Spontaneous bacterial peritonitis (SBP) is a life-threatening complication of idiopathic nephrotic syndrome (INS) in children. Evidence on the optimal duration of antibiotics in this population is limited. We investigated whether 5-day antibiotic therapy is non-inferior to 7-day therapy for SBP in children with INS. In this single-center, open-label, randomized controlled non-inferiority trial, 50 children aged 1-14 years with INS and SBP were allocated 1:1 to intravenous ceftriaxone for 5 days (Group A, n = 25) or 7 days (Group B, n = 25). The primary outcome was composite clinical response (resolution of fever, abdominal pain, and tenderness) at the end of treatment, analyzed by intention-to-treat. The pre-specified non-inferiority margin was -15%. Secondary outcomes included bacteriological cure, cytological response, and the need for additional antibiotics. Fifty children [median age 50 (30.8-92) months] were randomized. Composite clinical response was achieved in 25/25 (100%) in Group A versus 22/25 (88%) in Group B (risk difference 12%, 95% CI -3.5% to 30.0%; P = 0.23); the lower CI bound exceeded the -15% non-inferiority margin, establishing non-inferiority. Bacteriological cure was achieved in 96% of both groups. Cytological response (64% vs 72%; P = 0.54) was inconclusive for non-inferiority. Additional or modified antibiotic therapy was required in 16% versus 20% (P = 1.00). Median hospitalization was comparable (10 vs 11 days; P > 0.05). No ceftriaxone-related adverse events were recorded. Five-day intravenous ceftriaxone is non-inferior to 7-day therapy for SBP in children with INS, with respect to composite clinical response; the secondary outcome of cytological response was inconclusive for non-inferiority.
Critically ill children face high risks of mortality and healthcare-associated infections. Probiotics may improve outcomes by modulating gut microbiota and enhancing immune function. To evaluate the efficacy and safety of probiotics in critically ill children in pediatric intensive care units (PICUs). We systematically reviewed randomized controlled trials (RCTs) from PubMed, EMBASE, SCOPUS, and Web of Science until 10 June 2024. The primary outcome was all-cause mortality; secondary outcomes were ventilator-associated pneumonia (VAP), length of hospital stay (LOS), and duration of mechanical ventilation (MV). Risk ratios (RR) and mean differences (MD) were pooled using random-effects models (DerSimonian-Laird), with Hartung-Knapp adjustment as a sensitivity analysis. Evidence certainty was assessed using GRADE. Eight RCTs involving 744 children were included. Probiotics did not significantly reduce all-cause mortality (RR 0.85, 95% CI 0.66-1.11; P = .24; I² = 0%; low certainty); estimates were similar under Hartung-Knapp adjustment (RR 0.85, 0.69-1.06; P = .14) and in a sensitivity analysis restricted to low-risk-of-bias trials (RR 0.89, 0.60-1.34; P = .58). Probiotics significantly reduced VAP (RR 0.47, 95% CI 0.35-0.64; P < .0001; I² = 0%; high certainty), halving pneumonia risk (absolute risk reduction 21.9%; number needed to treat approximately 5). Reductions in LOS (MD -2.57 days, 95% CI -7.26 to 2.11; P = .20) and MV (MD -1.61 days, -4.43 to 1.20; P = .17) were nonsignificant (low certainty). No serious probiotic-associated adverse events occurred. High-certainty evidence indicates probiotics reduce VAP in critically ill children; the mortality effect was inconclusive. Probiotics may be considered an adjunctive strategy for VAP prevention in the PICU, pending larger multicenter trials. PROSPERO REGISTRY NUMBER:CRD42024546238.
Meconium aspiration syndrome (MAS) is one of the common causes of respiratory distress among newborn. Severe MAS is associated with considerable morbidity and mortality, and there is sparse data on this entity from large studies from low- and middle-income countries. To determine the incidence of meconium aspiration syndrome (MAS) and severe MAS in a large perinatal centre over a 17-year period and to study the clinical course, complications, and outcomes of newborn with severe MAS. This was a retrospective study of babies admitted in the unit between 2006 and 2022. The list of babies with a diagnosis of MAS was extracted from the admission register and cross-checked with the ventilation database and discharge summaries. Relevant maternal, perinatal as well as postnatal courses, investigations, and outcomes were collected from the clinical workstation and the summaries. During the 17-year period, there were 206 377 deliveries in the hospital. There were 1294 babies admitted with MAS; 146 (11.3%) babies satisfied the criteria for severe MAS. With 73 of these newborn being inborn, incidence of severe MAS was 3.5/10 000 (95% CI 2.7-4.3/10 000) live births among inborn babies. High-frequency ventilation was required in 54 newborn (37%). The median duration of ventilation was 4 days (IQR 3-7 days). Sixteen babies had pulmonary air leak (11%) and persistent pulmonary hypertension (PPHN) was present in 63 babies (43%). The median length of hospital stay was 13 days (IQR 9-18). Of the 146 newborn with severe MAS, 118 survived (80.8%). Adverse outcome was associated with presence of PPHN [OR-5.24 (95% CI 1.7-15.9)] and pneumothorax [OR-17.3 (95% CI 3.5-85.2)]. Sixty-nine (53.9%) of the survivors had long-term follow-up. Adverse neurodevelopmental outcomes were present in 7.8% of neonates, which included developmental delay, microcephaly, cerebral palsy, seizure disorder, autistic traits, and hearing loss. A small proportion (11.3%) of babies with MAS had severe MAS. Nearly one-fifth of babies with severe MAS had adverse short-term outcome. The presence of PPHN and air leaks were significantly associated with adverse outcomes.
Over the past three decades, the recognition and management of dengue fever (DF) and severe dengue (SD) in children have undergone significant transformation. In the 1990s, limited understanding of dengue pathophysiology led to delayed recognition, with aggressive fluid resuscitation, invasive ventilation, and frequent blood product use, often resulting in adverse outcomes. The 1997 World Health Organisation (WHO) Guidelines introduced a structured classification and emphasized cautious fluid management, improving survival. Advances in diagnostics, particularly non-structural (NS) protein antigen testing, enabled earlier detection in the 2000s. The revised WHO 2009 classification and recognition of Expanded Dengue Syndrome (EDS) in 2012 broadened the understanding of severe organ involvement beyond plasma leakage. In the 2020s, improved intensive care unit (ICU) technologies enabled advanced organ support, and the coronavirus disease of 2019 (COVID-19) pandemic highlighted potential viral interactions. Ongoing controversy remains regarding the role of immunomodulation for dengue-associated hyperinflammation. Continued clinical research is essential to refine management strategies and optimize outcomes in severe dengue.
