTO(S)

microbial sensitivity tests pneumonia pneumocócica streptococcus pneumoniae testes de sensibilidade microbiana pneumonia/complicações vacinas pneumocócicas streptococcus pneumoniae pneumococcal vaccines pneumonia/complications variações sazonais sorotipagem serotyping seasonal variations pneumococcal pneumonia

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