diagnosis of pediatric infectious diseases

Susanna EspositoPediatric Highly Intensive Care Unit

Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università di Milano

Milano

DIAGNOSIS OF PEDIATRIC INFECTIOUS DISEASES

Laboratory diagnosis in pediatric CAP: diffliculties in everyday practice

Enterovirus D68: importance of surveillance

Measles: importance of prevention

AGENDA

ETIOLOGY OF COMMUNITY-ACQUIRED PNEUMONIA IN HOSPITALIZED CHILDREN

AGE

(Years)

N° VIRAL ETIOLOGY

BACTERIAL ETIOLOGY

MIXED ETIOLOGY

ALL*

<2 108 80 47 34 93

2-5 84 58 56 33 81

>5 62 37 58 19 76

TOTAL 254 62 53 30 85

*Total with detected etiology. Results expressed as percentages of patients. Adapted from Juven et al. Pediatr Infect Dis J 2000

Episodes of Rx-confirmed CAP with viruses in childrenaged 0-12 months (Esposito S et al., Influenza & Other Resp Viruses 2013)

VIRUS No.(%) *

Coinf.No.(%)

^

No. (%)*

Coinf. No.(%)^

No. (%)*

Coinf.No.(%)^

No. (%)*

Coinf.No.(%)^

RSV 14 (33.3)

3 (21.4) 26 (44.8) 13 (50.0) 22 (22.2) 10 (45.4) 62 (36.8) 26 (41.9)

Rhinovirus 17 (40.4)

11 (64.7) 15 (25.8) 10 (66.6) 15 (15.1) 7 (87.5) 47(28.1)

28 (59.5)

Bocavirus 7 (16.6)

6 (85.7) 2 (3,4) 2 (100) 5 (5,0) 5 (100) 14 (10.1)

13 (92.8)

Influenza 2 (4.7) 1 (50.0) 5 (8.6) 1 (20.0) 3 (3.0) 2 (66.6) 10 (7.2) 4 (40.0)

Metapneu. 10 (23.8)

3 (30.0) 5(8.6) 1 (20.0) 2 (2.0) 1 (50.0) 17 (12.2)

5 (29.4)

Coronavirus 2 (4.7) 2 (100) 0 (0.0) 0 5 (5.0) 5 (100) 7 (5.0) 7 (100)

Parainfluenza (1-4)

0 (0) 0 1 (1.7) 0 (0.0) 1 (1.0) 1 (100) 2 (1.4) 1 (50.0)

Adenovirus 0 (0) 0 0 (0.0) 0 (0.0) 1 (1.0) 1 (100) 1 (0.7) 1 (100)

Episodes with viruses

38/42(90.4)

12/38 (31.5)

43/58 (74.1)

16/43 (37.2)

37/39(94.8)

15/37 (40.5)

118/139(84.9)

43/118 (36.4)

•% among the total number of CAP investigated; •^ % of the total number of infections in which the virus was identified

2007-08 2008-09 2009-10 Total episodes

Episodes of Rx-confirmed CAP with viruses in children aged 13-36 months

((Esposito S et al., Influenza & Other Resp Viruses 2013)

VIRUS No.(%) *

Coinf.No.(%)^

No. (%)*

Coinf. No.(%)^

No. (%)*

Coinf.No.(%)^

No. (%)*

Coinf.No.(%)^

RSV 35 (41.1)

16 58 (38.6) 21 30 (30.3)

10 123 (36.8)

47

Rhinovirus 26 (30.5)

15 44 (29.3) 21 24 (24.2)

7 94(28.1)

43

Bocavirus 12 (14.1)

9 15 (10.0) 11 12 (12.1)

6 39 (11.6)

26

Influenza 4 (4.7) 1 16 (10.6) 6 10 (10.1)

1 39 (11.6)

8

Metapneumo.

