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Brown E, Hay AD. Point-of-care tests: the key to reducing antibiotic prescribing for respiratory tract infections in primary care? Expert Rev Mol Diagn 2024; 24:139-141. [PMID: 37222481 DOI: 10.1080/14737159.2023.2217330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/19/2023] [Indexed: 05/25/2023]
Affiliation(s)
- Emily Brown
- Centre of Academic Primary Care, NIHR School for Primary Care Research, Bristol Medical School: Population Health Sciences, Canynge Hall, UK
| | - Alastair D Hay
- Centre of Academic Primary Care, NIHR School for Primary Care Research, Bristol Medical School: Population Health Sciences, Canynge Hall, UK
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Mohindra R, K D, Kalyan M, Bora I, Soni RK, Suri V, Behera A, Saini N, Sharma V, Zohmangaihi D. The continuum of liver injury with severity of dengue fever: A retrospective observational study. J R Coll Physicians Edinb 2024; 54:7-13. [PMID: 38112152 DOI: 10.1177/14782715231216157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Dengue is a major international health concern prevalent in tropical and sub-tropical countries. There are a paucity of studies on the relationship of hepatic complications with inflammatory parameters in dengue infection. METHODS Single-centre observational study was conducted at the tertiary care centre in North India. Patients (>12 years) diagnosed with dengue infection between August and November 2021 were enrolled in the study. The frequency of hepatic derangements and their associations with inflammatory severity was analysed. RESULTS Based on the clinical symptoms, 170 patients were classified into three categories, namely, dengue fever, warning dengue and severe dengue. Higher incidence of liver dysfunction was observed in severe dengue patients with median values of aspartate aminotransferase (AST) (3051 U/L, p < 0.001), alanine aminotransferase (ALT) (1792 U/L, p = 0.009), alkaline phosphatase (172 U/L, p = 0.001), T.Bil (34.2 µmol/L, p < 0.001), albumin (30 g/L, <0.001), and gamma-glutamyl transferase (152 U/L, p < 0.001) along with inflammatory marker C-reactive protein (CRP) (43 mg/dL, p < 0.001) highly deranged, in comparison to patients with/without warning signs. Median levels of CRP were found to be positively and significantly correlated with the median levels of AST and ALT (p < 0.05, r = 0.99) in all three categories of dengue patients. Liver injury was noted in 107 (63%) of the cohort, and mixed type of liver injury involving both hepatocellular and cholestatic patterns was observed as the most common type of injury (n = 50, 29.4%). Liver injury correlated with the severity of dengue illness as about 85% of severe dengue patients had significant liver injury (p = 0.014). CONCLUSION In dengue patients, the association of the liver injury with inflammatory severity suggests that the mechanism of liver injury may be related to inflammatory response apart from the hepatotropic nature of the virus.
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Affiliation(s)
- Ritin Mohindra
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Divyashree K
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhur Kalyan
- Department of Biochemistry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ishani Bora
- Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Roop Kishore Soni
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Suri
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Behera
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Neha Saini
- University Institute of Agricultural Sciences (UIAS), Chandigarh University, Gharuan, Mohali, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepy Zohmangaihi
- Department of Biochemistry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Lim PPC, Bondarev DJ, Edwards AM, Hoyen CM, Macias CG. The evolving value of older biomarkers in the clinical diagnosis of pediatric sepsis. Pediatr Res 2023; 93:789-796. [PMID: 35927575 DOI: 10.1038/s41390-022-02190-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 06/07/2022] [Accepted: 06/28/2022] [Indexed: 11/09/2022]
Abstract
Sepsis remains the leading cause of childhood mortality worldwide. The evolving definition of pediatric sepsis is extrapolated from adult studies. Although lacking formal validation in the pediatric population, this working definition has historically proven its clinical utility. Prompt identification of pediatric sepsis is challenging as clinical picture is often variable. Timely intervention is crucial for optimal outcome, thus biomarkers are utilized to aid in immediate, yet judicious, diagnosis of sepsis. Over time, their use in sepsis has expanded with discovery of newer biomarkers that include genomic bio-signatures. Despite recent scientific advances, there is no biomarker that can accurately diagnose sepsis. Furthermore, older biomarkers are readily available in most institutions while newer biomarkers are not. Hence, the latter's clinical value in pediatric sepsis remains theoretical. Albeit promising, scarce data on newer biomarkers have been extracted from research settings making their clinical value unclear. As interest in newer biomarkers continue to proliferate despite their ambiguous clinical use, the literature on older biomarkers in clinical settings continue to diminish. Thus, revisiting the evolving value of these earliest biomarkers in optimizing pediatric sepsis diagnosis is warranted. This review focuses on the four most readily available biomarkers to bedside clinicians in diagnosing pediatric sepsis. IMPACT: The definition of pediatric sepsis remains an extrapolation from adult studies. Older biomarkers that include C-reactive protein, procalcitonin, ferritin, and lactate are the most readily available biomarkers in most pediatric institutions to aid in the diagnosis of pediatric sepsis. Older biomarkers, although in varying levels of reliability, remain to be useful clinical adjuncts in the diagnosis of pediatric sepsis if used in the appropriate clinical context. C-reactive protein and procalcitonin are more sensitive and specific among these older biomarkers in diagnosing pediatric sepsis although evidence varies in different age groups and clinical scenarios.
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Affiliation(s)
- Peter Paul C Lim
- Division of Infectious Diseases, Department of Pediatrics, University Hospitals-Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
| | - Dayle J Bondarev
- Division of Neonatology, Department of Pediatrics, University Hospitals-Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Amy M Edwards
- Division of Infectious Diseases, Department of Pediatrics, University Hospitals-Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Claudia M Hoyen
- Division of Infectious Diseases, Department of Pediatrics, University Hospitals-Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Charles G Macias
- Division of Emergency Medicine, Department of Pediatrics, University Hospitals-Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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Fickweiler W, Mitzner M, Jacoba CMP, Sun JK. Circulatory Biomarkers and Diabetic Retinopathy in Racial and Ethnic Populations. Semin Ophthalmol 2023:1-11. [PMID: 36710371 DOI: 10.1080/08820538.2023.2168488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Clinical staging systems for diagnosis and treatment of diabetic retinopathy (DR) must closely relate to endpoints that are both relevant for patients and feasible for physicians to implement. Current DR staging systems for clinical eye care and research provide detailed phenotypic characterization to predict patient outcomes in diabetes but have limitations. Biochemical biomarkers provide a rich pool of potential candidates for new DR staging systems that can be readily measured in accessible fluids. Circulating biomarkers that are specific to the retina and relate to angiogenesis and inflammation have been suggested as relevant for DR. Although there is a lack of multi-ethnic studies evaluating circulatory biomarkers in DR, variability in circulatory biomarkers have been reported in people from different ethnic and racial backgrounds. Therefore, there is a need for future studies to evaluate individual or combinations of biomarkers in diverse populations with DR from different ethnic and racial backgrounds.
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Affiliation(s)
- Ward Fickweiler
- Research Division, Joslin Diabetes Center, Boston, MA, USA.,Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Margalit Mitzner
- Research Division, Joslin Diabetes Center, Boston, MA, USA.,Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
| | - Cris Martin P Jacoba
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jennifer K Sun
- Research Division, Joslin Diabetes Center, Boston, MA, USA.,Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Khera D, Toteja N, Singh S, Didel S, Singh K, Chugh A, Singh S. The Role of Presepsin as a Biomarker of Sepsis in Children: A Systemic Review and Meta-Analysis. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1758479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objectives Biomarkers in sepsis are an arena of avid research as they can facilitate timely diagnosis and help reduce mortality. Presepsin is a promising candidate with good diagnostic performance reported in adult and neonatal studies. However, there is no clear consensus about its utility in the pediatric age group. This study aimed to synthesize scientific evidence regarding the diagnostic and prognostic performance of presepsin in pediatric sepsis.
Data Sources A systematic literature search was conducted in MEDLINE/PubMed, Cochrane Central Register of Clinical Trials, Google Scholar, and Scopus to identify relevant studies reporting the diagnostic and prognostic accuracy of presepsin.
Study Selection Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we retrieved all controlled trials and observational studies on presepsin as a biomarker in children aged <19 years with sepsis.
Data Extraction Two authors independently performed study screening, data extraction, and quality assessment of the included studies.
Data Synthesis Among the 267 citations identified, a total of nine relevant studies were included in the final analysis. The pooled diagnostic sensitivity and specificity of presepsin were 0.99 (95% confidence interval [CI]; 0.97–1.00) and 0.88 (95% CI; 0.83–0.92), respectively, with a diagnostic odds ratio (DOR) of 28.15 (95% CI; 0.74–1065.67) and area under the curve (AUC) in summary receiver operating curve of 0.89. Prognostic accuracy for presepsin had a sensitivity of 0.64 (95% CI; 0.35–1.0), specificity of 0.62 (95% CI; 0.44–0.87), and DOR of 3.3 (95% CI; 0.20–53.43). For procalcitonin, the pooled sensitivity for diagnostic accuracy was 0.97 (95% CI; 0.94–1.00), specificity was 0.76 (95% CI; 0.69–0.82), DOR was 10.53 (95% CI; 5.31–20.88), and AUC was 0.81.
Conclusion Presepsin has good diagnostic accuracy with high sensitivity and specificity. Its prognostic accuracy in predicting mortality is low.
