Resumo Objetivo: Caracterizar o papel do VPH-4 e suas características clínicas em crianças brasileiras com menos de dois anos de idade com infecções agudas do trato respiratório inferior. Métodos: Ensaios em tempo real foram utilizados para identificar tipos de VPH e outros vírus respiratórios comuns em aspirados nasofaríngeos. Mil e duas crianças com doença aguda do trato respiratório inferior foram inscritas para participar de fevereiro de 2008 a agosto de 2010. Resultados: 104 (10,4%) pacientes eram VPH positivos, dos quais 60 (57,7%) eram positivos para VPH-3, 30 (28,8%) para VPH-4, 12 (11,5%) para VPH-1 e dois (1,9%) para VPH-2. Sete (6,7%) pacientes apresentaram mais de um tipo de VPH detectado. Os sintomas mais frequentes foram tosse e taquipneia, semelhantes a outras infecções respiratórias virais. As manifestações clínicas não diferiram de forma significativa entre as infecções por VPH-1, -2, -3 e -4. Os VPH-1, -3 e -4 estavam presentes na população estudada ao longo dos três anos de vigilância, e o VPH-3 foi o tipo predominante identificado nos primeiros dois anos. Conclusão: Os VPHs contribuem substancialmente para a DRA pediátrica no Brasil com quase 30% dessa contribuição atribuível ao VPH-4.

Abstract Objective: Characterize the role of human parainfluenza virus and its clinical features in Brazilian children under 2 years of age presenting with acute lower respiratory tract infections. Methods: Real-time assays were used to identify strains of human parainfluenza virus and other common respiratory viruses in nasopharyngeal aspirates. One thousand and two children presenting with acute lower respiratory tract illnesses were enrolled from February 2008 to August 2010. Results: One hundred and four (10.4%) patients were human parainfluenza virus positive, of whom 60 (57.7%) were positive for human parainfluenza virus-3, 30 (28.8%) for human parainfluenza virus-4, 12 (11.5%) for human parainfluenza virus-1, and two (1.9%) for human parainfluenza virus-2. Seven (6.7%) patients had more than one strain of human parainfluenza virus detected. The most frequent symptoms were tachypnea and cough, similar to other viral respiratory infections. Clinical manifestations did not differ significantly between human parainfluenza virus-1, -2, -3, and -4 infections. Human parainfluenza virus-1, -3, and -4 were present in the population studied throughout the three years of surveillance, with human parainfluenza virus-3 being the predominant type identified in the first two years. Conclusion: Human parainfluenza viruses contribute substantially to pediatric acute respiratory illness (ARI) in Brazil, with nearly 30% of this contribution attributable to human parainfluenza virus-4.

OBJETIVO: estimar a prevalência da infecção pelos vírus respiratórios em pacientes pediátricos com câncer e infecção respiratória aguda (IRA) e/ou febre. MÉTODOS: estudo transversal, de janeiro de 2011 a dezembro de 2012. Foram analisadas secreções de aspirado da nasofaringe de menores de 21 anos, com quadro respiratório agudo, atendidos nos hospitais Grendacc e HU, Jundiaí, SP. Foi aplicado o teste rápido para detecção dos vírus influenza (Kit Biotrin(r)) e a reação em cadeia da polimerase multiplex em tempo real (Kit multiplex/Fast Trade(r)) para detecção dos vírus: influenza (A, H1N1, B), rinovírus, parainfluenza, adenovírus respiratório, vírus respiratório sincicial, parechovírus, bocavírus, metapneumovírus humano e coronavírus humano. Foi estimada a prevalência de infecção viral e usados testes de associação (χ2 ou teste exato de Fisher). RESULTADOS: foram analisadas 104 amostras de aspirado de nasofaringe e sangue. A mediana para a idade foi 12±5,2 anos; masculino (51%); cor branca (68%); IVAS de repetição (32%); uso prévio de antibiótico (32%); tosse (19,8%); e contato com IVAS (8%). Apresentavam-se em bom estado geral 94,3% dos pacientes. A leucemia linfocítica aguda (42,3%) foi mais prevalente. Foram detectados vírus respiratórios em 50% das amostras: rinovírus (23,1%), vírus sincicial respiratório A/B (8,7%) e coronavírus (6,8%). Ocorreu codetecção em 19% entre dois vírus, e de 3% entre três vírus, sendo a mais frequente entre rinovírus e coronavírus 43. Febre em neutropênicos foi de 13%, sendo quatro (30,7%) com vírus positivo. Não houve óbitos. CONCLUSÕES: a prevalência de vírus respiratórios foi importante no episódio infeccioso, sem aumento da morbimortalidade. As codetecções foram frequentes em pacientes com câncer e IRA.