12 (14.1) 5 13(8.6) 4 6 (6.1) 0 31 (9.2) 9

Coronavirus 3 (3.5) 2 7 (5.8) 3 5 (5.0) 4 15 (4.5) 9

Parainfluenza (1-4)

0 (0) 0 4 (2.6) 2 6 (6.1) 2 10 (3.0) 4

Adenovirus 1 (1.1) 0 4 (2.6) 3 2 (2.0) 1 7 (2.1) 4

Episodes with viruses

68/85(80.0)

20/68 (29.4)

122/150 (81.3)

36/122 (29.5)

78/99(78.8)

14/78 (17.9)

268/334(80.2)

70/268 (26.1)

2007-08 2008-09 Total episodes2009-10

•% among the total number of CAP investigated; •^ % of the total number of infections in which the single virus was identified

• Blood cultures should be obtained in children requiring

hospitalization for presumed bacterial CAP that is

moderate to severe, particularly those with complicated

pneumonia (strong recommendation; low-quality

evidence)

• In improving patients who otherwise meet criteria for

discharge, a positive blood culture with identification or

susceptibility results pending should not routinely

preclude discharge of that patient with appropriate oral

or intravenous antimicrobial therapy. The patient can be

discharged if close follow-up is assured (weak

recommendation; low-quality evidence)

Blood Cultures: Inpatient

IDSA guidelines; CID 2011. Kindly provided by Prof. Greenberg

Blood culture and RT-PCR for the diagnosis of pneumococcal bacteremic CAP

(From Esposito et al., Pediatr Infect Dis J 2012)

� Radiographically confirmed CAP: 510

� Cases associated to S. pneumoniae infection: 73 (14.3%)

� RT-PCR positive: 67 (91.8%)

Blood culture positive: 1 (1.4)

RT-PCR and blood culture positive: 5 (6.8%)

PNEUMOCOCCAL SEROTYPES IN CHILDREN WITH CAP AGED <5 YRS BEFORE THE USE OF PCV-13

(From Esposito S et al., Pediatr Infect Dis 2012 )

4; 2.0%

14; 18.0%

5; 0%

19F; 2.0%

23F; 2.0%

3; 4.0%

6A; 2.0%

9V; 2.0%

18C; 0%

1; 2.0%

7F; 6.0%

6B; 2.0%

Not Typeable;

26.0 %

19A; 32.0%

COVERAGEPCV-7 : 28%PCV-10: 36%PCV-13: 74%

• Sputum samples for culture and Gram stain should be

obtained in hospitalized children who can produce sputum

(weak recommendation; low-quality evidence)

• Urinary antigen detection tests are not recommended for

the diagnosis of pneumococcal pneumonia in children;

false-positive tests are common (strong recommendation;

high quality evidence)


NASOPHARYNGEAL COLONIZATION (%)

IN PNEUMONIA VS HEALTHY CHILDREN

0

5

10

15

20

25

30

S.pneumoniae H.influenzae M.catarrhalis

Healthy Pneumonia

From Nohynek et al., Pediatr Infect Dis J 1995

THE PROPORTION OF BACTERIAL ISOLATES USING NPS AND NTA APPROACHES IN ALRI AND CONTROL CHILDREN

(From Zhang T et al. PLoS One 2010)

URINARY RAPID TEST BINAX NOW FOR PNEUMOCOCCAL DETECTION

Population Binax NOW positive (%)

Binax NOW positive and NP colonization (%)

Binax NOW positive and no NP colonization (%)

Children with IPD

5/5 (100.0)* 2/2 (100.0)* 3/3 (100.0)*

Children with fever but no IPD

29/150 (19.3) 16/28 (57.1)° 13/122 (10.7)

Healthycontrols

35/200 (17.5) 26/53 (49.1)° 9/147 (6.1)

*p<0.05 vs no IPD and controls

°p<0.0001 vs no IPD and controls with no NP colonization

From Esposito S et al. Pediatr Infect Dis J 2004

PNEUMOCOCCAL COLONIZATION IN CAP: ROLE OF BACTERIAL LOAD (From Esposito S et al., PIDJ 2013)

)

1-Number of positive sample with CAP to17 viruses

n°=309/386(80%)

n°=77/386(20%)

2-Number of positive sample with CAP to Sp

n°=209/386(54.1%)

n°=177/386(45.9%)