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Affiliation(s)
- Daisy Khera
- Department of Paediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Nisha Toteja
- Department of Paediatrics, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India
| | - Simranjeet Singh
- Department of Paediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Siyaram Didel
- Department of Paediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Kuldeep Singh
- Department of Paediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Ankita Chugh
- Department of Dentistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Surjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Byler S, Baker A, Freiman E, Herigon JC, Eisenberg MA. Utility of specific laboratory biomarkers to predict severe sepsis in pediatric patients with SIRS. Am J Emerg Med 2021; 50:778-783. [PMID: 34879502 DOI: 10.1016/j.ajem.2021.09.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/27/2021] [Accepted: 09/30/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To identify the association between readily available laboratory biomarkers and the development of severe sepsis in children presenting to the emergency department (ED) with systemic inflammatory response syndrome (SIRS). METHODS In this retrospective cohort study, ED patient encounters from June 2018 to June 2019 that triggered an automated sepsis alert based on SIRS criteria were analyzed. Encounters were included if the patient had any of the following laboratory tests sent within 6 h of ED arrival: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), lactic acid, and procalcitonin. For each of the biomarkers, a receiver operating characteristic (ROC) curve was created for our primary outcome, severe sepsis within 24 h of ED disposition, and our secondary outcome, severe sepsis with a positive bacterial culture. For each ROC curve, we calculated the area under the curve (AUC) with 95% confidence intervals (95% CI) and created cutoff points to achieve 90% sensitivity and 90% sensitivity for the primary and secondary outcomes. RESULTS During the study period, 4349/61,195 (7.1%) encounters triggered an automated sepsis alert. Of those, 1207/4349 (27.8%) had one of the candidate biomarkers sent within 6 h of ED arrival and were included in the study. A total of 100/1207 (8.3%) met criteria for severe sepsis within 24 h of arrival, and 41/100 severe sepsis cases (41%) were deemed culture-positive. Procalcitonin had the highest AUC for identifying severe sepsis [0.62 (95% CI 0.52-0.73)] while ESR and CRP had the highest AUC for culture-positive sepsis [0.68 (95% CI 0.47-0.89) and 0.67 (95% CI 0.53-0.81), respectively]. At 90% sensitivity for detecting severe sepsis, all of the biomarker threshold values fell within that laboratory test's normal range. At 90% specificity for severe sepsis, threshold values were as follows: procalcitonin 2.72 ng/mL, CRP 16.79 mg/dL, ESR 79.5 mm/h and lactic acid 3.6 mmol/L. CONCLUSION Our data indicate that CRP, ESR, lactic acid, and procalcitonin elevations were all specific, but not sensitive, in identifying children in the ED with SIRS who go on to develop severe sepsis.
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Affiliation(s)
- Shannon Byler
- Boston Combined Residency Program, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States of America.
| | - Alexandra Baker
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Eli Freiman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Joshua C Herigon
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America; Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States of America
| | - Matthew A Eisenberg
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
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Ohana-Sarna-Cahan L, Hurvitz N, Gross I, Cohen A, Hashavya S. Factors Associated With Increased Risk of Pediatric Orbital Cellulitis-Who Should Be Scanned? Pediatr Emerg Care 2021; 37:e1473-e1477. [PMID: 32205800 DOI: 10.1097/pec.0000000000002083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evaluation of a child with POC/OC is complicated due difficulties in physical examination and risks of imaging by computed tomography. METHOD Retrospective review of children 0-16 years admitted to the pediatric emergency department for POC/OC from 2009 to 2019. RESULTS Ten years study period, 243 children younger than 16 years presented to the pediatric emergency department with a diagnosis of POC/OC. OC was documented in 51 (20.6%) patients. The mean age was 7.8 years (±4.3 years). Fever (80.4%), upper respiratory tract infection (43%), swelling of both eyelids (96%), proptosis (33.3%), and tenderness on percussion (24.5%) were more common in comparison to POC (P = 0.0001, 0.03, 0.0001, 0.0001, 0.0001 respectively). All children with suspected diagnosis of OC underwent computed tomography scan. POC accounted for 196 patients. Mean age was 4.6 (±4.3) years. Twenty percent of the cases were recorded as local trauma or insect bite in the infected eye.Mean leukocyte count in the OC group had higher mean of 15.2 (109/L) versus 13.4(109/L) (P = 0.05), absolute neutrophil count was significantly higher in the OC 11.3(109/L) versus 7.2(109/L) (P = 0.0001) whereas the lymphocyte count was higher in the POC 4.5(109/L) versus 2.4(109/L) (P = 0.0001), NLR of 0.318 correlates with orbital cellulitis with sensitivity of 75.5% and specificity of 77.4%.Patients with OC had mean C-reactive protein levels of 11.7 (mg/dL) versus 4.9(mg/dL) (P = 0.0001), erythrocyte sedimentation rate was elevated in the OC 53.6 (cm/h) versus 36.4 (cm/h) (P = 0.02).Based on the aforementioned study a risk calculator for OC was formulated with 6 major variables. CONCLUSIONS Differentiation between POC/OC is cardinal. This study highlights the importance of ancillary laboratory tests especially C-reactive protein in the assessment of infections of the eye.
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Affiliation(s)
| | | | - Itai Gross
- Department of Pediatric Emergency Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Novel Biomarkers Differentiating Viral from Bacterial Infection in Febrile Children: Future Perspectives for Management in Clinical Praxis. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8111070. [PMID: 34828783 PMCID: PMC8623137 DOI: 10.3390/children8111070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/31/2021] [Accepted: 11/18/2021] [Indexed: 01/12/2023]
Abstract
Differentiating viral from bacterial infections in febrile children is challenging and often leads to an unnecessary use of antibiotics. There is a great need for more accurate diagnostic tools. New molecular methods have improved the particular diagnostics of viral respiratory tract infections, but defining etiology can still be challenging, as certain viruses are frequently detected in asymptomatic children. For the detection of bacterial infections, time consuming cultures with limited sensitivity are still the gold standard. As a response to infection, the immune system elicits a cascade of events, which aims to eliminate the invading pathogen. Recent studies have focused on these host–pathogen interactions to identify pathogen-specific biomarkers (gene expression profiles), or “pathogen signatures”, as potential future diagnostic tools. Other studies have assessed combinations of traditional bacterial and viral biomarkers (C-reactive protein, interleukins, myxovirus resistance protein A, procalcitonin, tumor necrosis factor-related apoptosis-inducing ligand) to establish etiology. In this review we discuss the performance of such novel diagnostics and their potential role in clinical praxis. In conclusion, there are several promising novel biomarkers in the pipeline, but well-designed randomized controlled trials are needed to evaluate the safety of using these novel biomarkers to guide clinical decisions.
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Carlton HC, Savović J, Dawson S, Mitchelmore PJ, Elwenspoek MMC. Novel point-of-care biomarker combination tests to differentiate acute bacterial from viral respiratory tract infections to guide antibiotic prescribing: a systematic review. Clin Microbiol Infect 2021; 27:1096-1108. [PMID: 34015531 DOI: 10.1016/j.cmi.2021.05.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/30/2021] [Accepted: 05/04/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Acute respiratory tract infections (RTIs) are the most common reason to seek medical care, with many patients receiving inappropriate antibiotics. Novel testing approaches to identify aetiology at the point-of-care are required to accurately guide antibiotic treatment. OBJECTIVE To assess the diagnostic accuracy of biomarker combinations to rapidly differentiate between acute bacterial or viral RTI aetiology. DATA SOURCES MEDLINE, Embase and Web of Science databases were searched to February 2021. STUDY ELIGIBILITY CRITERIA Diagnostic accuracy studies comparing accuracy of point-of-care and rapid diagnostic tests in primary or secondary care, consisting of biomarker combinations, to identify bacterial or viral aetiology of RTI. METHODS Risk of bias was assessed using the QUADAS-2 tool. Sensitivity and specificity of tests reported by more than one study were meta-analysed using a random effects model. RESULTS Twenty observational studies (3514 patients) were identified. Eighteen were judged at high risk of bias. For bacterial aetiologies, sensitivity ranged from 61% to 100% and specificity from 18% to 96%. For viral aetiologies, sensitivity ranged from 59% to 97% and specificity from 74% to 100%. Studies evaluating two commercial tests were meta-analysed. For ImmunoXpert, the summary sensitivity and specificity were 85% (95% CI 75%-91%, k = 4) and 86% (95% CI 73%-93%, k = 4) for bacterial infections, and 90% (95% CI 79%-96%, k = 3) and 92% (95% CI 83%-96%, k = 3) for viral infections, respectively. FebriDx had pooled sensitivity and specificity of 84% (95% CI 75%-90%, k = 4) and 93% (95% CI 90%-95%, k = 4) for bacterial infections, and 87% (95% CI 72%-95%; k = 4) and 82% (95% CI 66%-86%, k = 4) for viral infections, respectively. CONCLUSION Combinations of biomarkers show potential clinical utility in discriminating the aetiology of RTIs. However, the limitations in the evidence base, due to a high proportion of studies with high risk of bias, preclude firm conclusions. Future research should be in primary care and evaluate patient outcomes and cost-effectiveness with experimental study designs. CLINICAL TRIAL PROSPERO registration number: CRD42020178973.
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Affiliation(s)
- Henry C Carlton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Philip J Mitchelmore
- Department of Respiratory Medicine, Royal Devon & Exeter Hospital, Exeter, UK; Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Exeter, UK
| | - Martha M C Elwenspoek
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Adamczewska K, Adamczewski Z, Stasiak M, Lewiński A, Stawerska R. Transient Hyperthyrotropinemia in Outpatient Children with Acute Infections of the Respiratory System. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084115. [PMID: 33924694 PMCID: PMC8070413 DOI: 10.3390/ijerph18084115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 12/16/2022]
Abstract
Background: Diagnostics of thyroid disorders (TD) are frequently based on the measurements of thyroid stimulating hormone (TSH) concentration only. If TSH is outside the reference range, the diagnostic procedure used in patients with TD isintroduced. Observations indicate that in a considerable number of these patients, TD is not confirmed. The aim of the study was to assess the incidence of transient hyperthyrotropinemia in healthy children during acute infections of the respiratory system. Patients and Methods: The study included consecutive children (49 boys and 45 girls), aged 2.2–17.3 years, who visited one General Practitioner (GP) due to respiratory tract infections. The tests: complete blood count (CBC), C-reactive protein (CRP), TSH and FT4 were run on the next day after the visit at the physician’s (initial visit) and ≥2 weeks after recovery. Results: Among these children, elevated TSH values were found in about 10% of patients, and they went back to normal values after recovery. A prospective analysis showed a reduction of TSH values in approx. 65% of all groups and TSH at the follow-up visit was significantly lower. Conclusions: Transient hyperthyrotropinemia was observed in about 10% of children with acute respiratory tract infection. This preliminary finding remains unexplained.
