Comparamos crianças menores de cinco anos com pneumonia pneumocócica bacterêmica (PPB) àquelas com empiema pneumocócico (EP) quanto aos achados clínicos, radiológicos e laboratoriais. Um estudo de coorte aninhado transversal, com 102 crianças com EP e 128 com PPB, foi realizado em 12 centros na Argentina, no Brasil e na República Dominicana. Nas crianças com EP, a média de idade e a duração da doença foram maiores. Taquipneia, dispneia e contagem de leucócitos alta foram mais comuns nas crianças com EP; febre e letargia foram mais comuns naquelas com PPB. Parece possível distinguir crianças com EP de crianças com PPB a partir de achados clínicos e laboratoriais. Como essas duas doenças estão associadas a altas taxas de morbidade e mortalidade, o diagnóstico rápido é crucial.

We compared bacteremic pneumococcal pneumonia (BPP) and pneumococcal empyema (PE), in terms of clinical, radiological, and laboratory findings, in under-fives. A cross-sectional nested cohort study, involving under-fives (102 with PE and 128 with BPP), was conducted at 12 centers in Argentina, Brazil, and the Dominican Republic. Among those with PE, mean age was higher; disease duration was longer; and tachypnea, dyspnea, and high leukocyte counts were more common. Among those with BPP, fever and lethargy were more common. It seems that children with PE can be distinguished from those with BPP on the basis of clinical and laboratory findings. Because both conditions are associated with high rates of morbidity and mortality, prompt diagnosis is crucial.

Objective. To evaluate the accuracy of World Health Organization (WHO) method of interpreting chest radiographs on identifying young children with bacterial pneumonia, and to compare its accuracy with other method. Methods. Chest radiographs from children aged under 5 years old hospitalized for pneumonia, with microbiological evidence of bacterial or viral infection, were evaluated by 3 observers blinded to other data (pediatrician [P], pulmonologist [N], radiologist [R]) according to WHO and Khamapirad scores. A WHO score=1 and a Khamapirad score >2 were selected as the thresholds suggesting bacterial pneumonia. The relationship between radiographic scores and etiology was evaluated using chi square. Sensitivity (Se), specificity (Sp), positive (PPV) and negative (NPV) predictive values for predicting bacterial pneumonia were calculated. Interobserver agreement (P vs. N vs. R) was calculated (kappa). Results. 108 chest radiographs were evaluated (87 viral, 21 bacterial). WHO score= 1 was associated with bacterial pneumonia (p <0.001; OR= 6.4; CI 95%= 1.629.7), achieving a Se= 85%, Sp= 51%, PPV= 30%, NPV= 93%. Khamapirad score >2, evaluated by P, was also associated with bacterial pneumonia (p <0.0008; OR= 6.31; CI 95%= 1.8-24.4), achieving a Se= 80%, Sp= 59%, PPV= 32% NPV= 92%. Interobserver agreement was slightly better using WHO score (P vs. N= 0.82, P vs. R= 0.69, N vs. R= 0.85) than Khamapirad score (P vs. N= 0.48, P vs. R= 0.69, N vs. R= 0.82). Conclusions. Both methods showed similar accuracy in order to identify bacterial pneumonia. WHO score is simpler than Khamapirad score and showed a better interobserver agreement.

Objetivos. Evaluar la capacidad diagnóstica del método de interpretación radiográfico de la Organización Mundial de la Salud (OMS) para identificar neumonía bacteriana en niños y comparar su desempeño con otro método similar. Población, material y métodos. Radiografías de tórax de pacientes menores de 5 años de edad hospitalizados por neumonía con etiología confirmada (bacteriana o viral), fueron evaluadas por 3 observadores (pediatra [P], neumonólogo [N] y radiólogo [R]) según los métodos de OMS y Khamapirad. Se seleccionaron un puntaje OMS= 1 y un Khamapirad >2 para definir neumonía radiológica, presumiblemente bacteriana. Se evaluó asociación entre cada puntaje y etiología por χ² . Se calculó sensibilidad (S), especificidad (E) y valores predictivos positivo (VPP) y negativo (VPN) para predecir neumonía de etiología bacteriana confirmada. Se calculó el acuerdo interobservador (coeficiente kappa). Resultados. Se evaluaron 108 radiografías (87 neumonías virales y 21 bacterianas). Un puntaje OMS= 1, en la evaluación de P, se asoció con etiología bacteriana (p <0, 001; OR= 6, 4; IC 95%= 1, 6-29, 7), alcanzando S= 85%, E= 51%, VPP= 30%, VPN= 93%. Un puntaje Khamapirad >2, se asoció con etiología bacteriana (p= 0, 0008; OR= 6, 31; IC95%= 1, 8-24, 4), alcanzando S= 80%, E= 59%, VPP= 32%, VPN= 92%. Al evaluar las con etiología bacteriana confirmada, el acuerdo interobservador fue ligeramente superior con método OMS (P contra N= 0, 82, P contra R= 0, 69, N contra R= 0, 85) que con Khamapirad (P contra N= 0, 48, P contra R= 0, 69, N contra R= 0, 82). Conclusiones. Ambos métodos mostraron similar capacidad diagnóstica para identificar neumonía bacteriana. El método OMS es más simple y mostró mejor acuerdo interobservador.

