Emergency physician diagnosis of pediatric infective endocarditis by point-of-care echocardiography

Point of care ultrasonography in the pediatric emergency department

IMPORTANCE

Point-of-care ultrasonography (POCUS) allows to obtain real-time images to correlate with the patient's presenting signs and symptoms. It can be used by various specialties and may be broadly divided into diagnostic and procedural applications.

OBJECTIVE

We aimed at reviewing current knowledge on the use of POCUS in Pediatric Emergency Departments (PEDs).

FINDINGS

US diagnostic capacity in paediatric patients with suspected pneumonia has been studied and debated whereas literature regarding the usefulness of point-of-care echocardiography in the pediatric setting is still limited. Similarly, Focused Assessment with Sonography for Trauma (FAST) has become a standard procedure in adult emergency medicine but it is still not well codified in the pediatric practice. Concerning procedural applications of POCUS we identified 4 main groups: peripheral vascular access, bladder catheterizations, identification and drainage of abnormal fluid collections and foreign body identification.

CONCLUSIONS AND RELEVANCE

Bedside emergency ultrasound is routinely used by adult emergency physicians and in the last 10 years its application is recognized and applied in PED. Pediatric emergency physicians are encouraged to familiarize with POCUS as it is a safe technology and can be extremely helpful in performing diagnosis, managing critical situations and guiding procedures, which results in globally improving pediatric patients care.

Clinical features of patients with infective endocarditis presenting to the emergency department: a retrospective case series

Infective endocarditis (IE) is an uncommon clinical problem with diverse, nonspecific presentations. Therefore, information on the clinical features of IE patients presenting to emergency departments (EDs) is scarce. To descriptively analyze the pertinent data, we performed a retrospective chart review. We reviewed 15 consecutive IE patients admitted directly from ED in a university hospital in Japan between 2013 and 2015. We compared their clinical features with those of 14 IE patients admitted during the same period without ED presentations. Patients admitted directly from ED were older than those without ED presentations (median, 78 vs. 52 years; adjusted p = 0.036) and were more likely to have come without referrals (referral rate, 21% vs. 86%; adjusted p = 0.012). These patients were less likely to have been treated with antibiotics before admission (antibiotic-exposure rate, 7% vs. 64%; adjusted p = 0.013) and had earlier blood-culture positivity (median, 2 vs. 5 days; adjusted p = 0.012), resulting in earlier diagnosis (median duration of symptoms before diagnosis, 5 vs. 30 days; adjusted p = 0.012). Other clinical features, including causative pathogens and IE-related comorbidities, were similar between the groups, consistent with previous a nationwide Japanese study. In conclusion, most IE patients admitted to the hospital from ED were elderly, were antibiotic-naïve, and had presented without a referral. Relatively few patients had classical presentations of IE. Given the limited data, more research is needed to confirm that IE patients presenting to EDs constitute a unique group of elderly patients with specific clinical features.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Nasopharyngeal and Adenoid Colonization by Haemophilus influenzae and Haemophilus parainfluenzae in Children Undergoing Adenoidectomy and the Ability of Bacterial Isolates to Biofilm Production

Haemophili are pathogenic or opportunistic bacteria often colonizing the upper respiratory tract mucosa. The prevalence of Haemophilus influenzae (with serotypes distribution), and H. parainfluenzae in the nasopharynx and/or the adenoid core in children with recurrent pharyngotonsillitis undergoing adenoidectomy was assessed. Haemophili isolates were investigated for their ability to biofilm production.Nasopharyngeal swabs and the adenoid core were collected from 164 children who underwent adenoidectomy (2-5 years old). Bacteria were identified by the standard methods. Serotyping of H. influenzae was performed using polyclonal and monoclonal antisera. Biofilm formation was detected spectrophotometrically using 96-well microplates and 0.1% crystal violet.Ninety seven percent (159/164) children who underwent adenoidectomy were colonized by Haemophilus spp. The adenoid core was colonized in 99.4% (158/159) children, whereas the nasopharynx in 47.2% (75/159) children (P < 0.0001). In 32% (51/159) children only encapsulated (typeable) isolates of H. influenzae were identified, in 22.6% (36/159) children only (nonencapsulated) H. influenzae NTHi (nonencapsulated) isolates were present, whereas 7.5% (12/159) children were colonized by both types. 14.5% (23/159) children were colonized by untypeable (rough) H. influenzae. In 22% (35/159) children H. influenzae serotype d was isolated. Totally, 192 isolates of H. influenzae, 96 isolates of H. parainfluenzae and 14 isolates of other Haemophilus spp. were selected. In 20.1% (32/159) children 2 or 3 phenotypically different isolates of the same species (H. influenzae or H. parainfluenzae) or serotypes (H. influenzae) were identified in 1 child. 67.2% (129/192) isolates of H. influenzae, 56.3% (54/96) isolates of H. parainfluenzae and 85.7% (12/14) isolates of other Haemophilus spp. were positive for biofilm production. Statistically significant differences (P = 0.0029) among H. parainfluenzae biofilm producers and nonproducers in the adenoid core and the nasopharynx were detected.H. influenzae and H. parainfluenzae carriage rate was comparatively higher in the adenoid core than that in the nasopharynx in children undergoing adenoidectomy, suggesting that their involvement in chronic adenoiditis. The growth in the biofilm seems to be an important feature of haemophili colonizing the upper respiratory tract responsible for their persistence.

Validation of a prediction rule for endocarditis in febrile injection drug users

BACKGROUND

Infectious endocarditis (IE) in febrile injection drug users (IDUs) is a critical diagnosis to identify in the emergency department (ED). A decision tool that identifies patients at very low risk for endocarditis using readily available clinical data could reduce admissions and cost.

OBJECTIVE

To evaluate the diagnostic performance of a previously derived decision instrument to rule out endocarditis in febrile IDUs (Prediction Rule for Endocarditis in Injection Drug Users [PRE-IDU]) and to develop a prediction model for likelihood of endocarditis for those who are not ruled out by PRE-IDU.

METHODS

Febrile IDUs admitted to rule out endocarditis were prospectively enrolled from 2 urban EDs in June 2007 to March 2011. Clinical data from ED presentation (first 6 hours) and outcome data from inpatient records were recorded and reviewed by 2 independent investigators. Diagnosis of IE was based on modified Duke criteria and discharge summaries. The diagnostic performance of PRE-IDU, which combines tachycardia, cardiac murmur, and absence of skin infection, was determined using recursive partitioning and logistic regression modeling.

RESULTS

Of the 249 subjects, 18 (7%) had IE. Recursive partitioning yielded an instrument with 100% sensitivity (95% confidence interval [CI], 84%-100%) and 100% negative predictive value (95% CI, 91%-100%), but low specificity (13%; 95% CI, 12%-13%). Multiple logistic regression modeling with the 3 clinical predictors allowed risk stratification with posttest probabilities ranging from 3% to 20%.

CONCLUSION

The PRE-IDU instrument predicted IE with high sensitivity and ruled out IE with high negative predictive value. Our logistic regression model provided posttest probabilities ranging from 3% to 20%. The PRE-IDU instrument and the associated model may help guide hospital admission and diagnostic testing in evaluation of febrile IDUs in the ED.