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Affiliation(s)
| | - Zbigniew Adamczewski
- Department of Nuclear Medicine, Medical University of Lodz, 92-216 Lodz, Poland;
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland; (M.S.); (A.L.)
| | - Magdalena Stasiak
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland; (M.S.); (A.L.)
| | - Andrzej Lewiński
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland; (M.S.); (A.L.)
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, 93-338 Lodz, Poland
| | - Renata Stawerska
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland; (M.S.); (A.L.)
- Department of Pediatric Endocrinology, Medical University of Lodz, 93-338 Lodz, Poland
- Correspondence: ; Tel.: +48-42-2711141
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Huth PFB, Addo M, Daniel T, Groendahl B, Hokororo A, Koliopoulos P, Mshana S, Pretsch L, Schmidt C, Zuechner A, Gehring S, Kayange N. Extensive Antibiotic and Antimalarial Prescription Rate among Children with Acute Febrile Diseases in the Lake Victoria Region, Tanzania. J Trop Pediatr 2021; 67:6133215. [PMID: 33575804 DOI: 10.1093/tropej/fmaa135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Acute mosquito-borne febrile diseases pose a threat to children in the Sub-Saharan-Africa with ∼272 000 children dying worldwide from malaria in 2018. Although the awareness for malaria in this area has increased due to improved health education, the apparent decline of actual malaria cases has not affected clinical practice significantly. This study collected clinical and epidemiologic data of children presenting with acute febrile diseases in order delineate their diagnostic and therapeutic management. METHODS A hospital-based cross-sectional clinical study was conducted at the Sekou Toure Regional Referral Hospital in Tanzania. Children between 1 month and 12 years of age with an axillary temperature ≥ 37.5°C were recruited from August 2016 to December 2016. Children received full clinical examination. In addition, file data about diagnostics and treatment were collected and malaria rapid diagnostic tests (mRDTs) were performed. Confirmatory malaria polymerase chain reaction was performed from dry blood spots. RESULTS From 1381 children presented in the pediatric outpatient department, 133 met the inclusion criteria. Out of 133 febrile children, 10.5% were malaria positive. Treatment data indicate the prescription of antimalarials in 35.3% and antibiotics in 63.9% of the children with an overlap of 24.1% receiving both. Despite a negative mRDT, 36 patients received antimalarials. CONCLUSIONS The findings of this study confirm a significant decline of malaria cases in the Lake Victoria region. The discrepancy between the valuable results provided by mRDTs and the high prescription rates of antibiotics and antimalarials call for an enforced diagnostic and therapeutic algorithm. LAY SUMMARY The aim of the study was to take a closer look at reported cases of febrile diseases in the Lake Victoria region and assess the relationship between clinical as well as diagnostic findings and the resulting therapeutic concept. Based on these findings the prescription rate of antimalarial and antibiotic drugs was analyzed. The results showed an overall high prescription rate of antimalarials and antibiotics in both diagnosed malaria cases and cases with diagnosed bacterial infections.Not only with regards to the possible side effects of these medications but also keeping in mind the apparent misuse of resources this practice poses a serious burden to the health care system in this low resource country.
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Affiliation(s)
- Philipp Florian Brixius Huth
- Department of Infectiology and Tropical Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Marylyn Addo
- Department of Infectiology and Tropical Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Tim Daniel
- Center of Pediatric and Adolescent Medicine, Johannes Gutenberg-University Medical Center, 55131 Mainz, Germany
| | - Britta Groendahl
- Center of Pediatric and Adolescent Medicine, Johannes Gutenberg-University Medical Center, 55131 Mainz, Germany
| | - Adolfine Hokororo
- Department of Pediatric and Child Health, Bugando Medical Centre/Catholic University of Health and Allied Sciences, P.o. Box 1370 Mwanza, Tanzania
| | - Philip Koliopoulos
- Center of Pediatric and Adolescent Medicine, Johannes Gutenberg-University Medical Center, 55131 Mainz, Germany
| | - Stephen Mshana
- Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences (CUHAS), Mwanza, Tanzania
| | - Leah Pretsch
- Center of Pediatric and Adolescent Medicine, Johannes Gutenberg-University Medical Center, 55131 Mainz, Germany
| | - Christian Schmidt
- Department of Pediatric and Adolescent Medicine, 46535 Dinslaken, Germany
| | - Antke Zuechner
- Department of Pediatric and Child Health, Bugando Medical Centre/Catholic University of Health and Allied Sciences, P.o. Box 1370 Mwanza, Tanzania
| | - Stephan Gehring
- Center of Pediatric and Adolescent Medicine, Johannes Gutenberg-University Medical Center, 55131 Mainz, Germany
| | - Neema Kayange
- Department of Pediatric and Child Health, Bugando Medical Centre/Catholic University of Health and Allied Sciences, P.o. Box 1370 Mwanza, Tanzania
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Patra G, Saha B, Mukhopadhyay S. Increased levels of pentraxins protein and cytokines bear good association in patients with severe dengue infection. Sci Rep 2021; 11:511. [PMID: 33436908 PMCID: PMC7804429 DOI: 10.1038/s41598-020-80144-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/14/2020] [Indexed: 01/08/2023] Open
Abstract
Dengue is an arboviral infection with high rates of morbidity and mortality throughout the tropics and sub-tropics. This work studied the status of pentraxin (CRP/SAP) protein, ferritin, TNF-α and IL-1β levels in Dengue patients of different pathophysiological manifestations. Accordingly, clinically confirmed Dengue cases (n = 97) were enrolled and subsequently blood parameters were studied by Haematology cell counter and Biochemistry Autoanalyser. CRP, SAP, ferritin, TNF-α and IL-1β ELISA were done in all the samples by using standard ELISA kits. Statistical Analysis was done in all the experiments. The levels of CRP (p < 0.0001), SAP (p < 0.0001), ferritin (p < 0.0001), TNF-α (p < 0.0001) and IL-1β (p < 0.0001) were high in patients with Severe Dengue as compared to Dengue without warning signs. High levels of SGOT, SGPT and decreased platelet counts were found in severe patients as compared to Healthy donor. CRP/SAP as well as TNF-α/IL-1β were independently associated with both dengue severity and overall disease manifestation. Statistically significant increased CRP, SAP, ferritin, TNF-α and IL-1β titres were correlated in patients with severe clinical manifestations as compared to mild disease forms of dengue. Elevated levels of pentraxin, TNF-α/IL-1β in blood during dengue infection could act as an early predictor in Severe Dengue infection.
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Affiliation(s)
- Goutam Patra
- Department of Laboratory Medicine, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| | - Bibhuti Saha
- Department of Tropical Medicine, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| | - Sumi Mukhopadhyay
- Department of Laboratory Medicine, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India.
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Pediatric infection and sepsis in five age subgroups: single-center registry. Wien Med Wochenschr 2020; 171:29-35. [PMID: 33108806 PMCID: PMC7835161 DOI: 10.1007/s10354-020-00787-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/28/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Sepsis is, worldwide, one of the leading causes of death among infants and children. Over the past two decades, mortality rates have declined due to advanced treatment options; however, the incidence of sepsis and septic shock is still on the rise in many hospital settings. The objective of this study was to evaluate the course of this disease in pediatric intensive care patients. METHODS An evaluation of pediatric patients in the intensive care unit diagnosed with infections or sepsis between 2005 and 2015 was performed via a retrospective exploratory data analysis. RESULTS During the observational period, 201 patients were diagnosed with infection or sepsis. The study population was divided into five age subgroups. The majority of patients were newborns, infants, and toddlers. Forty percent had sepsis; 6% had septic shock. Viral infection was the most prevalent (59%). The overall survival rate was 83%; newborns and adolescents had the lowest survival rates. CONCLUSION With this registry, children divided into five age subgroups with infection or sepsis were evaluated and treatment strategies were examined. We have shown that our findings on children treated in our pediatric intensive care unit conform with current literature about pediatric sepsis. In addition to maintaining strict hygiene standards, optimal aspects of sepsis care should be stringently observed, such as the quick administration of empirical broad-spectrum antibiotics, initial adequate fluid resuscitation, and a reliable and frequent routine of source control.
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Tsai CM, Tang KS, Cheng MC, Liu TY, Huang YH, Chen CC, Yu HR. Use of saliva sample to detect C-reactive protein in children with pneumonia. Pediatr Pulmonol 2020; 55:2457-2462. [PMID: 32633868 DOI: 10.1002/ppul.24947] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Serum C-reactive protein (CRP) is a sensitive biomarker for inflammation and is broadly used to clinically diagnose infectious diseases, including pneumonia. However, blood sampling is fraught with technical difficulties in children. The salivary analysis may be a potential diagnostic tool, as it is noninvasive, patient-friendly, and easy to perform in children. This study aimed to evaluate the use of salivary CRP as a biomarker for children with pneumonia. METHODS A prospective study was conducted in patients aged 2 to 17 years, admitted to the hospital with pneumonia. Saliva and serum samples for CRP and chemokine determination were collected at the initial admission and during a follow-up from pediatric patients with pneumonia. Salivary samples were also collected from healthy subjects used as controls. RESULTS A total of 60 healthy children and 106 pediatric patients with pneumonia were enrolled in this study. The salivary CRP level was much higher in pediatric patients with pneumonia than in healthy children (48.77 ± 5.52 ng/mL vs 14.78 ± 3.92 ng/mL; P < .001). Salivary CRP level was highly correlated with serum CRP level in pediatric patients with pneumonia (r = .679; P < .001). Salivary CRP level (≥40.307 ng/mL) can be used to predict high serum CRP levels (≥80 mg/L) with an area under the curve of 0.810 (95% confidence interval, 0.740-0.881). As pneumonia improved, both salivary and serum CRP levels decreased during follow-up. CONCLUSIONS Salivary CRP could be an alternative biomarker for serum CRP in pediatric patients with pneumonia. This is especially beneficial for pediatric patients, as saliva collection is simple, noninvasive, and patient-friendly.
