Summary: Over the past decade, the genus Aeromonas has undergone a number of significant changes of practical importance to clinical microbiologists and scientists alike. In parallel with the molecular revolution in microbiology, several new species have been identified on a phylogenetic basis, and the genome of the type species, A. hydrophila ATCC 7966, has been sequenced. In addition to established disease associations, Aeromonas has been shown to be a significant cause of infections associated with natural disasters (hurricanes, tsunamis, and earthquakes) and has been linked to emerging or new illnesses, including near-drowning events, prostatitis, and hemolytic-uremic syndrome. Despite these achievements, issues still remain regarding the role that Aeromonas plays in bacterial gastroenteritis, the extent to which species identification should be attempted in the clinical laboratory, and laboratory reporting of test results from contaminated body sites containing aeromonads. This article provides an extensive review of these topics, in addition to others, such as taxonomic issues, microbial pathogenicity, and antimicrobial resistance markers.

The Genus Aeromonas: Taxonomy, Pathogenicity, and Infection

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

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The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America

The British Thoracic Society first published management guidelines for community acquired pneumonia in children in 2002 and covered available evidence to early 2000. These updated guidelines represent a review of new evidence since then and consensus clinical opinion where evidence was not found. This document incorporates material from the 2002 guidelines and supersedes the previous guideline document.

https://thorax.bmj.com/content/thoraxjnl/66/Suppl_2/ii1.full.pdf

British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011

### 1.1 An overview of the ILD guideline

Since the publication of the first BTS guidelines for diffuse lung disease nearly 10 years ago,1 the specialty has seen considerable change. The early discussions of the Guideline Group centred upon whether the revised document might consist of the 1999 document with minor adaptations. However, it was considered that too much change had taken place in the intervening years to justify a simple editorial approach. The last decade had seen the development of a new consensus terminology for the idiopathic interstitial pneumonias (IIP)2 stimulated, in part, by the identification of non-specific interstitial pneumonia (NSIP) as a discrete histological pattern with increasingly recognised clinical correlates.3 The better prognosis seen in fibrotic NSIP than in idiopathic pulmonary fibrosis (IPF)4 5 fuelled a more intense approach to diagnosis in cases of suspected IPF. This in turn has led to a radical change in accepted diagnostic gold standards, which have become increasingly multidisciplinary and dependent equally upon the skills of pathologists, radiologists and clinicians.6 NSIP, as a new entity, has posed particular difficulties. With more detailed studies of outcome specific to individual IIPs, especially IPF and fibrotic NSIP, the prognostic weighting given to pulmonary function impairment has been refined, especially with regard to longitudinal functional trends.7 Most important, with the standardisation of terminology, it became possible to recruit patients into multicentre treatment studies.8–10 With regard to IPF in particular, the last 3 years have seen more studies of treatment than in the previous history of the speciality, yet there is no universally accepted “best current treatment”.

### 1.2 Methodology for constructing guidelines and making recommendations

The overall process for generating BTS guidelines has been addressed in numerous recently published documents (available at http://www.brit-thoracic.org.uk/guidelines.html). The methodology applied herein is broadly similar and is not therefore described in detail. However, there are specific aspects in the …

https://thorax.bmj.com/content/thoraxjnl/63/Suppl_5/v1.full.pdf

Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society.

The aim of this study was to examine the associations between sleep and neurobehavioral functioning (NBF) in school-age children. These variables were assessed for 135 unreferred, healthy school children (69 boys and 66 girls), from second-, fourth-, and sixth-grade classes. Objective assessment methods were used on the participants in their regular home settings. Sleep was monitored using actigraphy for 5 consecutive nights; and NBF was assessed using a computerized neurobehavioral evaluation system, administered twice, at different times of the day. Significant correlations between sleep-quality measures and NBF measures were found, particularly in the younger age group. Children with fragmented sleep were characterized by lower performance on NBF measures, particularly those associated with more complex tasks such as a continuous performance test and a symbol-digit substitution test. These children also had higher rates of behavior problems as reported by their parents on the Child Behavior Checklist. These results highlight the association between sleep quality, NBF, and behavior regulation in child development; and raise important questions about the origins of these associations and their developmental and clinical significance.

/pdf/sleep-neurobehavioral-functioning-and-behavior-problems-in-57y3ccctz0.pdf

Sleep, neurobehavioral functioning, and behavior problems in school-age children

BACKGROUND—Respiratory syncytial virus (RSV) infects nearly all children by the end of their second winter. Why some develop bronchiolitis is poorly understood; it is not known whether there is a genetic component. The pathological features include neutrophil infiltration and high levels of interleukin 8 (IL-8), a potent neutrophil chemoattractant.
METHODS—Common genetic variants of the promoter region of the IL-8 gene were identified by sequencing DNA from 36 healthy individuals. Genetic correlates of IL-8 production were assessed using whole blood from 50 healthy subjects. To investigate genetic correlates of disease severity 117 nuclear families were recruited in which a child had required hospital admission for RSV bronchiolitis.
RESULTS—A common single nucleotide polymorphism (allele frequency 0.44) was identified 251 bp upstream of the IL-8 transcription start site. The IL8-251A allele tended to be associated with increased IL-8 production by lipopolysaccharide stimulated whole blood (p=0.07). Using the transmission disequilibrium test, the frequency of this allele was significantly increased in infants with bronchiolitis (transmission = 62% (95% confidence interval (CI) 53 to 71), p=0.014) and particularly in those without known risk factors (transmission= 78% (95% CI 62 to 93), p=0.004).
CONCLUSION—Disease severity following RSV infection appears to be determined by a genetic factor close to the IL-8 gene. Further analysis of this effect may elucidate causal processes in the pathogenesis of RSV bronchiolitis.

