Importance:Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infections in infants and young children, imposing a substantial burden on health care systems. Nirsevimab, a long-acting monoclonal antibody, has shown high efficacy in clinical trials, and modeling studies suggest it may be cost-effective; however, real-world evidence on its cost-effectiveness in European health care settings remains limited. Objective:To evaluate the real-world cost-effectiveness of nirsevimab immunization in preventing pediatric hospitalizations due to RSV. Design, Setting, and Participants:This multicenter, observational, real-world cost-effectiveness analysis was conducted between October 1, 2022, and March 31, 2025. Precampaign data were modeled using Poisson regression models to estimate expected hospitalizations in the absence of immunization. Data were gathered from 19 pediatric hospitals distributed across 11 Italian regions, from northern to southern areas. Included were all pediatric hospitalizations with RSV-specific International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnoses recorded at participating hospitals between October 1, 2022, and March 31, 2025. Exposures:Regional nirsevimab immunization campaigns with varying start dates and eligibility criteria, implemented between October 2024 and January 2025. Main Outcomes and Measures:Effectiveness, expressed as hospitalizations averted (ΔE), and incremental costs (ΔC) were estimated from the Italian National Health Service perspective. Cost-effectiveness ratios (CERs = ΔC/ΔE) were calculated for each center. Results:During the 2024 to 2025 season, 5924 RSV-related hospitalizations were recorded in children 18 years and younger across 19 centers. Observed admissions were consistently lower than model-based counterfactual predictions in most centers. Immunization averted between 6 and 151 admissions per center, corresponding to a rate of 83 and 1162 per 100 000 children. Incremental costs were negative in most centers, indicating cost savings ranging from -€10 924 (US $12 562.60) to -€266 954 (US $306 997.10) per center. Corresponding cost-effectiveness ratios were negative (-€1071 [US $1231.65] and -€1682 [(US $1934.30]), reflecting a cost-saving intervention. In 2 centers with late initiation and restricted eligibility, immunization was associated with higher costs relative to the number of hospitalizations prevented, with incremental costs of €19 715 (US $22 672.25) and €81 454 (US $93 672.10). Sensitivity analyses confirmed the robustness of results. Conclusions and Relevance:Results of this Italian multicenter, real-world economic evaluation suggest that nirsevimab immunization was both clinically effective and cost saving from a health system perspective. Timing and eligibility of immunization strongly influenced cost-effectiveness, highlighting the importance of early and broad rollout strategies to maximize clinical and economic benefits.

OBJECTIVES:To describe paediatric RSV-hospitalisation trends over six seasons and changes following regional nirsevimab strategies in Italy. METHODS:A Retrospective study across 19 Italian paediatric units was conducted analysing RSV-related hospitalisations in patients aged <18 years from January 2019 to March 2025. Centres were grouped by regional nirsevimab eligibility criteria (Groups A-G). Group-level ratios of 2024-2025 to pre-immunisation hospitalisations were estimated with a negative-binomial model. Influenza was analysed as a negative control RESULTS: 10,915 RSV hospitalisations were recorded. In 2024-2025 RSV season, hospitalisations decreased 43.6% overall. The largest reductions were in groups with broader eligibility and earlier initiation (Group B: ratio 0.28, 95% CI 0.22-0.36; Group A: 0.40, 95% CI 0.22-0.74) and Group F (0.24; single centre, interval indicative). Groups C, D, and E showed more modest reductions (ratios 0.58-0.70), with Group C spanning unity (0.58, 95% CI 0.27-1.25). Group G showed no clear change once baseline instability was accounted for (1.84, 95% CI 1.15-2.94). CONCLUSIONS:These population-level study describe a temporal association between the 2024-2025 nirsevimab rollout and reduced RSV hospitalisations, particularly with broader eligibility and timely rollout. The study design cannot establish causation or compare the effectiveness of regional strategies.