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Affiliation(s)
- Chih-Min Tsai
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Shu Tang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ming-Chou Cheng
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ta-Yu Liu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Hsien Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Cheng Chen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hong-Ren Yu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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15
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Jullien S, Pradhan D, Tshering T, Sharma R, Dema K, Garcia-Garcia S, Ribó JL, Muñoz-Almagro C, Bassat Q. Pneumonia in children admitted to the national referral hospital in Bhutan: A prospective cohort study. Int J Infect Dis 2020; 95:74-83. [PMID: 32283281 PMCID: PMC7195124 DOI: 10.1016/j.ijid.2020.04.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES The study aim was to describe the etiological profile and clinical characteristics of pneumonia among children hospitalized in Thimphu, Bhutan. METHODS This prospective study enrolled children aged 2-59 months admitted to the Jigme Dorji Wangchuck National Referral Hospital with World Health Organization (WHO)-defined clinical pneumonia. Demographic and clinico-radiological data were collected through questionnaires, physical examination, and chest radiography. Blood samples and nasopharyngeal washing were collected for microbiological analysis including culture and molecular methods. RESULTS From July 2017 to June 2018, 189 children were enrolled, of which 53.4% were infants. Pneumonia-related admissions were less frequent over the winter. Chest radiographies were obtained in 149 children; endpoints included pneumonia in 39 cases (26.2%), other infiltrates in 31 (20.8%), and were normal in 79 children (53.0%). Non-contaminated bacterial growth was detected in 8/152 (5.3%) blood cultures, with only two cases of Streptococcus pneumoniae. Viral detection in upper respiratory secretions was common, with at least one virus detected in 103/115 (89.6%). The three most-commonly isolated viruses were respiratory syncytial virus (52/115; 45.2%), rhinovirus (42/115; 36.5%), and human parainfluenza virus (19/115; 16.5%). A third of patients with viral infections showed mixed infections. Case fatality rate was 3.2% (6/189). CONCLUSION Respiratory viral infections predominated among this cohort of WHO-defined clinical pneumonia cases, whereas bacterial aetiologies were uncommon, highlighting the epidemiologic transition that Bhutan seems to have reached.
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MESH Headings
- Bacteria/isolation & purification
- Bhutan/epidemiology
- Child, Preschool
- Cohort Studies
- Coinfection/epidemiology
- Demography
- Female
- Hospitalization
- Humans
- Infant
- Male
- Pneumonia/epidemiology
- Pneumonia/mortality
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/diagnostic imaging
- Pneumonia, Bacterial/epidemiology
- Pneumonia, Bacterial/microbiology
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/diagnostic imaging
- Pneumonia, Viral/epidemiology
- Pneumonia, Viral/virology
- Prospective Studies
- Respiratory Syncytial Virus, Human/isolation & purification
- Respirovirus/isolation & purification
- Rhinovirus/isolation & purification
- Streptococcus pneumoniae/isolation & purification
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Affiliation(s)
- Sophie Jullien
- ISGlobal, Hospital Clínic - Universitat de Barcelona, carrer Rosselló, 132, 08036 Barcelona, Spain; Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Gongphel Lam, Thimphu, Bhutan.
| | - Dinesh Pradhan
- Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB), PO box 446, Old Medical Block, JDWNRH, Menkhang Lam, Thimphu, Bhutan.
| | - Tashi Tshering
- Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB), PO box 446, Old Medical Block, JDWNRH, Menkhang Lam, Thimphu, Bhutan.
| | - Ragunath Sharma
- Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Gongphel Lam, Thimphu, Bhutan.
| | - Kumbu Dema
- Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Gongphel Lam, Thimphu, Bhutan.
| | - Selene Garcia-Garcia
- Hospital Sant Joan de Déu (University of Barcelona), Pg. Sant Joan de Déu, 2, 08950 Esplugues de Llobregat, Barcelona, Spain.
| | - Jose Luis Ribó
- Hospital Universitari General de Catalunya, carrer Pedro i Pons 1, 08195 Sant Cugat del Vallés, Barcelona, Spain.
| | - Carmen Muñoz-Almagro
- Hospital Sant Joan de Déu (University of Barcelona), Pg. Sant Joan de Déu, 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain; Department of Medicine, Universitat Internacional de Catalunya, Carrer de Josep Trueta, 08195 Sant Cugat del Vallés, Barcelona, Spain.
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, carrer Rosselló, 132, 08036 Barcelona, Spain; Hospital Sant Joan de Déu (University of Barcelona), Pg. Sant Joan de Déu, 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Rua 12, Cambeve, Vila de Manhiça, CP 1929, Maputo, Mozambique; Catalan Institution for Research and Advanced Studies (ICREA), Pg. Lluís Companys 23, 08010 Barcelona, Spain.
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Taylor MD, Allada V, Moritz ML, Nowalk AJ, Sindhi R, Aneja RK, Torok K, Morowitz MJ, Michaels M, Carcillo JA. Use of C-Reactive Protein and Ferritin Biomarkers in Daily Pediatric Practice. Pediatr Rev 2020; 41:172-183. [PMID: 32238546 PMCID: PMC8546638 DOI: 10.1542/pir.2018-0101] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Recent pediatric clinical research has begun to focus on risk stratification tools using multibiomarker models. C-reactive protein (CRP) and ferriti biomarkers are widely available and used to varying degrees in daily practice, but there is no single source examining the evidence behind their use.We set out to summarize the evidence behind the use of CRP and ferritin biomarkers in pediatric practice and to begin development of a consensus for their future use for pediatricians.All the literature involving CRP and ferritin in pediatrics available on PubMed was surveyed. Research applicable to daily pediatric practice was summarized in the body of the article. Pediatric clinicians of various subspecialties contributed to the summary of the use of CRP and ferritin biomarkers in clinical practice in various disease processes. A clinical decision pathway is described, and evidence is summarized.CRP and ferritin biomarkers have diverse uses with various cutoff values in the literature, making their use in daily practice difficult. Elevation of these markers coincides with their significant elevation in uncontrolled inflammation.CRP and ferritin biomarkers are widely used in pediatrics. This review provides a resource summarizing evidence into a single source. There is sufficient evidence to indicate that these biomarkers of inflammation can be useful in guiding clinical decision making in specific clinical scenarios; however, further work is needed to improve their use in clinical practice.
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Affiliation(s)
- Matthew D Taylor
- Division of Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, NY
| | | | | | | | - Rakesh Sindhi
- Pediatric Transplant Division, Department of Surgery
| | | | | | - Michael J Morowitz
- General Pediatric Surgery Division, Department of Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Garcia PCR, Tonial CT, Piva JP. Septic shock in pediatrics: the state‐of‐the‐art. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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18
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Garcia PCR, Tonial CT, Piva JP. Septic shock in pediatrics: the state-of-the-art. J Pediatr (Rio J) 2020; 96 Suppl 1:87-98. [PMID: 31843507 PMCID: PMC9432279 DOI: 10.1016/j.jped.2019.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock. SOURCE OF DATA A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years. SYNTHESIS OF DATA Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection. CONCLUSIONS The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management.
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Affiliation(s)
- Pedro Celiny Ramos Garcia
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Terapia Intensiva Pediátrica, Programa de Pós-Graduação em Pediatria e Saúde Infantil, Porto Alegre, RS, Brazil
| | - Cristian Tedesco Tonial
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Terapia Intensiva Pediátrica, Departamento de Pediatria, Porto Alegre, RS, Brazil.
| | - Jefferson Pedro Piva
- Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina, Porto Alegre, RS, Brazil; Hospital de Clínicas de Porto Alegre, Departamento de Emergência e Cuidados Intensivos Pediátricos, Porto Alegre, RS, Brazil
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19
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Chiang CY, Chen YL, Lin YR, Cheng FJ, Wu KH, Chiu IM. Characteristics of Febrile Children Admitted to the ICU Following an Unscheduled ED Revisit Within 72 h, a Case-Control Study. Front Pediatr 2020; 8:411. [PMID: 32850531 PMCID: PMC7426702 DOI: 10.3389/fped.2020.00411] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/15/2020] [Indexed: 11/24/2022] Open
Abstract
Objective: The purpose of this article was to demonstrate related characteristics of intensive care unit (ICU) admission after an unscheduled revisit by febrile children visiting the emergency department (ED). Method: We performed a retrospective study in a tertiary medical center from 2010 to 2016. Patients whose chief complaint was fever and who were admitted to the ICU following a 72-h return visit to the ED were included, and we selected patients who were discharged from the same emergency department for comparison. Results: During the study period, 54 (0.03%) patients met the inclusion criteria, and 216 patients were selected for the matched control group. Regarding clinical variables on initial ED visit, visiting during the night shift (66.7 vs. 46.8%, p = 0.010), shorter length of 1st ED stay (2.5 ± 2.63 vs. 3.5 ± 3.44 h, p = 0.017), and higher shock index (SI) (1.6 ± 0.07 vs. 1.4 ± 0.02, p = 0.008) were associated with ICU admission following a return visit. On the return ED visit, we found that clinical variables such as elevated heart rate, SI, white blood cell count, and C-reactive protein level were all associated with ICU admission. Furthermore, elevated SI and pediatric age-adjusted (SIPA) values were observed in the study group in both the initial (42.2 vs. 20.1%, OR:2.3 (1.37-4.31), p = 0.002) and return ED visits (29.7 vs. 6.9%, OR: 4.6 (2.42-8.26), p < 0.001). Conclusion: For children who visited the emergency department with a febrile complaint, elevated SIPA values on the initial ED visit were associated with ICU admission following an unscheduled ED revisit within 72 h.