https://thorax.bmj.com/content/thoraxjnl/55/12/1023.full.pdf

Association of respiratory syncytial virus bronchiolitis with the interleukin 8 gene region in UK families.

“It seems probable that this study covers the period of practical extinction of empyema as an important disease.” Lionakis B et al , J Pediatr 1958. 

### 1.1 Structure of the guideline

The format follows that used for the BTS guidelines on the management of pleural disease in adults.1 At the start there is a summary table of the abstracted bullet points from each section. Following that is an algorithm summarising the management of pleural infection in children (fig 1). Each section starts with bulleted points of key recommendations using the revised SIGN grading system (table 1) available on http://www.sign.ac.uk/guidelines/fulltext/50/section6.html. Beneath each set of bullet points is a short paragraph detailing the referenced literature and the rationale behind the recommendations. The primary source literature has been individually graded for its methodology and the grading is given alongside each reference using the revised SIGN levels of evidence (table 2).

View this table:

 Table 1 
 Revised SIGN grading system: grades of recommendation



View this table:

 Table 2 
 Revised SIGN grading system: levels of evidence





 Figure 1 
 Algorithm for the management of pleural infection in children.



### 1.2 Methodology for generation of the guidelines

The initial literature search was carried out by the Library of the National Heart Lung Institute, Imperial College London. Further searches were then carried out by members of the working group who concentrated on their own topics. Details of the search strategy are given in Appendix 1.

Each section of the guideline was researched and drafted by a subgroup of the Paediatric Pleural Diseases Subcommittee (itself a subcommittee of the BTS Standards of Care Committee). Publications were rated according to the SIGN criteria for the calibre of the methodology of the research to give levels of evidence (table 2). Tables of evidence were then produced before writing the guideline sections using the SIGN grades of recommendations (table 1). Once all parts were merged into one document, the whole group then met to discuss …

https://thorax.bmj.com/content/thoraxjnl/60/suppl_1/i1.full.pdf

BTS guidelines for the management of pleural infection in children

Background: The role of intrapleural fibrinolytic agents in the treatment of childhood empyema has not been established. A randomised double blind placebo controlled trial of intrapleural urokinase was performed in children with parapneumonic empyema. Methods: Sixty children (median age 3.3 years) were recruited from 10 centres and randomised to receive either intrapleural urokinase 40 000 units in 40 ml or saline 12 hourly for 3 days. The primary outcome measure was length of hospital stay after entry to the trial. Results: Treatment with urokinase resulted in a significantly shorter hospital stay (7.4 v 9.5 days; ratio of geometric means 1.28, CI 1.16 to 1.41 p=0.027). A post hoc analysis showed that the use of small percutaneous drains was also associated with shorter hospital stay. Children treated with a combination of urokinase and a small drain had the shortest stay (6.0 days, CI 4.6 to 7.8). Conclusion: Intrapleural urokinase is effective in treating empyema in children and significantly shortens hospital stay.

https://thorax.bmj.com/content/thoraxjnl/57/4/343.full.pdf

Randomised trial of intrapleural urokinase in the treatment of childhood empyema

Objective To investigate a reported rise in the emergency hospital admission of children in England for conditions usually managed in the community. Setting and design Population-based study of hospital admission rates for children aged under 15, based on analysis of Hospital Episode Statistics and population estimates for England, 1999–2010. Main outcome Trends in rates of emergency admission to hospital. Results The emergency admission rate for children aged under 15 in England has increased by 28% in the past decade, from 63 per 1000 population in 1999 to 81 per 1000 in 2010. A persistent year-on-year increase is apparent from 2003 onwards. A small decline in the rates of admissions lasting 1 day or more has been offset by a twofold increase in short-term admissions of Conclusions The continuing increase in very-short-term admission of children with common infections suggests a systematic failure, both in primary care (by general practice, out-of-hours care and National Health Service Direct) and in hospital (by emergency departments and paediatricians), in the assessment of children with acute illness that could be managed in the community. Solving the problem is likely to require restructuring of the way acute paediatric care is delivered.

https://adc.bmj.com/content/archdischild/98/5/328.full.pdf

Anne Thomson

Papers

British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011

Association of respiratory syncytial virus bronchiolitis with the interleukin 8 gene region in UK families.

BTS guidelines for the management of pleural infection in children

Randomised trial of intrapleural urokinase in the treatment of childhood empyema

Increase in emergency admissions to hospital for children aged under 15 in England, 1999-2010: National database analysis