Acute mastoiditis (AM) is the most common intratemporal complication of acute otitis media in children. This multicenter study aimed to describe the epidemiological, clinical, microbiological, and radiological features of pediatric AM in four Italian regions and to identify factors associated with radiologic complications. This retrospective, observational cohort study included all patients under 18 years hospitalized with AM in the pediatric departments of Bari, Forlì, Macerata, and Pescara between January 2022 and May 2025. Demographic, clinical, microbiological, imaging, and management data were extracted from medical records using a standardized form and analyzed descriptively. Logistic regression explored associations between clinical variables and radiologic complications. A total of 118 hospitalizations (117 children; median age 4 years, IQR 2–7.8; 56

AIM:This study summarised the global epidemiology, prevention policies, and public health communication strategies related to infant botulism and exposure to honey. METHODS:A narrative review of epidemiological data was carried out from 1976 to 2024, using surveillance reports, national health agency documents, and peer-reviewed literature. RESULTS:Cases were rare, but honey was the only consistently confirmed dietary source of infant botulism. The median age at onset was 3-4 months, and mortality was below 1% if the infants received intensive care support and specific therapy with human botulism immune globulin. A global review from 2007 to 2021 reported that the USA had approximately 130 cases of infant botulism per year, while Europe, Canada, Japan, and Australia reported markedly lower incidences. Italy had 36 cases between 2001-2020, which represented 8% of all confirmed botulism cases in the country during that period. We found that health authorities uniformly advised against consuming honey before 12 months of age, but warning labels remained voluntary in many regions, and caregiver awareness varied. CONCLUSION:Strengthened paediatric counselling, harmonised labelling policies, and culturally tailored communication strategies are needed to reduce infant botulism by preventing infants under 12 months of age from consuming honey.

Background/Objectives. Respiratory syncytial virus (RSV) bronchiolitis remains a leading cause of hospitalization in infants. In the 2024–2025 season, passive newborn immunization with nirsevimab, a long-acting anti-RSV monoclonal antibody, was introduced for the first time in Italy. However, the immunization campaign was not uniformly implemented on a regional basis due to supply and organizational difficulties. The aim of the study was to assess the real-world impact of nirsevimab prophylaxis during the 2024–2025 bronchiolitis season in four regions of Italy. Methods. This multicenter observational study included infants <12 months hospitalized for bronchiolitis across four Italian centers. Hospitalizations due to RSV and non-RSV bronchiolitis were compared across the 2023–2024 and 2024–2025 seasons, in relation to the timing and coverage of nirsevimab’s introduction in each of the four regions. Results. Early and widespread nirsevimab administration was associated with a significant reduction in RSV hospitalizations and severity of disease. Centers located in regions that had delayed implementation of immunization observed higher RSV burden and intensive care unit admissions. Admissions for non-RSV bronchiolitis remained stable. Conclusions. Timely and universal administration of nirsevimab significantly reduced RSV hospitalizations and severity, while delayed implementation resulted in limited benefit. These findings support early and uniform prophylaxis to mitigate health disparities and seasonal pressure on pediatric healthcare systems.

BACKGROUND:Since March 2024, the European Center for Disease Prevention and Control has reported increased Parvovirus B19 (B19V) infections across 14 European countries. While often self-limiting in healthy children, B19V may cause severe disease in vulnerable populations. METHODS:This multicenter prospective study aimed to characterize the clinical presentation of B19V infection in hospitalized children and identify risk factors for severe outcomes. Data were collected through the INF-ACT pediatric surveillance system, as part of the National Recovery and Resilience Plan. Children hospitalized with confirmed B19V infection were enrolled from January to December 2024 in 10 Italian INF-ACT centers. RESULTS:A total of 135 children were included (median age 7.6 years, interquartile range 4.4-9.9), with 78.5% of cases occurring between April and July 2024. Acute myocarditis (20.7%) and neurologic complications (17.8%) were the most frequent severe manifestations. Myocarditis was significantly associated with younger age ( P < 0.001), longer hospital stays (median 19.5 vs. 6.5 days; P = 0.0018) and higher intensive care unit (ICU) admission rates (71.4% vs. 20.8%; P < 0.001). Multivariate analysis showed myocardial involvement increased the risk of ICU admission over 20-fold ( P < 0.001). CONCLUSIONS:Although often mild, B19V infection can cause severe complications in children, particularly myocarditis and neurologic involvement. Prompt recognition is essential, even in the absence of classic features like erythema infectiosum, to ensure timely monitoring and management of potentially life-threatening outcomes.