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Affiliation(s)
- Charng-Yen Chiang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yu-Lun Chen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yan-Ren Lin
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kuan-Han Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Department of Computer Science and Engineering, National Sun Yet-sen University, Kaohsiung, Taiwan
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20
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Antoon JW, Peritz DC, Parsons MR, Skinner AC, Lohr JA. Etiology and Resource Use of Fever of Unknown Origin in Hospitalized Children. Hosp Pediatr 2019; 8:135-140. [PMID: 29487087 DOI: 10.1542/hpeds.2017-0098] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Fever of unknown origin (FUO) is a well-known pediatric presentation. The primary studies determining the causes of prolonged fever in children were performed 4 decades ago, before major advances in laboratory and diagnostic testing. Given that the distribution of diagnosed causes of adult FUO has changed in recent decades, we hypothesized that the etiology of FUO in children has concordantly changed and also may be impacted by a definition that includes a shorter required duration of fever. METHODS A single-center, retrospective review of patients 6 months to 18 years of age admitted to the North Carolina Children's Hospital from January 1, 2002, to December 21, 2012, with an International Classification of Diseases, Ninth Revision diagnosis of fever, a documented fever duration >7 days before admission, and a previous physician evaluation of each patient's illness. RESULTS A total of 1164 patients were identified, and of these, 102 met our inclusion criteria for FUO. Etiologic categories included "infectious" (42 out of 102 patients), "autoimmune" (28 out of 102 patients), "oncologic" (18 out of 102 patients), and "other" or "unknown" (14 out of 102 patients). Several clinical factors were statistically and significantly different between etiologic categories, including fever length, laboratory values, imaging performed, length of stay, and hospital costs. CONCLUSIONS Unlike adult studies, the categorical distribution of diagnoses for pediatric FUO has marginally shifted compared to previously reported pediatric studies. Patients hospitalized with FUO undergo prolonged hospital stays and have high hospital costs. Additional study is needed to improve the recognition, treatment, and expense of diagnosis of prolonged fever in children.
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Affiliation(s)
- James W Antoon
- Department of Pediatric and Adolescent Medicine, Children's Hospital, University of Illinois Hospital & Health Sciences System, Chicago, Illinois;
| | - David C Peritz
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael R Parsons
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
| | - Asheley C Skinner
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; and
| | - Jacob A Lohr
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine and North Carolina Children's Hospital, Chapel Hill, North Carolina
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21
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Yoon SH, Kim EH, Kim HY, Ahn JG. Presepsin as a diagnostic marker of sepsis in children and adolescents: a systemic review and meta-analysis. BMC Infect Dis 2019; 19:760. [PMID: 31470804 PMCID: PMC6717384 DOI: 10.1186/s12879-019-4397-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/23/2019] [Indexed: 12/15/2022] Open
Abstract
Background Early diagnosis of sepsis in pediatric patients is vital but remains a major challenge. Previous studies showed that presepsin is potentially a reliable diagnostic biomarker for sepsis in adult and neonates. However, there is no pooled analysis of its efficacy as a diagnostic biomarker for sepsis in children. The aims of the present meta-analysis were to assess the overall diagnostic accuracy of presepsin in pediatric sepsis and compare it to those for C-reactive protein (CRP) and procalcitonin (PCT). Methods A systematic literature search was performed in Medline/Pubmed, Embase, the Cochrane Library, and ISI Web of Science to identify relevant studies reporting the diagnostic accuracy of presepsin in patients with pediatric sepsis. Sensitivities and specificities were pooled by bivariate meta-analysis. Heterogeneity was evaluated by χ2 test. Results We identified 129 studies in total. Most were disqualified on the basis of their titles/abstracts and duplication. Four studies were included in the final analysis. They comprised 308 patients aged between 1 mo and 18 y. The pooled diagnostic sensitivity and specificity of presepsin were 0.94 (95% confidence interval [CI]: 0.74–0.99) and 0.71 (95% CI: 0.35–0.92), respectively. The pooled diagnostic odds ratio, positive likelihood ratio (LR), and negative LR of presepsin were 32.87 (95% CI: 2.12–510.09), 3.24 (95% CI, 1.14–12.38), and 0.08 (95% CI, 0.01–0.74), respectively. Heterogeneity was found in both sensitivity (χ2 = 11.17; P = 0.011) and specificity (χ2 = 65.78; P < 0.001). No threshold effect was identified among the studies (r = − 0.938). The pooled sensitivity of presepsin (0.94) was higher than that of CRP (0.51) and PCT (0.76), whereas the overall specificity of presepsin (0.71) was lower than that of CRP (0.81) and PCT (0.76). The AUC of presepsin (0.925) was higher than that of CRP (0.715) and PCT (0.820). Conclusion Currently available evidence indicates that presepsin has higher sensitivity and diagnostic accuracy, but lower specificity, than PCT or CRP in detecting sepsis in children. However, these results must be carefully interpreted as the number of studies included was small and the studies were statistically heterogeneous. Electronic supplementary material The online version of this article (10.1186/s12879-019-4397-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Seo Hee Yoon
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Eun Hwa Kim
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Yan Kim
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Gyun Ahn
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
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22
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Yan JH, Cai XY, Huang YH. The clinical value of plasma hepcidin levels in predicting bacterial infections in febrile children. Pediatr Neonatol 2019; 60:377-381. [PMID: 30316735 DOI: 10.1016/j.pedneo.2018.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 08/01/2018] [Accepted: 09/14/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Febrile children are often evaluated for the risk of bacterial infections in the pediatric emergency department (PER). Hepcidin is an acute phase inflammatory protein. In this study, we examined the plasma hepcidin levels in febrile children. METHODS This study was conducted at a pediatric emergency department with 123 febrile children. We measured plasma hepcidin levels using an enzyme-linked immunosorbent assay. We further evaluated clinical characteristics and routine blood tests along with the hepcidin levels. RESULTS We observed significantly higher plasma hepcidin levels in bacterial enteritis (p = 0.026) and combined with urinary tract infection (p = 0.007). Furthermore, hepcidin levels had a significantly positive correlation with CRP level and length of hospital stay (R = 0.296, p = 0.001 and R = 0.213, p = 0.018). Hepcidin levels greater than 65 ng/mL also more accurately predicted bacterial infections than values below 65 ng/mL (11.7% vs. 2.1%, Odds ratio 8.4, 95% confident interval 1.7-40.9, p = 0.002). CONCLUSION This study provides evidence that febrile children with bacterial infection have higher plasma hepcidin levels, and the values correlated with CRP level and length of hospital stay. Therefore, hepcidin values can potentially be adopted as a biomarker for identifying febrile children with bacterial infection, particularly bacterial enteritis and urinary tract infection.
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Affiliation(s)
- Jia-Huei Yan
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, Taiwan
| | - Xin-Yuan Cai
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Hsien Huang
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, Taiwan; Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Park Y, Son M, Jekarl DW, Choi HY, Kim SY, Lee S. Clinical Significance of Inflammatory Biomarkers in Acute Pediatric Diarrhea. Pediatr Gastroenterol Hepatol Nutr 2019; 22:369-376. [PMID: 31338312 PMCID: PMC6629592 DOI: 10.5223/pghn.2019.22.4.369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/09/2018] [Accepted: 10/21/2018] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The aim of this study was to evaluate the clinical significance of inflammatory biomarkers in acute infectious diarrhea among children. METHODS Clinical parameters including fever, bacterial and viral etiology based on stool culture and multiplex polymerase chain reaction, and nine biomarkers including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and leukocytes in blood and calprotectin, lactoferrin, myeloperoxidase, polymorphonuclear elastase, leukocytes, and occult blood in feces were evaluated in children who were hospitalized due to acute diarrhea without underlying disease. RESULTS A total of 62 patients were included. Among these patients, 33 had fever, 18 showed bacterial infections, and 40 patients were infected with 43 viruses. Of all the biomarkers, CRP was significantly correlated with fever (p<0.001). CRP, ESR, calprotectin, lactoferrin, myeloperoxidase, fecal leukocytes, and occult blood were significantly associated with infection with bacterial pathogens (p<0.001, p=0.04, p=0.03, p=0.003, p=0.02, p=0.03, p=0.002, respectively). The combination of CRP and fecal lactoferrin at their best cut-off values (13.7 mg/L and 22.8 µg/mL, respectively) yielded a sensitivity of 72.2%, and a specificity of 95.5% for bacterial etiology compared with their individual use. CONCLUSION Blood CRP is a useful diagnostic marker for both fever and bacterial etiology in acute pediatric diarrhea. The combination of CRP and fecal lactoferrin yields better diagnostic capability for bacterial etiology than their use alone for acute diarrhea in children without underlying gastrointestinal disease.
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Affiliation(s)
- Yoonseon Park
- Department of Pediatrics, Incheon St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Minji Son
- Department of Pediatrics, Incheon St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Dong Wook Jekarl
- Department of Laboratory Medicine, Incheon St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Hyun Yoo Choi
- Department of Laboratory Medicine, Incheon St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Sang Yong Kim
- Department of Pediatrics, Incheon St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Seungok Lee
- Department of Laboratory Medicine, Incheon St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Incheon, Korea
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Li Z, He L, Li S, He W, Zha C, Ou W, Hou Q, Wang W, Sun X, Liang H. Combination of procalcitonin and C-reactive protein levels in the early diagnosis of bacterial co-infections in children with H1N1 influenza. Influenza Other Respir Viruses 2018; 13:184-190. [PMID: 30443990 PMCID: PMC6379630 DOI: 10.1111/irv.12621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 11/08/2018] [Accepted: 11/13/2018] [Indexed: 12/22/2022] Open
Abstract
Objective This study evaluated the diagnostic value of measuring the levels of procalcitonin (PCT) and C‐reactive protein (CRP) to differentiate children co‐infected with H1N1 influenza and bacteria from children infected with H1N1 influenza alone. Methods Consecutive patients (children aged < 5 years) with laboratory‐confirmed H1N1 influenza who were hospitalized or received outpatient care from a tertiary‐care hospital in Canton, China, between January 1, 2012, and September 1, 2017, were included in the present study. Laboratory results, including serum PCT and CRP levels, white blood cell (WBC) counts, and bacterial cultures, were analyzed. The predictive value of the combination of biomarkers versus any of the biomarkers alone for diagnosing bacterial co‐infections was evaluated using logistic regression analyses. Results Significantly higher PCT (1.46 vs 0.21 ng/mL, P < 0.001) and CRP (19.20 vs 5.10 mg/dL, P < 0.001) levels were detected in the bacterial co‐infection group than in the H1N1 infection‐alone group. Using PCT or CRP levels alone, the areas under the curves (AUCs) for predicting bacterial co‐infections were 0.801 (95% CI, 0.772‐0.855) and 0.762 (95% CI, 0.722‐0.803), respectively. Using a combination of PCT and CRP, the logistic regression‐based model, Logit(P) = −1.912 + 0.546 PCT + 0.087 CRP, showed significantly greater accuracy (AUC: 0.893, 95% CI: 0.842‐0.934) than did the other three biomarkers. Conclusions The combination of PCT and CRP levels could provide a useful method of distinguishing bacterial co‐infections from an H1N1 influenza infection alone in children during the early disease phase. After further validation, the flexible model derived here could assist clinicians in decision‐making processes.