3-Differences between positivity for Sp on alveolar CAP vs non alveolar CAP cases

n°=148/ 250 (59.2%)

n°=61/ 136 (44.8%)

4-Differences between Sp bacterial load on alveolar CAP vs non alveolar CAP cases

P=0.025

4.13 ± 1.41

3.63 ±1.55

• Sensitive and specific tests for the rapid diagnosis of

influenza virus and other respiratory viruses should be

used in the evaluation of children with CAP. A positive

influenza test may decrease both the need for additional

diagnostic studies and antibiotic use, while guiding

appropriate use of antiviral agents in both outpatient and

inpatient settings (strong recommendation; high-quality

evidence)

• Antibacterial therapy is not necessary for children, either

outpatients or inpatients, with a positive test for influenza

virus in the absence of clinical, laboratory, or radiographic

findings that suggest bacterial co-infection (strong

recommendation; high-quality evidence)

Testing For Viral Pathogens


IMPACT OF RAPID FLU TEST ON PEDIATRICIAN DECISION-MAKING

(From Esposito S et al., Arch Dis Child 2003)

CASES (n=43)

CONTROL GROUP 1 (n=435)

P VALUE CONTROL GROUP 2 (n=479)

PVALUE

Routine blood examination

1 (2.3) 63 (14.5) 0.045 72 (15.0) 0.038

Chest radiograph

2 (4.6) 50 (11.5) 0.207 56 (11.7) 0.208

Antibiotic use 14 (32.6)

282 (64.8) <0.0001 296 (61.8)

0.0003

Days of antib.

Median Range

Antiviral use

Admitted

7

4-10

0

0

7

3-20

0

20 (4.6)

0.944

0.240

7

5-14

0

28 (5.8)

0.961

0.154

Percentages in parentheses

DETECTION OF 17 RESPIRATORY VIRUSES AMONG CHILDREN WITH CAP ADMITTED TO THE ER

(From Esposito et al., Influenza Other Resp Vir 2012)

BACTERIA CULTURED IN CHILDREN DIED DURING INFLUENZA PANDEMIC IN 1918-1919

(From Morens DM et al., J Infect Dis 2008)

CHARACTERISTIC OF PEDIATRIC PATIENTS (7/22) WITH FATAL A/H1N1 INFLUENZA AND BACTERIAL

LUNG INFECTION (From MMWR 2009)

GUIDELINES FOR STARTING, CONTINUING OR STOPPING ANTIBIOTIC THERAPY ACCORDING TO

PCT CONCENTRATION(Esposito et al., Resp Med 2011)

GUIDELINES

Concentration < 0.25 ng/mL

Initiation or continuation of

antibiotics strongly discouraged

Concentration > 0.25 ng/mL

Initiation of continuation of

antibiotics strongly encouraged

CLINICAL, LABORATORY AND RADIOGRAPHIC FINDINGS OF THE STUDY CHILDREN AT

ADMISSION (Esposito et al., Resp Med 2011)

PCT Group (n=155) Controls (n=155)

Clinical findings, mean value + SDAxill. Temp. Peak day value (°C)SpO2 in room air, (%)

38.8 + 0.8591 + 4

38.6 + 0.9692 + 5

Laboratory data, mean value + SDCRP, mg/dLWBC, cell/µLNeutrophils, %

PCT, ng/L

8.8 + 4.716,300 + 4,250

76 + 141.82 + 1.76

7.1 + 3.915,155 + 6,140

67 + 191.79 + 1.88

Positive blood cultures, no. (%) 2 (1.3) 1 (0.6)

Radiographic findings, no. (%)Reticulo-nodular infiltrateSegmental or lobar consolidationBilateral consolidation

55 (35.5)61 (39.3)39 (25.2)

60 (38.7)58 (37.4)37 (23.9)

No significant differences between the groups

ANTIBIOTIC EXPOSURE,

MEAN DAYS ± SD (Esposito et al., Resp Med 2011)

02468

10121416

Mild

CAP (

PCT)

Severe

CAP

(PCT)

Mild

CAP (

CRL)

Severe

CAP

(CRL)

day

s

^p<0.05 vs mild CAP in control group (CRL); °p<0.05 vs severe CAP in control group (CRL).