Background: Bronchiolitis accounts for a substantial number of pediatric hospitalizations and its epidemiology closely parallels that of respiratory syncytial virus (RSV), its principal etiological agent. International guidelines recommend supportive therapy based primarily on oxygen supplementation and hydration. Methods: This study aimed to assess, across three pediatric wards, the impact of internal monitoring and targeted educational interventions on adherence to bronchiolitis management guidelines. Focus was placed on evaluating the effectiveness of tailored strategies in enhancing the appropriateness of treatment practices. Each center independently developed an audit and feedback strategy aligned with local practices and available resources. In Center 1, monthly staff meetings included guideline refreshers throughout the epidemic season. Center 2 appointed two attending physicians to monitor treatment prescriptions and report deviations. Center 3 established an internal protocol through staff consensus, followed by monthly review sessions. In this retrospective analysis, all consecutive patients admitted with bronchiolitis during the winter seasons of 2022–2023 and 2023–2024 (Period 2) were compared with those admitted in 2021–2022 (Period 1). Results: A total of 623 infants under 24 months of age were included, 451 (72%) of whom tested positive for RSV. Their median length of hospital stay was 6 days; 26 infants (4%) required intensive care, and no deaths were recorded. A comparative analysis of the treatment modalities used—high-flow nasal cannula (HFNC) oxygen therapy, inhaled medications, corticosteroids, and antibiotics—revealed a reduced use of non-recommended therapies (e.g., nebulized β2-agonists, steroids, and antibiotics) in Period 2, alongside heterogeneous patterns in HFNC use. Center-specific strategies, tailored to team dynamics and resource availability, effectively promoted greater adherence to evidence-based guidelines. Conclusions: Our findings suggest that structured internal interventions can lead to more appropriate bronchiolitis management and the improved standardization of care.

Objectives: The aim of this work was to perform a systematic review assessing the pharmacokinetic/pharmacodynamic (PK/PD) properties of dalbavancin and the clinical use for in-label and off-label indications in pediatric patients. Methods: Two authors independently searched the PubMed-MEDLINE and Scopus databases and clinicaltrials.gov up to 20 November 2024, to retrieve randomized controlled trials (RCTs), observational studies, PK studies, and case series/reports assessing dalbavancin PK/PD properties or the clinical use for both in-label and off-label indications in pediatric patients. Data were independently extracted by the two authors, and the quality of the included studies was independently assessed by means of specific tools according to study design. Clinical success was selected as the primary outcome. Descriptive statistics were used for summarizing the retrieved data. Subgroup analysis according to PK/PD data, as well as in-label and off-label indications, was performed. Results: After screening 206 articles, nine studies were included in the systematic review (one RCT, three PK studies, and five case series/reports; n = 267). Dalbavancin exposure was 30% lower in pediatric patients compared to adults. In acute bacterial skin and skin structure infections (ABSSSIs), the overall clinical success of dalbavancin was 96.1-97.3% and 92.9% in RCT and case series, respectively. Bone and joint infections (60.7%) and central-line-associated bloodstream infections (14.3%) represented the most common dalbavancin off-label indications in pediatric patients. Overall, the clinical success for off-label indications was 92.9%. The rate of adverse events ranged from 7.1% to 10.7%. Conclusions: Our systematic review summarized evidence concerning the PK/PD properties of dalbavancin and its use for in-label or off-label indications in pediatric patients. The available findings suggest that dalbavancin may be a valuable alternative for the management of ABSSSIs and/or off-label indications in pediatric patients according to efficacy and safety data, allowing for a potential minimized duration of hospital stay.

OBJECTIVES:A new variant of echovirus 11 (E11) infection is a major health concern in neonates. Here, we describe the clinical and virological characteristics of enterovirus (EV) infections in children hospitalized with acute respiratory infection in Southern Italy. METHODS:Between July 2022 and August 2023, 173 EV infections were identified. Demographic and clinical characteristics, comorbidities, and coinfections were analyzed. Genotypes were identified by sequencing of VP1. Whole-genome sequencing of five E11 strains was performed. RESULTS:Case numbers peaked in July 2022, November-December 2022, and June-July 2023. Coxsackievirus A2 was identified in 36.7%, coxsackievirus B5 in 13.8%, echovirus E11 in 9.2%, and EV-D68 in 6.4% of cases. No child had critical symptoms or a severe infection. The only neonate infected by E11 recovered fully after 5 days in hospital. Phylogenetic analysis revealed that four E11 strains were closely related to divergent lineage I E11 strains identified in France and Italy. CONCLUSIONS:The new variant of E11 was identified in children in Southern Italy. Although the cases were mild, the data suggest that transmission routes and host factors are likely to be main drivers for the development of potentially severe diseases. Systematic epidemiological/molecular surveillance will help us better understand the clinical impact of EV infections and develop preventive strategies.