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Affiliation(s)
- Zhihao Li
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Liya He
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Shuhua Li
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Waner He
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Caihui Zha
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wanxing Ou
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Qiaozhen Hou
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Weiying Wang
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xin Sun
- Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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Lemiengre MB, Verbakel JY, Colman R, Van Roy K, De Burghgraeve T, Buntinx F, Aertgeerts B, De Baets F, De Sutter A. Point-of-care CRP matters: normal CRP levels reduce immediate antibiotic prescribing for acutely ill children in primary care: a cluster randomized controlled trial. Scand J Prim Health Care 2018; 36:423-436. [PMID: 30354904 PMCID: PMC6381547 DOI: 10.1080/02813432.2018.1529900] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Antibiotics are prescribed too often in acutely ill children in primary care. We examined whether a Point-of-Care (POC) C-reactive Protein (CRP) test influences the family physicians' (FP) prescribing rate and adherence to the Evidence Based Medicine (EBM) practice guidelines. DESIGN Cluster randomized controlled trial. SETTING Primary care, Flanders, Belgium. INTERVENTION Half of the children with non-severe acute infections (random allocation of practices to perform POC CRP or not) and all children at risk for serious infection were tested with POC CRP. SUBJECTS Acutely ill children consulting their FP. MAIN OUTCOME MEASURE Immediate antibiotic prescribing. RESULTS 2844 infectious episodes recruited by 133 FPs between 15 February 2013 and 28 February 2014 were analyzed. A mixed logistic regression analysis was performed. Compared to episodes in which CRP was not tested, the mere performing of POC CRP reduced prescribing in case EBM practice guidelines advise to prescribe antibiotics (adjusted odds ratio (aOR) 0.54 (95% Confidence Interval (CI) 0.33-0.90). Normal CRP levels reduced antibiotic prescribing, regardless of whether the advice was to prescribe (aOR 0.24 (95%CI 0.11-0.50) or to withhold (aOR 0.31 (95%CI 0.17-0.57)). Elevated CRP levels did not increase antibiotic prescribing. CONCLUSION Normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing. Key points What is previously known or believed on this topic •Antibiotics are prescribed too often for non-severe conditions. Point-of-care (POC) C-reactive Protein (CRP) testing without guidance does not reduce immediate antibiotic prescribing in acutely ill children in primary care. What this research adds •FPs clearly consider CRP once available: normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. •Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing.
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Affiliation(s)
- Marieke B. Lemiengre
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium;
- CONTACT Marieke B. Lemiengre Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, 6K3, 9000Ghent, Belgium
| | - Jan Y. Verbakel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK;
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium;
| | - Roos Colman
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium;
| | - Kaatje Van Roy
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium;
| | | | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium;
- Research Institute Caphri, Maastricht University, Maastricht, The Netherlands;
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium;
| | - Frans De Baets
- Department of Pediatric Pulmonology, Infection and Immune Deficiencies, Ghent University Hospital, Ghent, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium;
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Lye PS, Densmore EM. Fever. NELSON PEDIATRIC SYMPTOM-BASED DIAGNOSIS 2018. [PMCID: PMC7173579 DOI: 10.1016/b978-0-323-39956-2.00039-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Trippella G, Galli L, De Martino M, Lisi C, Chiappini E. Procalcitonin performance in detecting serious and invasive bacterial infections in children with fever without apparent source: a systematic review and meta-analysis. Expert Rev Anti Infect Ther 2017; 15:1041-1057. [DOI: 10.1080/14787210.2017.1400907] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Giulia Trippella
- Post-graduate School of Pediatrics, Anna Meyer Children’s University Hospital, Department of Health Sciences, University of Florence, Florence, Italy
| | - Luisa Galli
- Division of Pediatric Infectious Disease, Anna Meyer Children’s University Hospital, Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Catiuscia Lisi
- Department of Statistics, University of Florence, Florence, Italy
| | - Elena Chiappini
- Division of Pediatric Infectious Disease, Anna Meyer Children’s University Hospital, Department of Health Sciences, University of Florence, Florence, Italy
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Lanziotti VS, Póvoa P, Soares M, Silva JRLE, Barbosa AP, Salluh JIF. Use of biomarkers in pediatric sepsis: literature review. Rev Bras Ter Intensiva 2017; 28:472-482. [PMID: 28099644 PMCID: PMC5225923 DOI: 10.5935/0103-507x.20160080] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/09/2016] [Indexed: 12/17/2022] Open
Abstract
Despite advances in recent years, sepsis is still a leading cause of
hospitalization and mortality in infants and children. The presence of
biomarkers during the response to an infectious insult makes it possible to use
such biomarkers in screening, diagnosis, prognosis (risk stratification),
monitoring of therapeutic response, and rational use of antibiotics (for
example, the determination of adequate treatment length). Studies of biomarkers
in sepsis in children are still relatively scarce. This review addresses the use
of biomarkers in sepsis in pediatric patients with emphasis on C-reactive
protein, procalcitonin, interleukins 6, 8, and 18, human neutrophil gelatinase,
and proadrenomedullin. Assessment of these biomarkers may be useful in the
management of pediatric sepsis.
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Affiliation(s)
- Vanessa Soares Lanziotti
- Instituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brasil.,Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | - Pedro Póvoa
- NOVA Medical School, Universidade Nova de Lisboa - Lisboa, Portugal.,Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental - Lisboa, Portugal
| | - Márcio Soares
- Instituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brasil
| | | | - Arnaldo Prata Barbosa
- Instituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brasil.,Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental - Lisboa, Portugal
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Chen CL, Chao HC, Kong MS, Chen SY. Risk Factors for Prolonged Hospitalization in Pediatric Appendicitis Patients with Medical Treatment. Pediatr Neonatol 2017; 58:223-228. [PMID: 27477876 DOI: 10.1016/j.pedneo.2016.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/02/2016] [Accepted: 02/26/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND With effective antibiotics against enteric flora and computed tomography-guided drainage for abscesses, the initial use of nonoperative therapy for children with appendicitis has increased both in recent reports and at our hospital. However, it has been reported that these patients have a relatively longer hospital stay and that their treatment is more expensive than those who undergo aggressive surgical intervention. METHODS This was a retrospective cohort study based in a single medical center. A systemic chart review was conducted to identify risk factors for prolonged hospitalization in pediatric appendicitis patients not initially undergoing surgical treatment. Patient demographics, clinical symptoms, duration of symptoms, laboratory findings, imaging findings, complications, and length of hospital stay were analyzed. Logistic regression analysis was used to identify significant predictors of prolonged hospitalization (≥15 days) and readmission. RESULTS One hundred and twenty-five patients were recruited in this study, of whom 53 (42.4%) had prolonged hospitalization. The values of serum C-reactive protein (CRP) were significantly higher in patients with prolonged hospitalization compared with those without prolonged hospitalization (203 ± 108.6 mg/L vs. 140 ± 93.0 mg/L, p = 0.001). Risk factors of prolonged hospitalization were serum CRP >150 mg/L (35/53 vs. 28/72, p = 0.001), abscess formation (38/53 vs. 35/72, p = 0.008), and multiple abscesses (10/53 vs. 1/72, p = 0.001). Under multivariate analysis, CRP >150 mg/L (odds ratio=1.004, p = 0.0334) and multiple abscesses (odds ratio = 8.788, p = 0.044) were two independent predictors for prolonged hospitalization. CONCLUSION Marked elevation of serum CRP (>150 mg/L) and multiple abscesses are two independent risk factors for prolonged hospitalization in children with appendicitis who are initially treated nonoperatively.
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Affiliation(s)
- Ching-Lun Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Guishan District, Taoyuan City, Taiwan
| | - Hsun-Chin Chao
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Guishan District, Taoyuan City, Taiwan; Chang Gung University College of Medicine, Guishan District, Taoyuan City, Taiwan.
| | - Man-Shan Kong
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Guishan District, Taoyuan City, Taiwan; Chang Gung University College of Medicine, Guishan District, Taoyuan City, Taiwan
| | - Shih-Yen Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Guishan District, Taoyuan City, Taiwan; Chang Gung University College of Medicine, Guishan District, Taoyuan City, Taiwan
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Abstract
Childhood fever of unknown origin (FUO) is most often related to an underlying infection but can also be associated with a variety of neoplastic, rheumatologic, and inflammatory conditions. Repeated, focused reviews of patient history and physical examination are often helpful in suggesting a likely diagnosis. Diagnostic workup should be staged, usually leaving invasive testing for last. Advances in molecular genetic techniques have increased the importance of these assays in the diagnosis of FUO in children.