^°

PERCENTAGE OF ANTIBIOTIC (AB) EXPOSURE (Esposito et al., Resp Med 2011)

0

10

20

30

40

50

60

70

80

90

100

%

AB exposure on

day 2

AB exposure on

day 4

AB exposure on

day 6

AB exposure on

day 8

AB exposure on

day 10

AB exposure on

day 12

AB exposure on

day 14

*p<0.05 vs severe CAP in PCT group; ^p<0.05 vs mild CAP in CRL group; °p<0.05 vs severe CAP in CRL group.

*̂* *̂

*^

^ ^ ^* *

°

°°

°

°

°

°

• Children with signs and symptoms suspicious for

Mycoplasma pneumoniae should be tested to help guide

antibiotic selection (weak recommendation; moderate-

quality evidence)

• Diagnostic testing for Chlamydophila pneumoniae is not

recommended as reliable and readily available diagnostic

tests do not currently exist. (strong recommendation; high-

quality evidence)

Testing for Atypical Bacteria


DIAGNOSTIC TESTS FOR M. PNEUMONIAE AND C. PNEUMONIAE

TEST SPECIMEN COMMENTS

CULTURE Throat or NP swab, Requires tissue culture; notsputum, bronchial routinely available; requireswashing, tissue several days of incubation

PCR Throat or NP swab, No FDA-approved kits; availablesputum, bronchial from research laboratories;washing, tissue potential for rapid diagnosis

SEROLOGY Serum Paired acute-convalescentsera preferred; IgM may take up to 4-6 weeks to appear(therefore retrospective)

CAP AND ATYPICAL BACTERIA IN 418 CHILDREN

0

10

20

30

40

50

60

70

80

2-4 years 5-7 years > 7 years All

M.p.

C.p.

M.p.+C.p.

All

(From Principi et al., Clin Infect Dis 2001)

%

Clinical characteristics of the study population at enrollment (Esposito S et al. CID 2002)

CharacteristicsMalesMean age ± SD, yrsOnset

GradualAcute

Similar illness within

the familyCoughTachypneaFeverRalesWheezesDays of hosp. ± SD

S. pneumoniaeinfection (%)

(N=48)25 (52.1)

3.66 ± 0.899

23 (47.9)25 (52.1)

6 (12.5)31 (64.5)12 (25.0)42 (91.3)45 (93.7)6 (12.5)

6.857 ± 3.52312.325 ± 6.065

Atypical bacteriainfection (%)

(N=46)22 (47.8)

3.75 ± 1.030

26 (56.5)20 (43.5)

9 (19.5)33 (71.7)11 (23.9)39 (84.7)41 (89.1)7 (15.2)

6.744 ± 2.67213.307±5.089

Mixed S. pneum.-atypical bacteria

infection (%) (N=16)8 (50.0)

3.76 ± 1.030

8 (50.0)8 (50.0)

3 (18.7)11 (68.7)4 (25.0)14 (87.5)15 (93.7)2 (12.5)

7.110 ± 2.37013.714±5.517

No significant differences were observed

Laboratory data in the various aetiological groups (Esposito S et al. CID 2002)

ParameterWBC (cells/ µL)

Neutrophils, %Lymphocytes,%Monocytes, %Eosinophils, %Basophils, %

CRP (µg/dL)ESR (mm/1h)

S. pneumoniaeinfection (%)

(N=48)16,669 ± 8,831*°

69 ± 17*°22 ± 15

7 ± 31 ± 2

0.3 ± 0.6109 ± 110*°

57 ± 28

Atypical bacteriainfection (%)