Acute bacterial skin and skin structure infections (ABSSSI) and osteoarticular infections compound the burden of morbidity, mortality and prolonged hospitalizations among gram-positive infections. Dalbavancin, a second-generation, intravenous lipoglycopeptide, due to its prolonged half-life, can be a valuable alternative in their treatment when administered as inpatient treatment at the price of an extended hospital stay. Between October 2019 and September 2023, 31 children and adolescents were treated with dalbavancin because of bone and joint infections (n = 12 patients, 39%), ABSSSI (n = 13 patients, 42%), mainly for the limbs, facial cellulitis or complicated ABSSSI (n = 6 patients, 19%), at five Italian pediatric centers. Microbiological study provided gram-positive bacterial isolate in 16 cases, in 11 cases from a positive blood culture; 9 of them were MRSA. Twenty-five patients were initially treated with a different antibiotic therapy: beta-lactam-based in 18 patients (58%), glycopeptide-based in 15 patients (48%) and daptomycin in 6 (19%). The median time that elapsed between admission and start of dalbavancin was 18 days. A total of 61 doses of dalbavancin were administered to the 31 patients: 16 received a single dose while the remaining 15 patients received between two (n = 9) and nine doses. The frequency of administration was weekly in five cases or fortnightly in nine patients. Median length of stay in hospital was 16 days. Median time to discharge after the first dose of dalbavancin was 1 day. Treatment was very well-tolerated: of the 61 administered doses, only four doses, administered to four patients, were associated with an adverse event: drug extravasation during intravenous administration occurred in two patients, with no sequelae; however, in two patients the first administration was stopped soon after infusion start: in one (ID #11), due to headache and vomiting; in another (ID #12) due to a systemic reaction. In both patients, drug infusion was not repeated. None of the remaining 29 patients reported treatment failure (resistant or recurrent disease) or an adverse effect during a median follow-up time of two months. The use of dalbavancin was safe, feasible and also effective in shortening the hospital stay in children and adolescents.

This multicenter study in Italian hospitals highlights the epidemiologic disruptions in the circulation of the 5 main respiratory viruses from 2019 to 2023. Our data reveal a resurgence of respiratory syncytial virus and influenza during the 2022-2023 winter season, with an earlier peak in cases for both viruses, emphasizing the importance of timely monitoring.

Background Bronchiolitis is a major cause of hospitalization in infants, particularly in the first six months of life, with approximately 60–80% of admissions due to respiratory syncytial virus (RSV) infection. Currently, no prophylactic options are available for healthy infants. The present study aimed at describing the demographic, clinical, and epidemiological characteristics of infants hospitalized for bronchiolitis in the Apulia region of Italy in 2021. Methods From January to December 2021, data on children aged 0–12 months admitted for bronchiolitis in nine neonatal or pediatric units covering 61% of pediatric beds of hospitals in the Apulia region of Italy were analyzed. Demographic data, comorbidities, need for oxygen support, length of hospital stay, palivizumab administration, and outcomes were collected. For the purpose of the analysis, patients were divided into those aged 0–3 months and > 3 months. A multivariate logistic regression model was used to explore associations between the need for oxygen support and sex, age, comorbidities, history of prematurity, length of hospital stay, and palivizumab administration. Results This study included 349 children aged 0–12 months admitted for bronchiolitis, with a peak of hospitalization in November (7.4 cases/1,000 children). Of these patients, 70.5% were RSV positive, 80.2% were aged 0–3 months, and 73.1% required oxygen support. Moreover, 34.9% required observation in the sub-intensive care unit, and 12.9% in the intensive care unit. Of the infants who required intensive care, 96.9% were aged 0–3 months and 78.8% were born at term. Three patients required mechanical ventilation and one, who required Extra Corporeal Membrane Oxygenation, died. Children aged 0–3 months were more likely to show dyspnea, need oxygen support, and have a longer hospital stay. Conclusions The present study showed that almost all of the children who required intensive care support were aged ≤ 3 months and most were born at term. Therefore, this age group remains the highest risk group for severe bronchiolitis. Preventive measures such as single-dose monoclonal antibody immunoprophylaxis, and maternal and childhood vaccination against RSV, may reduce the high public health burden of bronchiolitis.