OBJECTIVE: to estimate the prevalence of infection by respiratory viruses in pediatric patients with cancer and acute respiratory infection (ARI) and/or fever. METHODS: cross-sectional study, from January 2011 to December 2012. The secretions of nasopharyngeal aspirates were analyzed in children younger than 21 years with acute respiratory infections. Patients were treated at the Grupo em Defesa da Criança Com Câncer (Grendacc) and University Hospital (HU), Jundiaí, SP. The rapid test was used for detection of influenza virus (Kit Biotrin, Inc. Ireland), and real-time multiplex polymerase chain reaction (FTD, Respiratory pathogens, multiplex Fast Trade Kit, Malta) for detection of influenza virus (H1N1, B), rhinovirus, parainfluenza virus, adenovirus, respiratory syncytial virus, human parechovirus, bocavirus, metapneumovirus, and human coronavirus. The prevalence of viral infection was estimated and association tests were used (χ2 or Fisher's exact test). RESULTS: 104 samples of nasopharyngeal aspirate and blood were analyzed. The median age was 12 ± 5.2 years, 51% males, 68% whites, 32% had repeated ARIs, 32% prior antibiotic use, 19.8% cough, and 8% contact with ARIs. A total of 94.3% were in good general status. Acute lymphocytic leukemia (42.3%) was the most prevalent neoplasia. Respiratory viruses were detected in 50 samples: rhinoviruses (23.1%), respiratory syncytial virus AB (8.7%), and coronavirus (6.8%). Co-detection occurred in 19% of cases with 2 viruses and in 3% of those with 3 viruses, and was more frequent between rhinovirus and coronavirus 43. Fever in neutropenic patients was observed in 13%, of which four (30.7) were positive for viruses. There were no deaths. CONCLUSIONS: the prevalence of respiratory viruses was relevant in the infectious episode, with no increase in morbidity and mortality. Viral co-detection was frequent in patients with cancer and ARIs.

OBJETIVO: Caracterizar e comparar aspectos clínicos, epidemiológicos e laboratoriais delactentes com evidências de infecção aguda do trato respiratório inferior (IATRI) associada à detecção do adenovírus (ADV) ou do vírus sincicial respiratório (VSR). MÉTODOS: Um estudo preliminar de vigilância de infecções respiratórias desenvolveu coleta de aspirado nasofaríngeo (ANF) para pesquisa viral, vinculada ao preenchimento de protocolo padrão, de menores de dois anos internados com quadro de IATRI em hospital universitário, entre março de 2008 e agosto de 2011. Utilizou-se técnica da reação em cadeia da polimerase (PCR) para oito vírus: ADV, VSR, metapneumovírus, parainfluenza 1, 2 e 3 e influenza A e B. Foram selecionados para comparações os casos com ANF coletado nas primeiras 24 horas da admissão, resultado de hemocultura negativo e detecção exclusiva de ADV (grupo Gadv) ou VSR (grupo Gvsr). RESULTADOS: O estudo preliminar incluiu coleta de 1.121 amostras de ANF, sendo 813 coletadas nas primeiras 24 h da admissão, das quais 50,3% foram positivas para ao menos um dos vírus, com VSR em primeiro lugar, em 27,3%, e ADV em segundo, em 15,8% dos casos pesquisados. Dentre os aspectos analisados nos grupos Gadv (n = 58) e Gvsr (n = 134), destacaram-se a média da idade mais elevada, maior frequência da prescrição de antibióticos e medianas mais elevadas para contagem total de leucócitos e valores da proteína C-reativa no Gadv. CONCLUSÕES: A PCR utilizada pode detectar formas persistentes/latentes de ADV, aspecto aser considerado ao interpretar os resultados. Estudos complementares com técnicas diagnósticas quantitativas, por exemplo, poderiam evidenciar a importância da elevada frequência verificada.