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Abstract
Mitochondrial DNA (mtDNA) is a novel danger-associated molecular pattern that on its release into the extracellular milieu acts via toll-like receptor-9, a pattern recognition receptor of the immune system. We hypothesized that plasma mtDNA concentrations will be elevated in septic children, and these elevations are associated with an increase in the severity of illness. In a separate set of in vitro experiments, we test the hypothesis that exposing peripheral blood mononuclear cells (PBMC) to mtDNA activates the immune response and induces tumor necrosis factor (TNF) release. Children with sepsis/systemic inflammatory response syndrome or control groups were enrolled within 24 h of admission to the pediatric intensive care unit. Mitochondrial gene cytochrome c oxidase 1 (COX1) concentrations were measured by real-time quantitative PCR in the DNA extracted from plasma. PBMCs were treated with mtDNA (10 μg/mL) and supernatant TNF levels were measured. The median plasma mtDNA concentrations were significantly elevated in the septic patients as compared with the critically ill non-septic and healthy control patients [1.75E+05 (IQR 6.64E+04-3.67E+05) versus 5.73E+03 (IQR 3.90E+03-1.28E+04) and 6.64E+03 (IQR 5.22E+03-1.63E+04) copies/μL respectively]. The median concentrations of plasma mtDNA were significantly greater in patients with MOF as compared with patients without MOF (3.2E+05 (IQR 1.41E+05-1.08E+06) vs. 2.9E+04 (IQR 2.47E+04-5.43E+04) copies/μL). PBMCs treated with mtDNA demonstrated higher supernatant TNF levels as compared with control cells (6.5 ± 1.8 vs. 3.5 ± 0.5 pg/mL, P > 0.05). Our data suggest that plasma mtDNA is a novel danger-associated molecular pattern in pediatric sepsis and appears to be associated with MOF.
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Westwood M, Ramaekers B, Whiting P, Tomini F, Joore M, Armstrong N, Ryder S, Stirk L, Severens J, Kleijnen J. Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016; 19:v-xxv, 1-236. [PMID: 26569153 DOI: 10.3310/hta19960] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Determination of the presence or absence of bacterial infection is important to guide appropriate therapy and reduce antibiotic exposure. Procalcitonin (PCT) is an inflammatory marker that has been suggested as a marker for bacterial infection. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of adding PCT testing to the information used to guide antibiotic therapy in adults and children (1) with confirmed or highly suspected sepsis in intensive care and (2) presenting to the emergency department (ED) with suspected bacterial infection. METHODS Twelve databases were searched to June 2014. Randomised controlled trials were assessed for quality using the Cochrane Risk of Bias tool. Summary relative risks (RRs) and weighted mean differences (WMDs) were estimated using random-effects models. Heterogeneity was assessed visually using forest plots and statistically using the I (2) and Q statistics and investigated through subgroup analysis. The cost-effectiveness of PCT testing in addition to current clinical practice was compared with current clinical practice using a decision tree with a 6 months' time horizon. RESULTS Eighteen studies (36 reports) were included in the systematic review. PCT algorithms were associated with reduced antibiotic duration [WMD -3.19 days, 95% confidence interval (CI) -5.44 to -0.95 days, I (2) = 95.2%; four studies], hospital stay (WMD -3.85 days, 95% CI -6.78 to -0.92 days, I (2) = 75.2%; four studies) and a trend towards reduced intensive care unit (ICU) stay (WMD -2.03 days, 95% CI -4.19 to 0.13 days, I (2) = 81.0%; four studies). There were no differences for adverse clinical outcomes. PCT algorithms were associated with a reduction in the proportion of adults (RR 0.77, 95% CI 0.68 to 0.87; seven studies) and children (RR 0.86, 95% CI 0.80 to 0.93) receiving antibiotics, reduced antibiotic duration (two studies). There were no differences for adverse clinical outcomes. All but one of the studies in the ED were conducted in people presenting with respiratory symptoms. Cost-effectiveness: the base-case analyses indicated that PCT testing was cost-saving for (1) adults with confirmed or highly suspected sepsis in an ICU setting; (2) adults with suspected bacterial infection presenting to the ED; and (3) children with suspected bacterial infection presenting to the ED. Cost-savings ranged from £368 to £3268. Moreover, PCT-guided treatment resulted in a small quality-adjusted life-year (QALY) gain (ranging between < 0.001 and 0.005). Cost-effectiveness acceptability curves showed that PCT-guided treatment has a probability of ≥ 84% of being cost-effective for all settings and populations considered (at willingness-to-pay thresholds of £20,000 and £30,000 per QALY). CONCLUSIONS The limited available data suggest that PCT testing may be effective and cost-effective when used to guide discontinuation of antibiotics in adults being treated for suspected or confirmed sepsis in ICU settings and initiation of antibiotics in adults presenting to the ED with respiratory symptoms and suspected bacterial infection. However, it is not clear that observed costs and effects are directly attributable to PCT testing, are generalisable outside people presenting with respiratory symptoms (for the ED setting) and would be reproducible in the UK NHS. Further studies are needed to assess the effectiveness of adding PCT algorithms to the information used to guide antibiotic treatment in children with suspected or confirmed sepsis in ICU settings. Additional research is needed to examine whether the outcomes presented in this report are fully generalisable to the UK. STUDY REGISTRATION This study is registered as PROSPERO CRD42014010822. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Bram Ramaekers
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Florian Tomini
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Manuela Joore
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Lisa Stirk
- Kleijnen Systematic Reviews Ltd, York, UK
| | - Johan Severens
- Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jos Kleijnen
- Maastricht University Medical Centre, Maastricht, The Netherlands
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'I'm fishing really'--inflammatory marker testing in primary care: a qualitative study. Br J Gen Pract 2016; 66:e200-6. [PMID: 26852797 PMCID: PMC4758500 DOI: 10.3399/bjgp16x683857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/24/2015] [Indexed: 12/17/2022] Open
Abstract
Background Inflammatory markers can be helpful as part of the diagnostic workup for specific diseases or for monitoring disease activity. A third use is as a screening and/or triage tool to differentiate between the presence or absence of disease. Most research into inflammatory markers looks at diagnosis of specific diseases and comes from secondary care. Qualitative studies to explore when and why clinicians use these tests in primary care are lacking. Aim To identify clinicians’ approaches to inflammatory marker testing in primary care. Design and setting Qualitative study with 26 GPs and nurse practitioners. Method Interviews were conducted using a semi-structured topic guide. Clinicians reviewed recent cases of inflammatory marker testing in their pathology inbox. Interviews were audiorecorded and transcribed. Qualitative analysis was conducted by two of the authors. Results Clinicians are uncertain about the appropriate use of inflammatory markers and differ in their approach to testing patients with undifferentiated symptoms. Normal or significantly elevated inflammatory markers are seen as helpful, but mildly raised inflammatory markers in the context of non-specific symptoms are difficult to interpret. Clinicians describe a tension between not wanting to ‘miss anything’ and, on the other hand, being wary of picking up borderline abnormalities that can lead to cascades of further tests. Diagnostic uncertainty is a common reason for inflammatory marker testing, with the aim to reassure; however, paradoxically, inconclusive results can generate a cycle of uncertainty and anxiety. Conclusion Further research is needed to define when inflammatory marker testing is useful in primary care and how to interpret results.
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C-Reactive Protein Bedside Testing in Febrile Children Lowers Length of Stay at the Emergency Department. Pediatr Emerg Care 2015; 31:633-9. [PMID: 26181498 DOI: 10.1097/pec.0000000000000466] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND C-Reactive protein (CRP) is an important diagnostic marker for serious bacterial infections in febrile children. C-Reactive protein bedside testing could potentially accelerate the diagnostic evaluation and shorten length of stay (LOS). OBJECTIVE The aim of the study was to study the effect of introducing CRP bedside testing on the LOS of febrile children at the emergency department (ED). DESIGN AND INTERVENTION A prospective observational study with a preimplementation cohort (2008) with traditional CRP testing and a postimplementation cohort (2009-2011) in which CRP bedside testing was introduced. PATIENTS AND SETTING All previously healthy children with fever, aged 1 month to 16 years, attending the ED of a university hospital were included; non-ill-appearing children with an upper airway infection were not eligible for CRP bedside testing. ANALYSIS AND MAIN OUTCOME MEASURE Multivariable linear regression and propensity score analyses were used to determine the effect of CRP bedside testing on the logarithmic transformation length of stay [(log)LOS]. RESULTS The preimplementation cohort included 609 children of whom 286 (47%) had traditional CRP. The postimplementation cohort included the following 1330 children: 728 (55%) children had bedside CRP and 156 (12%) children had traditional CRP. Bedside CRP significantly lowered the median LOS of children in whom an additional diagnostic CRP test was performed, from 178 minutes (interquartile range, 135-232 minutes) to 148 minutes (interquartile range, 108-200 minutes) (30 minutes, 19% of total LOS). A significant reduction of 15% of the (log)LOS remained after adjusting for other determinants of (log)LOS; propensity score analysis showed a 16% reduction. CONCLUSIONS C-Reactive protein bedside testing substantially lowered the LOS of children with fever at the ED in whom an additional diagnostic CRP test was performed.
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Affiliation(s)
- James W Antoon
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, University of Illinois at Chicago, Chicago, IL
| | - Nicholas M Potisek
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jacob A Lohr
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Lab-score is a valuable predictor of serious bacterial infection in infants admitted to hospital. Wien Klin Wochenschr 2015; 127:942-7. [DOI: 10.1007/s00508-015-0831-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 06/26/2015] [Indexed: 11/26/2022]
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Utility of C-Reactive Protein Levels for Early Prediction of Dengue Severity in Adults. BIOMED RESEARCH INTERNATIONAL 2015; 2015:936062. [PMID: 26247033 PMCID: PMC4515279 DOI: 10.1155/2015/936062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 11/28/2022]
Abstract
Dengue has broad clinical presentation with unpredictable clinical evolution and outcome. We aimed to evaluate the utility of C-reactive protein (CRP) levels for distinguishing between mild and severe cases in the early phase of the dengue illness. We retrospectively evaluated adults with dengue from 2006 to 2014, according to 1997 and 2009 World Health Organization (WHO) criteria for severity. Of 191 included patients, 32.9% had nonshock dengue hemorrhagic fever (DHF), 3.1% dengue shock syndrome (DSS), and 7.9% severe dengue. The risk of DHF/DSS and severe dengue is significantly related to the increasing levels of CRP. Of 191 patients, 97 had CRP levels measured during the febrile (days 1–3); 85 during the critical (days 4–6); and 9 during the convalescent (days 7–10) illness phases. During the febrile phase, there was significant higher CRP level for DSS versus DF/nonshock DHF and severe dengue versus nonsevere dengue, with CRP cutoff level 30.1 mg/L (area under the receiver operating characteristic curve (AUC), 0.938; 100% sensitivity, 76.3% specificity) and 24.2 mg/L (AUC, 0.717; 70% sensitivity, 71.3% specificity), respectively. Our study highlights the utility of the CRP levels in early prediction of DSS and severe dengue in adult patients.