Antibiotics account for over 10% of the overall drug expense of the National Health System in Italy in 2021. Their use in children is of particular interest on one side, because acute infections are very common in children, while they build their immunologic library of competence; on the other side, although many acute infections are expected and turn out to be of viral origin, caregivers will often ask the family doctor or primary care attending to reassure them by prescribing antibiotic treatment, although it may often be unnecessary. The inappropriate prescription of antibiotics in children may likely be a source not only of undue economic burden for the public health system but also of increasing development of antimicrobial resistance (AMR). Based on those issues, the inappropriate use of antibiotics in children should be avoided to reduce the risks of unnecessary toxicity, increase in health costs, lifelong effects, and selection of resistant organisms causing undue deaths. Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure an optimal use of antimicrobials to improve patient outcomes while limiting the risk of adverse events including AMR. The aim of this paper is to spread some concept of good use of antibiotics for pediatricians or every other physician involved in the choice to prescribe, or not, antibiotics in children. Several actions could be of help in this process, including the following: (1) identify patients with high probability of bacterial infection; (2) collect samples for culture study before starting antibiotic treatment if invasive bacterial infection is suspected; (3) select the appropriate antibiotic molecule based on local resistance and narrow spectrum for the suspected pathogen(s); avoid multi-antibiotic association; prescribe correct dosage; (4) choose the best route of administration (oral vs. parenteral) and the best schedule of administration for every prescription (i.e., multiple administration for beta lactam); (5) schedule clinical and laboratory re-evaluation with the aim to consider therapeutic de-escalation; (6) stop antibiotic administration as soon as possible, avoiding the application of "antibiotic course".

Bronchiolitis causes a remarkable number of hospitalizations; its epidemiology follows that of respiratory syncytial virus (RSV), its main pathogen. The aim of this study was to evaluate the presenting features, treatment approach, and impact of medical therapy in four pediatric hospitals in Italy. Data on infants < 24 months of age hospitalized with bronchiolitis in the 2021–2022 season were collected. Between October 2021 and February 2022, 214 children were admitted. Median hospital stay was 5 days; none of the patients died. The distribution of the presenting features is largely comparable in the 33 (15.8

Children with chronic disease are at higher risk of invasive infectious disease, including several vaccine-preventable infections. The Italian Association of Pediatric Hospitals (AOPI) carried out a survey of immunization practices: 14/16 AOPI hospitals completed the survey; 50% of them include 100-199 beds, while 21% have <100 beds. In 12/14 hospitals (86%) all vaccinations included in the National Immunization Plan (plus influenza e COVID-19 vaccines) are available for inpatients, in selected wards (n = 4), on single pediatrician initiative (n = 3), by a centralized in-hospital immunization service (n = 2), and the remaining 3 in a "protected vaccination area" or in a COVID-19 pathway. The wards in which vaccination is more frequently offered to in-patients are: General Pediatrics, Neonatology, Pediatric Hematology & Oncology, Pediatric Diabetology, Pediatric Cardiology, and Pediatric Infectious Diseases (range, 58% to 83%). In 58% of vaccinating hospitals, <500 vaccinations/year are reported, while in 17% this number is >2,000/year. A COVID-19 vaccination team is in place for any inpatient child older than 12 years in 42% of hospitals, in 42% only for "fragile" children. A centralized in-hospital immunization service is an emerging model that may contribute to increase compliance to vaccination of fragile patients and to fight against vaccination hesitancy.