OBJECTIVE: To characterize and compare clinical, epidemiological, and laboratory aspects ofinfants with acute lower respiratory infection (ALRI) associated with the detection of adenovirus(ADV) or respiratory syncytial virus (RSV). METHODS: A preliminary respiratory infection surveillance study collected samples of nasopharyngeal aspirate (NPA) for viral research, linked to the completion of a standard protocol, from children younger than two years admitted to a university hospital with ALRI, between March of 2008 and August of 2011. Polymerase chain reaction (PCR) was used for eight viruses: ADV, RSV, metapneumovirus, Parainfluenza 1, 2, and 3, and Influenza A and B. Cases with NPA collectedduring the first 24 hours of admission, negative results of blood culture, and exclusive detection of ADV (Gadv group) or RSV (Grsv group) were selected for comparisons. RESULTS: The preliminary study included collection of 1,121 samples of NPA, 813 collected in thefirst 24 hours of admission, of which 50.3% were positive for at least one virus; RSV was identifiedin 27.3% of cases surveyed, and ADV was identified in 15.8%. Among the aspects analyzed inthe Gadv (n = 58) and Grsv (n = 134) groups, the following are noteworthy: the higher meanage, more frequent prescription of antibiotics, and the highest median of total white blood cellcount and C-reactive protein values in Gadv. CONCLUSIONS: PCR can detect persistent/latent forms of ADV, an aspect to be considered wheninterpreting results. Additional studies with quantitative diagnostic techniques could elucidatethe importance of the high frequency observed.

Staphylococcus aureus resistentes à oxacilina (MRSA) são, atualmente, um problema global. Pacientes com fibrose cística (FC) são frequentemente colonizados e infectados por MRSA. A realização de testes de susceptibilidade acurados é extremamente importante para o manejo da terapia antimicrobiana nesses indivíduos. Nesse estudo, realizamos comparação entre as acurácias de diversos testes de susceptibilidade à oxacilina, em cepas de S. aureus isoladas de pacientes com fibrose cística, tanto sensíveis como resistentes à oxacilina, com diferentes tipos de SCCmec, e utilizando a detecção do gene mecA como método padrão. A sensibilidade e a especificidade do disco de oxacilina, do Etest, e da placa de agar screening com oxacilina foram de 100%. A sensibilidade do disco de cefoxitina foi 85%, com especificidade de 100%. Em cepas clinicamente relevantes, a utilização combinada de mais de um método deveria ser considerada.

Methicillin-resistant Staphylococcus aureus (MRSA) are now a worldwide problem. Cystic fibrosis (CF) patients are commonly colonized and infected by MRSA. Accurate oxacillin susceptibility testing is mandatory for the adequate management of these patients. We performed a comparison of the accuracy of different tests in CF isolates, including methicillin-susceptible S. aureus and MRSA with different SCCmec types, and using the mecA gene as the gold-standard. The sensitivity and specificity of oxacillin disc, Etest, and oxacillin agar screening plate were 100%. Sensitivity of the cefoxitin disc was 85% and specificity was 100%. For clinically relevant isolates, laboratories may consider the use of a combination of two phenotypic methods.