As infecções respiratórias agudas (IRA) são importante causa de morbidade e mortalidade em menores de cinco anos. Importantes contrastes são observados em relação a isto nos diferentes países das Américas, e também entre regiões ou estados de um mesmo país. A morbidade está associdada a vários fatores, especialmente com a situação nutricional das pacientes e o tempo de aleitamento materno. Também as características dos cuidados prestados a essas crianças durante a doença são essenciais, com destaque para a percepção dos pais ou responsáveis em relação à doença, os cuidados que os mesmos prestam à criança durante a doença, a preocupação em decidir e consultar os serviços de saúde, a forma em que esses cuidados são oferecidos pelos serviços de saúde e em que as orientações são cumpridas em casa. Especial preocupação deve existir em relação à resistência bacteriana aos antibióticos, sendo um problema crescente na América, com uma média de 26,1% de resistência do Streptococcus pneumoniae à penicilina. Os antibióticos são freqüentemente utilizados de forma irresponsável com 70% das crianças com IRA recebendo-os desnecessariamente. Controlar as IRA tem-se tornado prioridade. Intervenções preventivas como as atuais vacinas conjugadas para Haemophilus influenzae e Streptococcus pneumoniae, e o manejo padronizado de casos, como proposto pela estrategia Atenção Integrada a Doenças Prevalentes na Infância (AIDPI), aparecem como os mais importantes passos para este problema de Saúde Pública.

Acute respiratory infections (ARI) are an important cause of morbidiyty and mortality in children all over the World, particularly in developing countries. Contrasts in mortality can be observed among the countries in America, and also within the countries. Contrasts are also observed in morbidity, associated with differences in nutritional status, absence of breast-feeding and characteristics of care given for ill chidren. Parents perception of disease, patterns and habits of care administered to child during the illness, level of concern about decision to seek assistence, manner in wich care is sought and extent to wich recommendations are followed have great influence in the course and outcome of the disease. Bacterial resistance to antibiotics is an increasing problem in America, with an average of 26,1% resistance of Streptococcus pneumonia to penicilin. Antibiotics are frequently used in irrational way, and up to 70% of ARI receive antibiotics unnecessarily. Controlling IRA has become a priority. Preventive interventions with vaccines, specially current conjugate vaccines against Haemophilus influenzae and Streptococcus pneumoniae, and standardized case management, as proposed by Integrated Management of Childhood Ilness (IMCI) seems to be the most important steps for this public health problem.

OBJECTIVE: To determine which available information at an Emergency Room (ER) consultation is associated with hospitalization or death among children with pneumonia. DESIGN: Prospective cohort study. SETTING: The ER of one university and one private hospital. MEASUREMENT: Using stepwise logistic regression we analyzed factors that showed a univariate association. MAIN RESULTS: Of 2,970 cases, the median age was 1.83 years (range 2 days to 14.5 yrs, mean 2.76 + 2.72 yrs); 25.8% were hospitalized and 0.8% died. Age (2-11 mos, OR 0.4 [0.2-0.6]; 12-59 mos, OR 0.2 [0.1-0.4]; <FONT FACE=Symbol>³</FONT> 5yrs, OR 0.1 [0.08-0.3]), malnutrition (OR 2.0 [1.4-2.7]), underlying chronic illness (OR 1.4 [1.1-1.8]), tachypnea (OR 1.8 [1.4-2.4]), chest indrawing (OR 1.7 [1.4-2.2]), and somnolence (OR 1.8 [1.4-2.4]) were associated with hospitalization and age (2-11 mos, OR 0.3 [0.08-0.8]; <FONT FACE=Symbol>³</FONT> 12 mos, OR 0.06 [0.02-0.2]), malnutrition (OR 3.1 [1.2-7.7]) and underlying chronic illness (OR 4.3 [1.6-11.0]) were associated with death in the multivariate analysis. CONCLUSIONS: Several clinical aspects may be used in assessing need for hospitalization (i.e. young age, malnutrition, underlying chronic illness, tachypnea, chest indrawing and somnolence) for children with pneumonia seen at the ER. Individual intrinsic factors such as age, malnutrition and underlying chronic illness were independently associated with death. Pneumonia should be considered a treatable disease and complete recovery can be achieved in the majority of the cases.