CASE In June 2020, a previously healthy 11-year-old boy presented to the eye clinic in Bari, Italy with visual loss in his left eye. He was fully immunized and denied travel outside Italy. He lived in an industrial town in Southern Italy. There was a family history of systemic lupus erythematosus, thyroiditis, and asthma. He reported blunt trauma to his left eye while playing football a few days earlier. There was no history of weight loss, night sweats, headaches, or any neurological symptoms. The child appeared well, and his body weight was 30 kg. Ophthalmological examination showed corrected visual acuity in the right eye of 20/20 while corrected visual acuity in the left eye was 4/20; intraocular pressure was 16 mmHg bilaterally. The left eye had a responsive pupil and transparent lens but slight cellularity in the anterior chamber and inflammation in the pars plana (with snowballs and dense snowbanking). Both eyes had vitritis, though only slight on the right. Fundus examination showed a normal nerve head and no macular edema but peripheral vascular sheathing. The remainder of the physical examination was normal. An initial diagnosis of intermediate uveitis of the left eye was made. Fluorescein angiography showed mild optic nerve head leakage in both eyes, but extensive staining and late leakage of the retinal vessels in the left eye, whereas the right eye had only discrete fluorescein leakage, indicating chronic inflammation. Indocyanine green angiography (ICG), used for the study of choroidal vasculature, showed no sign of choroidal inflammation. Macular optical CT showed a normal macular profile and thickness in both eyes. B-scan ultrasonography showed bilateral vitritis, more evident in the left eye. In addition, the patient’s diagnostic work-up included the following tests: HLA B51, autoimmunity antibody panel (anti-nuclear, anti-dsDNA, ENA, and ANCA antibodies), Widal-Wright, fluorescent treponemal antibody absorption (FTA-ABS), ACE level, and antibodies against Bartonella henselae, Borrelia burgdorferi, toxocariasis, toxoplasma, herpes simplex virus, rubella, cytomegalovirus, mumps virus, and varicella-zoster virus. All these tests were negative. He was discharged with the diagnosis of uveitis of both eyes (left>right) and was treated with prednisone, 12.5 mg per day, with little improvement. An additional test was performed which pointed to the underlying infectious cause. DENOUEMENT Interferon-gamma release assay (IGRA) for tuberculosis was positive. Thus, the patient was sent to the Pediatric Infectious Diseases Unit for further management. No specific risk factors or exposure for TB were identified. Tuberculin skin test (TST) performed while on prednisone was negative. Additional TB diagnostic evaluation was completed including chest radiograph and CT, brain MRI, and bronchoscopy with bronchoalveolar lavage, all of which were negative for TB involvement. Based on the bilateral uveitis and positive IGRA, a final diagnosis of ocular tuberculosis (OTB) was made. Of note, his mother’s TST was positive, but she had no evidence of active disease so was diagnosed with latent TB infection. The remainder of the patient’s household had negative TSTs. No source case was identified. Multi-drug anti-TB therapy with isoniazid (300 mg per day), rifampicin (600 mg per day), and pyrazinamide (750 mg per day) was started. Prednisone (12.5 mg per day) was continued, along with lansoprazole (10 mg per day) and intraocular nepafenac. On day 15 of anti-TB therapy, the boy was discharged with no major change in his visual acuity or his ocular findings. Anti-TB therapy was continued for one year. Attempts at discontinuation of corticosteroid therapy led to worsening of the visual acuity; therefore, steroids were progressively tapered beginning at month 4 of therapy until discontinuation after 1 year. With this treatment, he had clear improvement by 3 months of therapy and complete resolution at 10 months and the patient’s best corrected visual acuity in both eyes was 20/20 after 1 year. The vitreous was clear, and fluorescein angiography only showed slight leakage phenomena in the peripheral lower retinal sectors. As in adults, pediatric uveitis incidence, prevalence, and etiology are affected by geographical variations and ethnicity.1 About 10% of uveitis occurs in children under 16. The yearly incidence of pediatric uveitis is about 4-6 cases per 100,000, and the prevalence rate is about 27 cases per 100,000. Most cases (70-90%) of uveitis in children are of noninfectious origin, and only a minority are due to infectious causes.2 Infectious pathogens associated with uveitis include herpes viruses (HSV, VZV, CMV), parasites (protozoa, nematodes, cestodes, trematodes, and ectoparasites), syphilis, toxoplasmosis, toxocariasis as well as tuberculosis, which is a great mimicker of all the various uveitis entities.3 According to 2019 data on tuberculosis from European Center for Disease Prevention and Control and WHO Europe, Italy has a very low TB incidence of <20/100,000.4 The mean age of new cases was 52.9 years for cases reported among native Italians and 37.2 years for foreign people; 60.6% of cases occurred in adults between 25 and 64 years of age, 19.1% among those >64 years, and 14.8% among those 15-24 years of age. There were 80 cases (2.5%) among children under 5 years of age, and 96 cases (3.0%) among children between 5 and 14 years of age.5 Ocular TB (OTB) is very unusual, especially in