Objetivo: Avaliar a genotipagem e subtipagem em crianças experimentadas e virgens de tratamento, assimcomoperfis de resistência a medicamentos através da genotipagem nessas crianças. Métodos: Estudo retrospectivo de crianças HIV positivas virgens de tratamento e HIV positivas que não responderam ao tratamento pela terapia antirretroviral altamente ativa (HAART), acompanhadas na Santa Casa de São Paulo (SP). A genotipagem foi realizada com produtos purificados de reação em cadeia da polimerase (PCR) de RNA retrotranscrito, utilizando-se o kit comercial Viroseq HIV-1 Genotyping System 2.0 ou a técnica de nested PCR in-house. O sequenciamento foi realizado com equipamento automático (ABI 3100). As mutações de resistência antirretroviral (ARV) foram analisadas no Stanford HIV Drug Resistance Database e a subtipagem realizada no U.S. National Center for Biotechnology Information (NCBI), utilizando-se o programa de análises SimPlot, juntamente com a análise filogenética. Resultados: Não foi detectada nenhuma mutação de resistência primária ARV nas 24 crianças virgens de tratamento, embora tenham ocorrido mutações que podem contribuir para a resistência aos inibidores da transcriptase reversa análogos de nucleosídeos (ITRN) (12,5%) e aos inibidores da protease (IP) (95,8%). Para as 23 crianças que não responderam à HAART, foram encontradas mutações de resistência ARV aos ITR Nem 95,6% e aos inibidores da transcriptase reversa não-análogos de nucleosídeos (ITRNN) em 60,8%. Para os IP, foram observadas mutações de resistência ARV em 95,7%, 47,8% das quais apresentavam apenas polimorfismos. Nas análises de subtipagem,78,3%das sequências agruparam-se no subtipo B do HIV-1, 4,3% no C, 13% no F e 4,4% em formas recombinantes. Conclusões: Nossos resultados mostrambaixas taxas de resistência primária em crianças virgens de tratamento e altas taxas de resistência emcrianças que não responderamao tratamento ARV, o que é compatível com o uso ARV nesses pacientes.

Objective: To evaluate genotyping and subtyping in antiretroviral (ARV) naïve and experienced children, as well as drug resistance profiles through genotyping in these children. Methods: This retrospective study assessed ARV-naïve HIV children and HIV children failing highly active antiretroviral treatment (HAART) followed up at Santa Casa de São Paulo. Genotypingwas performed using purified polymerase chain reaction (PCR) products from retrotranscribed RNA using Kit Viroseq HIV-1 Genotyping System 2.0 or nested PCR in-house. Sequencing was performed using automatic equipment (ABI 3100). ARV resistance mutations were analyzed in the Stanford HIV Drug Resistance Database and subtypingwas performed at the National Center for Biotechnology Information (NCBI), using SimPlot analysis, together with phylogenetic analysis. Results: No primary ARV resistance mutation was detected in the 24 ARV-naïve children, although there were mutations that may contribute to resistance to nucleoside analogue reverse transcriptase inhibitors (NRTI) (12.5%) and to protease inhibitors (PI) (95.8%). For the 23 children failing HAART, we found ARV resistance mutations to NRTI in 95.6% and to non-nucleoside analogue reverse transcriptase inhibitors (NNRTI) in 60.8%. For PI, we found ARV resistance mutations in 95.7%, 47.8% of which had only polymorfisms. In the subtyping analyses, 78.3% of the sequences clustered in HIV-1 subtype B, 4.3% in C, 13% in F and 4.4% in recombinant forms. Conclusion: Our results show low rates of primary resistance in ARV-naïve children and high rates of resistance in children failing ARV treatment, which is compatible with ARV use in these patients.