(N=46)12,554±5,404*

59 ± 18*28 ± 17

8 ± 31 ± 1

0.4 ± 0.759 ± 88*47 ± 27

Mixed S.pneum.-atypical bacteria infect. (%) (N=16)13,141 ± 4,540°

63 ± 16°25 ± 16

7 ± 31 ± 2

0.3 ± 0.477 ± 79°52 ± 44

Mean values ± SD. *p < 0.05 vs *atypical bacteria infection and ° mixed S. pneumoniae -atypical bacteria infection; no other significant differences were

observed. WBC, white blood cell count; CRP, C-react ive protein, ESR, erythrocyte sedimentation rate

CHARACTERI-SATION OF

NOVELENTEROVIRUSES

(From Piralla A et al., PLoS One 2013)

Division of Clinical Virology

What is enterovirus D68

• Isolated in 1962• Respiratory samples• Children with bronchiolitis-type illness• Between 1970 and 2005, 26 cases reported


Before 2010

• 2005 to 2010 reports from France, Philippines, USA, UK, Netherlands, Japan…

• Mostly respiratory problems, bronchiolitis type illness• Summer and early fall


2010 Groningen

• Bronchiolitis-type illness• Some severe cases requiring

intensive care treatment• Many patients had underlying

condition


After 2010

• Very few reported cases• Many labs fail to detect EV-

D68 in quality assurance panels

• No EV-D68 specific test• Not all rhinovirus PCRs pick

up EV-D68• Not all labs look for rhinovirus


Problem of underdetecting

• What if I want to start looking for EV-D68:– Develop EV-D68 specific PCR– Add enterovirus PCR to routine screening and subsequent

sequencing

Parainfluenza 4

Coronavirus OC43


2014

• August: first reports of severe respiratory illness in Children in Missouri (USA)

• Week later: reports of severe respiratory illness in children in Illinois (2014)

• Sequencing by CDC • 19/22 Missouri cases EV-D68• 11/14 cases from Illinois EV-D68


Enterovirus D68 outbreak

• Children (<16 years)• 68% had prior history of wheezing• Nearly all patients required intensive care treament• Many reports from other states and Canada• Testing (sequencing) at CDC: only severe cases


What’s up

• Several labs have started looking for EV-D68• Sequencing gives most info (a lot of work)• 2 new targeted PCRs available

Niesters et al., unpublished data

patient Sex age date symptoms ICU/days Underlying conditon

1 F 1y/ 11m Feb 2014 Moderate bronchilitis-type respiratory illness

no none

2 F 1y/ 7m May 2014 Severe respiratory illness, intubaton, mechanical ventilation

Yes/4 none

3 F 6m June 2014 Mild cold symptoms no Congenital heart disease

4 M 3y/ 9m June 2014 Severe respiratory illness, intubation, mechanical ventilation

Yes/8 Sickle cell anemia

5 M 65y July 2014 Moderate wheezing and cough

no Lung transplantation

6 M 1 y July 2014 Severe respiratory illness, intubation, mechanical ventilation

Yes/5 none

7 F 6w July 2014 Feeding problem no Gastro-esophageal reflux

8 M 3y/ 10m July 2014 Severe respiratory illness, intubation, mechanical ventilation

Yes/1 Ex-premature

9 M 6m Aug 2014 Mild cold symptoms * Congenital heart disease

10 M 14y Aug 2014 Mild cold symptoms * Traumatic brain injury

11 F 1y/ 6m Aug 2014 Mild cold symptoms no epilepsy

12 M 1m Aug 2014 Severe respiratory illness, intubation, mechanical ventilation

Yes/1 Ex-premature

13 F 22y Aug 2014 Cough, SOB, fatigue No Heart transplantation

14 F 44y Aug 2014 Cough, SOB No COPD

15 M 1y/ 5m Sep 2014 Moderate wheezing, cough No Tracheomalacia, heart disease

16 F 63y Sep 2014 Asthma exacerbation no asthma

17 F 53y Sep 2014 Wheezing, pneumonia no Renal transplantation

* These children were admitted to ICU for other reasonsSOB=shortness of breath

EV-D68 CAPs in Milan

CAP = community acquired pneumoniaMELAS syndrome = mithocondrial encephalopathy, lactic acidosis and stroke-like episodes Sp= Streptococcus pneumoniae

Esposito et al., unpublished data

Measles Case Distribution by Month and WHO Regions, 2008-2014

This is surveillance data, hence for the last month, the data may be incomplete. SEAR India is not included in this graph.As of 27 May 2013, South Sudan has been reassigned to the Africa region (AFR) from the Eastern Mediterranean region (EMR).