children, and few cases have been reported in Italy. Almost all intraocular segments may be involved in OTB, and patients may develop acute or chronic inflammation, either unilateral or bilateral. Anterior uveitis is usually granulomatous, with posterior synechiae, Koeppe and Busacca nodules, mutton-fat keratic precipitates, and/or complicated cataracts. In children, band keratopathy can occur. Intermediate uveitis appears like pars planitis. Features include vitritis with snowball, snow banking, peripheral vascular sheathing, and/or peripheral retino-choroidal granulomas. Posterior uveitis is the most common presentation of OTB with solitary or multiple tubercles, miliary choroidal tubercles, or multifocal choroiditis that may progress to a serpiginous-like lesion. Retinal lesions may take the form of either focal tubercles, subretinal abscesses, or diffuse retinitis with retinal hemorrhagic vasculitis. Exudative retinal hemorrhagic periphlebitis with uveitis is highly suggestive of OTB. While OTB is an extrapulmonary form of TB, in most patients, clinical manifestations at other sites are absent6,7 as in the present pediatric case. Due to the variety of ocular manifestations, a clinical diagnosis of OTB is quite challenging and requires a complete history, physical examination, and fundoscopy. In most cases, a presumptive diagnosis is made based on epidemiological factors, clinical manifestations, and corroborating immunologic evidence. Loss of visual acuity is the most frequent ophthalmological symptom (87.5%); posterior uveitis is the most frequent localization (72.9%). Gupta et al.6 identified broad-based posterior synechiae, retinal vasculitis without choroiditis, retinal vasculitis with choroiditis, and serpiginous-like choroiditis as features of OTB with specificities of 93%, 97%, 99%, and 98%, respectively. However, all these features have poor sensitivity. Other highly suspicious lesions include choroidal granulomas (granulomatous uveitis), multifocal serpiginous choroiditis, occlusive retinal periphlebitis, or vasculitis.6 Confirmation of the diagnosis of OTB is difficult as direct microscopic examination of lesional tissue to find Mycobacterium tuberculosis (MTb) is impractical, and ocular manifestations may also represent a delayed hypersensitivity reaction rather than direct infection.8,9 Polymerase chain reaction (PCR) is considered a rapid method for detecting infectious causes of uveitis, including MTb,10 but the sensitivity and specificity of PCR using ocular samples remains uncertain.11 Diagnosis of tuberculous uveitis (TBU) is also usually made after excluding other causes of uveitis. TBU can cause permanent damage to visual acuity, particularly in patients with a delayed diagnosis. Therefore, prompt initiation of systemic TB treatment is essential to improve prognosis as significant delays are associated with increased morbidity.3 Typically, there is improvement in visual acuity in 74.4% of eyes, but complete response is achieved in only 56.4%.3,12 The Collaborative Ocular Tuberculosis Study 1 (COTS-1) represents the largest collaborative multicenter dataset of ocular TB, including patients from both endemic and nonendemic countries. The diagnostic and inclusion criteria defined by COTS-1 include (1) clinical signs suggestive of ocular tuberculosis and (2) exclusion of other uveitis entities where relevant based on clinical manifestations of disease and regional epidemiology, plus either investigations documenting the mycobacteria or its genome or corroborative investigations such as positive TST, positive IGRA, or evidence of healed or active tuberculosis on chest radiography. The COTS-1 Consensus Group also proposed criteria for treatment13 based on TST, IGRA, and radiology results, type of uveitis (intermediate versus pan-uveitis), and endemic versus nonendemic area. In all scenarios, radiologic evidence of TB disease is required before treatment is recommended. It is interesting to note that based on the inclusion criteria, our patient qualified for the diagnosis of OTB; however, he did not meet the treatment criteria for antitubercular therapy because his chest radiograph was normal. Therefore, strictly following these criteria could have resulted in the inadvertent withholding of specific TB therapy in our patient, which could have had negative prognostic implications. Thus, these guidelines should be applied with caution, particularly for pediatric patients.14

Antimicrobial resistance is a public health problem emerging in all areas of the world, making difficult to treat many common infections. Antimicrobial stewardship is an instrument to fight antimicrobial resistance. Antimicrobial stewardship is a set of procedures aimed at saving as many doses of antibiotics as possible to preserve their future efficacy, limiting the selective pressure on world microbial population. It includes those assessments regarding the administration of antibiotics that start from the correct patient’s selection to start antibiotic treatment, to choose the most suitable molecule and the route of administration, collecting microbiological samples to isolate a microorganism and arrive at any modification of narrow-spectrum antibiotic therapy or even discontinuation of the antibiotic.

On 31 March 2022, Public Health Scotland was alerted to five children aged 3-5 years, presenting to the Glasgow children's hospital with severe hepatitis of unknown etiology within a 3-week period [...].