Pneumococcal (Pnc) carriage is associated with pneumococcal diseases. Breast feeding and maternal vaccination may be a useful approach to prevent pneumococcal infection in young infants. We examined the risk of Pnc carriage by infants at six months of age after pneumococcal polysaccharide vaccination of pregnant women. We selected 139 pregnant woman. The woman were randomly allocated to receive 23-valent polysaccharide vaccines during pregnancy (Group 1) after pregnancy (Group 2) or not receive any vaccine (Group 3). Nasopharyngeal swabs were collected from the infants at three and six months of age. The infants were evaluated monthly during the first six months. We included 47 mothers in Group 1, 45 mothers in Group 2 and 47 mothers in Group 3. Forty-seven percent of the babies were exclusively breast fed until six months, 26% received both breast feeding and artificial feeding and 13% received only artificial feeding. Among those patients, 26% were colonized by Pnc at six months (12 from Group 1, 13 from Group 2, and 12 from Group 3). There was no significant difference in colonization between the three groups. Thirty percent of the children were colonized by a non-susceptible strain. We concluded that young infants (three months old) are already susceptible to pneumococcal carriage. Vaccination during pregnancy with a polysaccharide vaccine did not decrease Pnc colonization.

OBJETIVO: Avaliar a genotipagem e subtipagem em crianças experimentadas e virgens de tratamento, assim como perfis de resistência a medicamentos através da genotipagem nessas crianças. MÉTODOS: Estudo retrospectivo de crianças HIV positivas virgens de tratamento e HIV positivas que não responderam ao tratamento pela terapia antirretroviral altamente ativa (HAART), acompanhadas na Santa Casa de São Paulo (SP). A genotipagem foi realizada com produtos purificados de reação em cadeia da polimerase (PCR) de RNA retrotranscrito, utilizando-se o kit comercial Viroseq HIV-1 Genotyping System 2.0 ou a técnica de nested PCR in-house. O sequenciamento foi realizado com equipamento automático (ABI 3100). As mutações de resistência antirretroviral (ARV) foram analisadas no Stanford HIV Drug Resistance Database e a subtipagem realizada no U.S. National Center for Biotechnology Information (NCBI), utilizando-se o programa de análises SimPlot, juntamente com a análise filogenética. RESULTADOS: Não foi detectada nenhuma mutação de resistência primária ARV nas 24 crianças virgens de tratamento, embora tenham ocorrido mutações que podem contribuir para a resistência aos inibidores da transcriptase reversa análogos de nucleosídeos (ITRN) (12,5%) e aos inibidores da protease (IP) (95,8%). Para as 23 crianças que não responderam à HAART, foram encontradas mutações de resistência ARV aos ITRN em 95,6% e aos inibidores da transcriptase reversa não-análogos de nucleosídeos (ITRNN) em 60,8%. Para os IP, foram observadas mutações de resistência ARV em 95,7%, 47,8% das quais apresentavam apenas polimorfismos. Nas análises de subtipagem, 78,3% das sequências agruparam-se no subtipo B do HIV-1, 4,3% no C, 13% no F e 4,4% em formas recombinantes. CONCLUSÕES: Nossos resultados mostram baixas taxas de resistência primária em crianças virgens de tratamento e altas taxas de resistência em crianças que não responderam ao tratamento ARV, o que é compatível com o uso ARV nesses pacientes.

OBJECTIVE: To evaluate genotyping and subtyping in antiretroviral (ARV) naïve and experienced children, as well as drug resistance profiles through genotyping in these children. METHODS: This retrospective study assessed ARV-naïve HIV children and HIV children failing highly active antiretroviral treatment (HAART) followed up at Santa Casa de São Paulo. Genotyping was performed using purified polymerase chain reaction (PCR) products from retrotranscribed RNA using Kit Viroseq HIV-1 Genotyping System 2.0 or nested PCR in-house. Sequencing was performed using automatic equipment (ABI 3100). ARV resistance mutations were analyzed in the Stanford HIV Drug Resistance Database and subtyping was performed at the National Center for Biotechnology Information (NCBI), using SimPlot analysis, together with phylogenetic analysis. RESULTS: No primary ARV resistance mutation was detected in the 24 ARV-naïve children, although there were mutations that may contribute to resistance to nucleoside analogue reverse transcriptase inhibitors (NRTI) (12.5%) and to protease inhibitors (PI) (95.8%). For the 23 children failing HAART, we found ARV resistance mutations to NRTI in 95.6% and to non-nucleoside analogue reverse transcriptase inhibitors (NNRTI) in 60.8%. For PI, we found ARV resistance mutations in 95.7%, 47.8% of which had only polymorfisms. In the subtyping analyses, 78.3% of the sequences clustered in HIV-1 subtype B, 4.3% in C, 13% in F and 4.4% in recombinant forms. CONCLUSION: Our results show low rates of primary resistance in ARV-naïve children and high rates of resistance in children failing ARV treatment, which is compatible with ARV use in these patients.