A estratégia de Atenção Integrada às Doenças Prevalentes da Infância (AIDPI), desenvolvida pela Organização Mundial da Saúde (OMS), Organização Panamericana da Saúde (OPAS) e Fundo das Nações Unidas para à Infância (UNICEF), incorpora as experiências prévias de programas para tratar as principais doenças infantis, acrescentando aspectos preventivos e de promoção à saúde. Nesta nova visão, outorga papéis fundamentais à família, à comunidade e ao trabalhador de saúde que desenvolve o seu trabalho no primeiro nível de atenção. A estratégia visa principalmente diminuir as taxas de mortalidade infantil em países e regiões onde elas ainda são muito elevadas, com cifras acima de 40 por 1.000 nascidos vivos, situações em que as pneumonias, diarréias, desnutrição e outras doenças evitáveis são as principais causas de óbito. Pretende também mudar o perfil da demanda ambulatorial dando ênfase a atividades preventivas de alto impacto, como educação em saúde, imunizações e promoção ao aleitamento materno. Permite ainda ao trabalhador de saúde fazer a detecção precoce de sinais de perigo em doenças graves, assim como avaliar e tratar, de forma adequada, os problemas de saúde mais freqüentes, ao mesmo tempo que educa as famílias em relação aos cuidados a serem oferecidos em casa.

The Integrated Management of Childhood Illness (IMCI) strategy developed by the World Health Organization (WHO), Panamerican Health Organization (PAHO) and the United Nation Children's Fund (UNICEF), joint experiences of previous frequent diseases programs in children, with prevention and health promotion activities. In this new approach the family, the community and health workers have a leading role in health condition of the child. The strategy aims a reduction in Infant Mortality Rate, specially in those regions and countries in which it is high. Pneumonia, diarrhea, malnutrition and other preventable diseases are the main causes of deaths in this settings. Health workers can early recognized danger signs of severe diseases, as well as they can evaluate and treat the most frequent health problems. By enhancing prevention and health promotion activities, as better conditions of life, giving an holistic vision of the child and his family, and not only looking for the symptom that motivate the consultation.

Pneumonia is one of the leading causes of hospitalization and death among children in developing countries, and mortality due to pneumonia has been associated with S. pneumoniae infection. This investigation was designed to describe the antimicrobial susceptibility and serotype patterns of pneumococcal strains recovered from the blood of children with community-acquired pneumonia (CAP) and to assess the clinical findings of pneumococcal bacteremic patients with pneumonia. In a 26 month prospective study, blood cultures were obtained as often as possible from children (<16 years of age) diagnosed with CAP in two emergency rooms. Antimicrobial drug susceptibility tests and serotyping were performed when pneumococcus was identified. We studied 3,431 cases and cultured blood samples from 65.5% of those. Pneumococcus was recovered from 0.8% of the blood samples. The differences in age, somnolence, wheezing and hospitalization among children with and without pneumococcal bacteremia were statistically significant. Pneumococcal bacteremia was age-related (mean 1.63 ± 1.55; median 0.92) and associated with somnolence and hospitalization among children with CAP. One strain was recovered from pleural fluid. Penicillin resistance was detected in 21.0% (4/19) of the strains at an intermediate level, whereas 63.0% of the strains were resistant to trimethoprim-sulfamethoxazole. The most common serotypes were 14 and 6B, and these serotypes included the resistant strains. Eight of our 18 isolates from blood were of types included in the heptavalent conjugate pneumococcal vaccine, recently licensed in the USA.

Abstract Mortality in children under five years is still a great problem in the majority of countries in the Americas Region. Desp ite the success of main programs ofpediatric assistance in the 80 "s, like immunizations programs, acute respiratory infections and diarrheal diseases, results are still not satisfactories. Looking for improving the impact ofthis interventions, during the 90's World Health Organization, Pan-American Health Organization, WHO/PAHO and United Nations Children 's Fund (UNICEF) developed the Integrated Management of Childhood Illness (IMCI) strategy, that aims decrease this mortality with preventive and curative actions that focus the attention of the children as a who le, identifying rapidly the very ill children, rationalize the use ofdrugs and take advantage of the consult for making prevention and promotion of health, sp ecially in the familiar and community environment. This new strategy incorporates a global vision of health and disease process, with direct benefits for the children, his family and the community.

Resúmen La mortalidad en ninos menores de 5 anos continúa siendo un problema prioritario en la mayoría de los paises de la Región de las Américas. A pesar dei suceso de las principales campanas de asistencia pediatrica de la decada de 80, tales como los programas ampliados de vacunas, infecciones respiratorias agudas o enfermedades diarreicas agudas, los resultados aún no son satisfactorios. Buscando mejorar el impacto de estas intervenciones, durante la decada de 90 la Organización Panamericana de la Salud, Organización Mundial de la Saludo OPS, OMS y United Nations Children 's Fund ( UNICEF) desarrollaron la estratégia de A tención Integrada a las Enfermedades Prevalentes de la In - fancia (AIEPI) que pretende disminuir mas aún esta mortalidad con acciones preventivas y curativas que enfocan la atención dei nifzo como un todo, identificando rapidamente los ninos gravemente enfermos, racionaliza el uso de medicamentos y aprovecha la consulta para realizar prevención y promoción de salud, especialmente en el ámbito familiar y comunitario. Esta nueva estratégia incorpora una visión global dei proceso salud y enfermedad, con beneficios directos para el nino, su familia y su comunidad.