Data source: surveillance DEF fileData in HQ as of 19 January 2015

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

gen

2008

Apr Jul Oct gen

2009

Apr Jul Oct gen

2010

Apr Jul Oct gen

2011

Apr Jul Oct gen

2012

Apr Jul Oct gen

2013

Apr Jul Oct gen

2014

Apr Jul Oct

AFR SEAR AMR EMR EUR WPR

Reported Measles Incidence Rate*,Dec 2013 to Nov 2014 (12M period)

*Rate per 1'000'000 population


The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. ©WHO 2015. All rights reserved.

<1 (77 countries or 40%)

≥1 - <5 (32 countries or 16%)

≥5 - <10 (16 countries or 8%)

≥10 - <50 (40 countries or 21%)

≥50 (15 countries or 8%)

No data reported to WHO HQ

(14 countries or 7%)

Not applicable

Number of Reported Measles Cases with onset date from Jun 2014 to Nov 2014 (6M period)



0 (64 countries or 33%)

1 - 9 (33 countries or 17%)

10 - 99 (42 countries or 22%)

100 - 999 (28 countries or 15%)

≥1000 (7 countries or 4%)

No data reported to WHO HQ

(20 countries or 10%)

Not applicable

Distribution of measles genotypesfrom Dec-2013 to Nov-2014 (12M period)

Data source: MeaNS Database; 20 January 2015Updated on 20 January 2015


Countries with Genotype data available

Measles in the USA

Measles vaccination coverage in Europe(2 doses, 2012-2013)

(From ECDC, 2015)

From ECDC, 2014

February 2014 – Italian newspapersA measles outbreak was declared on 27 February 2014 on the Costa Pacifica ship cruising in the west Mediterranean sea. The index case was a crew member who sought medical care off the ship for fever and rash on 22 February and was laboratory confirmed to have measles on 27 February. As for 27 March, 37 cases of measles have been reported 36 from Italy and one from Austria: 21 cases were among the crew members, 7 among passengers and 9 are passengers contacts. More than 800 crew members were vaccinated in response to the outbreak.

March 2014 – Corriere della Sera

From ECDC, 2014

Status of measles and rubella elimination verification process WHO European Region*

50established National Verification

Committees 3 pending46 Annual Status Reports (2013)

MEASLES 22 interrupted

transmission

RUBELLA 24 interrupted

transmissionAndorra, Armenia, Azerbaijan, Belarus, Bulgaria, Cyprus, Czech Republic, Estonia, Finland, Hungary, Israel, Latvia, Luxembourg, Malta, Norway, Republic of Moldova, Portugal, Slovakia, Slovenia, Sweden, Tajikistan, Turkmenistan

Andorra, Armenia, Azerbaijan, Belarus, Cyprus, Czech Republic, Estonia, Finland, Hungary, Ireland, Israel, Latvia, Luxembourg, Malta, Netherlands, Norway, Republic of Moldova, Portugal, Slovakia, Slovenia, Spain, Tajikistan, Turkmenistan, United Kingdom

52

* Based on 2013 Annual Status Updates as of Nov 2014

Status reports have not been submitted* from:

53

Albania, Andorra, Bosnia and Herzegovina, Denmark, Hungary, Italy,

Monaco, Romania, San Marino, Slovenia, Turkey, Ukraine

* As of 5 March 2014

CONCLUSIONS

• Need of advanced appropriatelyinterpretated laboratory tests for common pediatric infecious diseases

• Role of surveillance in monitoringinfection outbreaks

• Impact of high vaccination coverage on vaccine-preventable diseases

54

diagnosis of pediatric infectious diseases

Health & Medicine

total number of cap

confirmed cap

pediatric cap

total number of infections

total episodes2009

total episodesepisodes

presumed bacterial cap

resp viruses