The purpose of this study was to identify the rate of infections due to RSV and other viruses in children. In addition we have analyzed demographic data and clinical characteristics of the RSV-positive patients comparing with patients infected by other respiratory viruses. We also described the seasonality of the RSV occurrence in a hospital in São Paulo. Children below 5 years old admitted in Santa Casa de São Paulo Hospital between February 2005 and September 2006 due to acute respiratory infections (ARI) were included. A nasopharyngeal specimens were obtained with sterile No. 5 French feeding catheters as soon as possible (usually within 24 h). Specimens were kept refrigerated at 4ºC and transported to Adolfo Lutz Institute, where the indirect immunofluorescent assay was performed. Virus identified by these assay included RSV, Adenovirus, Influenza A and B virus and Parainfluenza 1, 2, and 3. Clinical data from each group was compared. Four hundred and fifty five cases were included in the study, with 30% positive for some type of virus. Viruses that were identified included Respiratory Syncytial Virus (73.03%), Influenza (8.42%), Parainfluenza (8.42%) and Adenovirus (3.37%). We divided the subjects in 3 groups: Group 1 RSV-Positive, Group 2 Other Positive Viruses and Group 3 Negative for Respiratory Virus. Mean age (months) was of 7.5 for RSV-positive children, 7.6 for other viruses, and 8 for negative for respiratory virus. The RSV-Positive Group was significantly younger than the Group Negative for Respiratory Virus (p<0.05). Signs of UAI were more present in the Positive RSV Group (p<0.05). General mortality was of 2.41%. There was a higher incidence of RSV between the months of March and August in the two years of the study. Our study indicates RSV as the most prevalent viral agent in children admitted due to (ARI), especially in infants below 3 months old. We have also found that infections due to RSV can occur in months others than the classic seasonal period.

Knowledge about antimicrobial resistance patterns of the etiological agents of urinary tract infections (UTIs) is essential for appropriate therapy. Urinary isolates from symptomatic UTI cases attended at Santa Casa University Hospital of São Paulo from August 1986 to December 1989 and August 2004 to December 2005 were identified by conventional methods. Antimicrobial resistance testing was performed by Kirby Bauer's disc diffusion method. Among the 257 children, E. coli was found in 77%. A high prevalence of resistance was observed against ampicillin and TMP/SMX (55% and 51%). The antibiotic resistance rates for E. coli were: nitrofurantoin (6%), nalidixic acid (14%), 1st generation cephalosporin (13%), 3rd generation cephalosporins (5%), aminoglycosides (2%), norfloxacin (9%) and ciprofloxacin (4%). We found that E. coli was the predominant bacterial pathogen of community-acquired UTIs. We also detected increasing resistance to TMP/SMX among UTI pathogens in this population.

Streptococcus pyogenes meningitis (SPM) occurs sporadically, even with the increase of invasive streptococcal disease observed in the past years. We reported two cases of SPM in infants to alert pediatricians for the possibility of this agent as a cause of meningitis in previously healthy children.

The aim of this study was to identify the risk factors for nosocomial bloodstream infections by multidrug resistant Gram-negative bacilli. From November 2001 to December 2003, in the Pediatric Department of the Santa Casa de São Paulo, a retrospective case-control study was developed concerning patients who had nosocomial bloodstream infection caused by Gram-negative bacilli. Patients with multidrug resistant infections were designated as case patients, and control patients were those with an infection that did not meet the criteria for multidrug resistance. Previous use of central venous catheter and previous use of vancomycin plus third generation cephalosporins were associated to a higher chance of infections by multidrug resistant Gram-negative bacilli (Odds ratio - 5.8 and 5.2, respectively). Regarding sensitivity of the isolated agents, 47.8% were multidrug resistant, 54.2% were Klebsiella spp. ESBL producers and 36.4% were imipenem resistant Pseudomonas aeruginosa. The lethality rate was 36.9% in the studied cases and this rate was significantly higher in the group of patients with multidrug resistant infections (p=0.013). Risk factor identification as well as the knowledge of the susceptibility of the nosocomial infectious agents gave us the possibility to perform preventive and control strategies to reduce the costs and mortality related to these infections.

