Pediatric parapneumonic empyema (PPE) has been increasing in several countries including Spain. Streptococcus pneumoniae is a major PPE pathogen; however, antimicrobial pretreatment before pleural fl uid (PF) sampling frequently results in negative diagnostic cultures, thus greatly underestimating the contribution of pneumococci, especially pneumococci susceptible to antimicrobial agents, to PPE. The study aim was to identify the serotypes and genotypes that cause PPE by using molecular diagnostics and relate these data to disease incidence and severity. A total of 208 children with PPE were prospectively enrolled; blood and PF samples were collected. Pneumococci were detected in 79% of culture-positive and 84% of culture-negative samples. All pneumococci were genotyped by multilocus sequence typing. Serotypes were determined for 111 PPE cases; 48% were serotype 1, of 3 major genotypes previously circulating in Spain. Variance in patient complication rates was statistically signifi cant by serotype. The recent PPE increase is principally due to nonvaccine serotypes, especially the highly invasive serotype 1. P leural effusions occur in at least 40% of children hospitalized with bacterial pneumonia. Occasionally, the infectious agent invades the pleura to cause pediatric paraneumonic empyema (PPE) (1), characterized by the presence of pus. Although rarely associated with fatalities in industrialized countries, PPE often results in prolonged hospitalization and surgical intervention, and patients are at risk for serious and long-lasting illness (2,3).An increasing incidence of PPE has been reported in several countries since the mid-1990s (2-6), but it is not clear why. Streptococcus pneumoniae is the most frequently found microorganism in most recent reports. However, conventional microbiologic culture methods have low sensitivity, usually because of antimicrobial pretreatment before sterile-site sampling. Consequently, the contribution of antimicrobial drug-susceptible serotypes might be higher than reported estimates. Molecular and antigen detection-based techniques, including direct molecular typing of culture-negative pleural fl uid (PF) samples (7), can be useful adjuncts in defi ning the contributory role of different microorganisms and pneumococcal serotypes to PPE etiology (4,8).Our study's goal was to prospectively investigate the molecular epidemiology of pneumococcal PPE among children admitted to 3 of the largest tertiary-care pediatric hospitals in Spain. There were 4 objectives: 1) identify the serotypes and multilocus sequence typing (MLST) genotypes causing PPE and determine whether a temporal change in the circulating genotypes could explain the recent increase; 2) determine whether the causal genotypes were only associated with PPE or also caused other invasive pneumococcal disease (IPD) in the same population, or were carried by healthy children; 3) compare serotypes and genotypes recovered from northern and southern Spain in the context of regional differences in 7-valent pneumococcal conjugat...

There has been an increase in the incidence of PPE that parallels the increase in CAP. S. pneumoniae remains the principal causal agent, and NVS clearly predominate. The use of PCR to detect S. pneumoniae substantially increases etiologic diagnosis. The use of antigen assays to detect pneumococcus in pleural fluid is a quick and sensitive diagnostic method, and thus a valid alternative to PCR.

A blood culture (BC) is frequently requested in both patients with a suspected occult bacteremia/invasive infection as well as those with certain focal infections. Few data are available on the characteristics of patients in whom a bacteremia is identified in the Pediatric Emergency Department (PED). A prospective multicenter registry was established by the Spanish Pediatric Emergency Society. Epidemiological data, complementary test results, clinical management, and final outcome were recorded. Data from the first three years of the registry were analyzed. A true bacterial pathogen grew in 932 of 65,169 BCs collected [1.43 %; 95 % confidence interval (CI) 1.34-1.51 %], with 711 of them collected in patients without previously known bacteremia risk factors. Among them, 335 (47.1 %) were younger than 1 year old and 467 (65.7 %) had a normal Pediatric Assessment Triangle (PAT) on admission. Overall, the most frequently isolated bacterial species was Streptococcus pneumoniae (27.3 %; 47.6 % among patients with an altered PAT). The main pathogens were Escherichia coli (40.3 %) and S. agalactiae (35.7 %) among patients younger than 3 months, S. pneumoniae among patients 3-60 months old (40.0 %), and S. aureus (31.9 %) among patients over 60 months of age. Neisseria meningitidis was the leading cause of sepsis in patients older than 3 months. Eight patients died; none of them had a pneumococcal bacteremia and all had abnormal PAT findings on admission. S. pneumoniae is the main cause of bacteremia in patients without bacteremia risk factors who attended Spanish PEDs. Age and general appearance influence the frequency of each bacterial species. General appearance also influences the associated mortality.

There are no unified protocols governing the management of healthy children with febrile neutropenia in the emergency department (ED). Conservative management is the norm, with admission and empirical broad-spectrum antibiotics prescribed, although viral infections are considered the most frequent etiology. The aim of this study was to describe the clinical outcomes and identified etiologies of unsuspected neutropenia in febrile immunocompetent children assessed in the ED. This was a retrospective study: well-appearing healthy children <18 years old with febrile moderate [absolute neutrophil count (ANC) 500-999 neutrophils ×10(9)/l] or severe (ANC <500 neutrophils ×10(9)/l) neutropenia diagnosed in ED between 2005 and 2013 were included. Patients newly diagnosed with hematologic or oncologic disease were excluded. We included 190 patients: 158 (83.2 %) with moderate and 32(16.8 %) with severe neutropenia. One hundred and one (53.2 %) were admitted; 48(47.5 %) with broad-spectrum antibiotics. The median length of stay was 3 days (IQR 3-5) and the median duration of neutropenia was 6 days (IQR 3-12). An infectious agent was identified in 23(12.1 %); 21 (91.3 %) were viruses. Four (2.1 %) children had a serious bacterial infection (SBI): urinary tract infection and lobar pneumonia (two cases each). All blood cultures performed (144; 75.8 %) were negative. Over the 1-year follow-up, one or several blood tests were performed on 167 patients (87.9 %); two (1.2 %) were diagnosed with autoimmune chronic neutropenia. Previously healthy children with moderate or severe febrile neutropenia have a low risk of SBI and a favorable clinical outcome. Less aggressive management could be carried out in most of them. Although chronic hematological diseases are infrequently diagnosed, serial ANC are necessary to detect them.