OBJETIVOS: O diagnóstico e tratamento correto das faringotonsilites causadas pelo estreptococo beta-hemolítico do grupo A é importante, particularmente na prevenção das seqüelas não-supurativas. Achados clínicos continuam sendo utilizados para diferenciar infecção estreptocócica de faringotonsilite viral. A Academia Americana de Pediatria recomenda que o diagnóstico da faringotonsilite estreptocócica seja sempre confirmado por métodos de identificação microbiológica. O objetivo deste estudo foi avaliar a acurácia do diagnóstico clínico comparado com resultados de cultura e teste rápido no diagnóstico das faringotonsilites estreptocócicas. MÉTODOS: Crianças entre 2 e 13 anos com diagnóstico clínico de faringotonsilite avaliadas na unidade de emergência pediátrica da Santa Casa de São Paulo eram selecionadas, e aquelas com sintomas de infecção viral eram excluídas. Foram registrados achados clínicos e colhidos suabes para a realização de cultura e teste rápido para estreptococo do grupo A. RESULTADOS: Das 376 crianças avaliadas, a cultura foi positiva em 96 (24,4%). A presença de petéquias, exsudato e gânglios dolorosos foi mais comum nas crianças com culturas positivas, mas com baixa acurácia diagnóstica. A avaliação subjetiva do médico que assistia o paciente não identificou 21% dos casos positivos e recomendou antibióticos para 47% das crianças com cultura negativa, contra 3 e 6% identificados pelo teste rápido, respectivamente. CONCLUSÕES: Um método de diagnóstico microbiológico é necessário para a adequada prescrição de antibióticos em crianças com faringotonsilites estreptocócicas.

OBJECTIVES: Diagnosis and correct treatment of group A streptococcal sore throat is important particularly to prevent non-suppurative sequelae. Clinical findings continue to be used to differentiate streptococcal infection from viral sore throat. The American Academy of Pediatrics recommends that streptococcal sore throat diagnosis should always be performed by microbiological identification methods. The aim of this study is to evaluate the accuracy of clinical diagnosis in comparison with culture and rapid test. METHODS: Children aged 2 to 13 years who had received a clinical diagnosis of sore throat and sought treatment at the pediatric emergency unit of São Paulo Santa Casa were evaluated and those with clinical signs or viral infection were excluded. Clinical findings were recorded and swabs were taken for group A Streptococcus cultures and a Streptococcus rapid test. RESULTS: The culture was positive in 96 (24.4%) of the 376 children evaluated. The presence of petechiae, purulent exudate and painful tonsils were more likely to occur in children with positive streptococcus cultures, however they exhibited low diagnostic accuracy. The doctors' subjective evaluation failed to identify 21% of positive cases and antibiotics were prescribed in 47% of negative cases, compared with 3 and 6%, respectively, for the rapid test. CONCLUSIONS: A microbiologic method is necessary for the correct prescription of antibiotics in children with streptococcal sore throat.

OBJETIVO: Estudar seqüencialmente a flora traqueal em pacientes internados em unidade de terapia intensiva pediátrica e associar esta flora com o tempo de internação, a utilização prévia de antimicrobianos e o diagnóstico de pneumonia associada à ventilação mecânica. MÉTODOS: A população estudada foi constituída de pacientes pediátricos admitidos em uma unidade de terapia intensiva pediátrica entre novembro de 2002 e dezembro de 2003 e submetidos a ventilação mecânica. Foram coletadas três amostras seriadas de secreção traqueal de cada paciente. A primeira coleta foi realizada dentro das primeiras 6 horas após a admissão, e as amostras seguintes, depois de 48 e 96 horas. RESULTADOS: Foram estudados 100 pacientes com idade entre 1 dia e 14 anos. Nas três coletas realizadas, observou-se um aumento do percentual de culturas positivas para Pseudomonas aeruginosa, de 6 para 22% (p = 0,002), e também uma diminuição das culturas positivas para Staphylococcus aureus, de 23 para 8% (p = 0,009). No grupo com uso prévio de antimicrobianos, houve maior freqüência de isolamento de Candida spp (p < 0,05). Dezesseis (23,5%) dos 68 pacientes que foram internados sem diagnóstico de pneumonia desenvolveram pneumonia associada à ventilação mecânica. Em relação à cultura de secreção traqueal desses pacientes, foram obtidas culturas positivas em 10 casos: seis S. aureus (com três Acinetobacter baumanni concomitantes), dois Klebsiella spp. (com um Enterobacter spp. concomitante), um Candida spp. e um P. aeruginosa. CONCLUSÃO: O monitoramento seqüencial da secreção traqueal pode ser útil na avaliação das alterações da flora microbiana nas unidades de terapia intensiva pediátrica.

OBJECTIVE: To evaluate, sequentially, tracheal aspirates from patients admitted to a pediatric intensive care unit and to associate these pathogens with length of hospital stay, previous use of antimicrobial therapy and diagnoses of ventilator-associated pneumonia. METHODS: The study population consisted of patients admitted to a pediatric intensive care unit, between November 2002 and December 2003, on ventilator support. Three tracheal aspirates were collected serially from each patient. The first tracheal aspirate sample was obtained 6 hours after admission to the intensive care unit and the remaining samples were collected after 48 and 96 hours. RESULTS: One hundred patients aged from one day to 14 years were assessed. Positive tracheal cultures were observed to have increased in the three tracheal aspirate samples collected from each patient for Pseudomonas aeruginosa, from 6 to 22% (p = 0.002), and to have decreased for Staphylococcus aureus, from 23 to 8% (p = 0.009). Isolation of Candida spp increased for the subset that had received previous antimicrobial therapy (p < 0,05). Sixteen (23,5%) out of 68 patients admitted without pneumonia developed ventilator-associated pneumonia. Positive tracheal aspirate cultures were obtained in 10 out of 16 of these patients: six were positive for Staphylococcus aureus (three associated with Acinetobacter baumanii), two for Klebsiella spp (one associated with Enterobacter spp), one for Pseudomonas aeruginosa and one for Candida spp. CONCLUSION: Sequential evaluation of tracheal aspirates may be useful to track changes in bacterial flora at pediatric intensive care units.

We evaluated the clinical presentation and determined the ocular and neurologic sequelae in children with congenital toxoplasmosis in Brazil, taking into consideration the shortage of national publications on this disease. Follow-up evaluations were made of 43 children with congenital toxoplasmosis referred to Santa Casa de São Paulo, during a period of at least five years. Selection of the cases was based in clinical and laboratory criteria. A clear predominance of children with subclinical presentation of the disease at birth (88%) was found. Of the 43 children, 22 (51%) developed neurological manifestations. Using skull radiography, we detected neuroradiologic alterations in seven children (16%) and with tomography in 33 children (77%). Neurological sequelae were identified in 15 children (54%) in the group with cerebral calcifications and in 7 (47%) in the group without cerebral calcifications. We observed chorioretinitis in 95% of the cases. Reactivation of cicatricial lesions and the emergence of new ocular lesions were observed in five cases. The most frequent neurological manifestation was a delay in neuropsychomotor development. Most remarkable was the finding that cerebral calcifications were not associated with a higher incidence of neurological sequelae among the children. Chorioretinitis was the main ocular sequel of the infection, found in nearly all children; it can manifest years from birth, even in children submitted to specific therapy during the first year of life, highlighting the importance of a follow-up of these children.