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Méndez Espinola BM, Herrera Labarca P. [Children less than 3 months hospitalised due to acute febrile syndrome. 5 years clinical experience]. ACTA ACUST UNITED AC 2015; 86:270-8. [PMID: 26455695 DOI: 10.1016/j.rchipe.2015.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 02/24/2015] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Acute fever of unknown origin (AFUO) is established when the anamnesis and physical examination cannot identify the cause. In infants less than 3 months-old this is situation for concern, due to the risk of a serious bacterial infection. OBJECTIVE To describe the clinical and laboratory variable of patients with AFUO, in order to look for clues in order to base studies on the decisions arising drom this problem. PATIENTS AND METHODS A report is presented on a retrospective study conducted on a cohort of children less than three months-old admitted to the Hospital Roberto del Río (2007-2011) due to an AFUO. Clinical histories were reviewed and the patients were grouped, according to the severity of the admission diagnosis, into severe and non-severe. They were compared in strata determined by the variables of clinical interest. RESULTADOS A total of 550 children were admitted with AFUO during the study period. There was low agreement between the severity on admission and at discharge (kappa=0.079; P=.26). There were 23.8% of children in the severe group and 76.2% in the non-severe group. Urinary tract infection predominated in the severe group (68.7%) and 40.7% with acute febrile syndrome in the non-severe group. The cut-off levels for C-reactive protein, white cells, and neutrophils per mm(3), to calculate the fixed and variable indices, only showed negative predictive values of some use for ruling out serious bacterial infection. The ROC curves with white cell and neutrophil counts and C-reactive protein, did not provide andy fixed indices of clinical use. More than one-third (34.6%) of lumbar punctures were traumatic or failures. CONCLUSIONS According to the results of this study, there is an obvious excess of hospital admissions, little usefulness in the examinations to identify serious bacterial infection, a high percentage lumbar punctures traumatic and lumbar punctures failures, and an excess of antibiotic treatments. A review of clinical criteria and procedures is needed.
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Affiliation(s)
| | - Patricio Herrera Labarca
- Departamento de Pediatría, Campus Norte, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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Sepsis in head and neck cancer patients treated with chemotherapy and radiation: Literature review and consensus. Crit Rev Oncol Hematol 2015; 95:191-213. [PMID: 25818202 DOI: 10.1016/j.critrevonc.2015.03.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 01/25/2015] [Accepted: 03/05/2015] [Indexed: 12/31/2022] Open
Abstract
The reporting of infection/sepsis in chemo/radiation-treated head and neck cancer patients is sparse and the problem is underestimated. A multidisciplinary group of head and neck cancer specialists from Italy met with the aim of reaching a consensus on a clinical definition and management of infections and sepsis. The Delphi appropriateness method was used for this consensus. External expert reviewers then evaluated the conclusions carefully according to their area of expertise. The paper contains seven clusters of statements about the clinical definition and management of infections and sepsis in head and neck cancer patients, which had a consensus. Furthermore, it offers a review of recent literature in these topics.
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C-reactive protein, procalcitonin and the lab-score for detecting serious bacterial infections in febrile children at the emergency department: a prospective observational study. Pediatr Infect Dis J 2014; 33:e273-9. [PMID: 25093971 DOI: 10.1097/inf.0000000000000466] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND C-reactive protein (CRP) and procalcitonin (PCT) are useful diagnostic tools to estimate the risk of serious bacterial infection (SBI) in febrile children at the emergency department (ED). The Lab-score combines these 2 biomarkers with urinalysis in an easy to use validated model. Kinetics of inflammatory markers suggests a differentiating role of duration of disease. AIM : Appraisal of the diagnostic role of CRP and PCT in febrile children at risk of SBI, determining the differentiating value of duration of fever, and validating and updating the Lab-score. METHODS In this prospective observational study previously healthy children with fever, 1 month to 16 years of age, attending the EDs of a university hospital and a teaching hospital (Rotterdam, the Netherlands) between 2009 and 2012 were included. Standardized information on clinical signs and symptoms, CRP, PCT and urinalysis were collected prospectively. Logistic multivariable regression analysis was used to assess diagnostic performance. The original Lab-score included CRP, PCT and urinalysis and the total score ranged 0-9 points. RESULTS One thousand eighty-four children were included, median age was 1.6 years (interquartile range: 0.8-3.5), 170 children (16%) had SBI. CRP [receiver operating characteristic (ROC)-area 0.77 (95% confidence interval [CI]: 0.69-0.85)] and PCT [ROC-area 0.75 (95% CI: 0.67-0.83)] were both strong predictors of SBI. Duration of fever had no added diagnostic value to CRP and PCT. The Lab-score performed well [ROC area 0.79 (95% CI: 0.72-0.87)], but threshold values performed similar to often used cutoffs of single biomarkers. An updated Lab-score improved only moderately [ROC area 0.83 (95% CI: 0.76-0.90)]. PCT did not alter post-test probabilities for SBI substantially in patients with low (<20 mg/L) or elevated CRP (≥ 100 mg/L) levels (67% of population). CONCLUSION CRP and PCT were both strong predictors of SBI. The original and updated Lab-score performed well, but thresholds values lacked diagnostic value for ruling out SBI. Depending on clinical risk thresholds, diagnostic testing can be limited to CRP or PCT, rather than both, in many febrile children.
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Abstract
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are markers of inflammatory conditions and have been used extensively by clinicians both in outpatient and inpatient settings. It is important to understand the physiologic principles behind these two tests so clinicians may use them appropriately. For example, fibrinogen (for which ESR is an indirect measure) has a much longer half-life than CRP, making ESR helpful in monitoring chronic inflammatory conditions, whereas CRP is more useful in diagnosis as well as in monitoring responses to therapy in acute inflammatory conditions, such as acute infections. Many factors can result in falsely high or low ESR and CRP levels, and it is important to take note of these. Therefore, if used wisely, ESR and CRP can be complementary to good history taking and physical examination in the diagnosis and monitoring of inflammatory conditions.
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Are antibiotics beneficial to children suffering from enterovirus infection complicated with a high C-reactive protein level? Int J Infect Dis 2014; 25:100-3. [PMID: 24943410 DOI: 10.1016/j.ijid.2014.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/09/2014] [Accepted: 04/11/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Enteroviruses are seasonally prevalent each year in Southeast Asia. Elevated C-reactive protein (CRP) levels have been noted in minor populations of patients, and antibiotics may be prescribed under the impression of a suspected bacterial infection. This prescription might be inappropriate, resulting in further bacterial resistance and medical expense. The aim of this study was to delineate how effective antibiotics are for children suffering from enterovirus infection complicated with a high CRP level. METHODS The medical records of children hospitalized between January 2008 and December 2012 with herpangina or hand, foot and mouth disease were reviewed retrospectively. The children enrolled were divided into three groups, A, B, and C, by CRP level, which were <40, 40-80, and ≥ 80 mg/l, respectively. A case-control study of group C divided into subgroups according to the prescription of antibiotics for at least 24h during the admission was conducted for further analysis. RESULTS A total 3566 cases were identified; 214 were in group C and 71.0% of them received a prescription for antibiotics. There was a linear trend between a relatively higher CRP level and a higher proportion of antibiotics prescribed in the three groups (p=0.001). In the case-control study, there were no significant differences in age, sex, mean CRP, or febrile days. However, a relatively longer stay of hospitalization was recorded in the subgroup with an antibiotic prescription (p=0.020). CONCLUSIONS The present study indicated that antibiotics might not be beneficial in treating these patients, even those with a high CRP level. Clinicians should be more prudent in antibiotic use when no obvious evidence of bacterial infection is found.
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Alqahtani MF, Marsillio LE, Rozenfeld RA. A Review of Biomarkers and Physiomarkers in Pediatric Sepsis. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2014. [DOI: 10.1016/j.cpem.2014.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Elemraid MA, Rushton SP, Thomas MF, Spencer DA, Gennery AR, Clark JE. Utility of inflammatory markers in predicting the aetiology of pneumonia in children. Diagn Microbiol Infect Dis 2014; 79:458-62. [PMID: 24857169 DOI: 10.1016/j.diagmicrobio.2014.04.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 04/18/2014] [Accepted: 04/20/2014] [Indexed: 01/09/2023]
Abstract
We aimed to investigate the diagnostic value of applying cut-off levels of inflammatory markers and to develop a prediction model for differentiation between bacterial and viral infections in paediatric community-acquired pneumonia based on C-reactive protein (CRP), neutrophil, and white cell counts (WCC). Amongst 401 children, those with bacterial pneumonia were older than those with viral pneumonia (P<0.001). Compared to viral, bacterial infections had a higher median CRP level (P<0.001), whereas WCC and neutrophil count were not different. Bacterial infections were associated with higher CRP >80 mg/L than viral infections (P=0.001), but levels <20 mg/L were not discriminatory (P=0.254). Receiver operating characteristic curve of the model for differentiating bacterial from viral pneumonia based on age, CRP, and neutrophil count produced area under the curve of 0.894 with 75.7% sensitivity and 89.4% specificity. This aetiological discriminant prediction model is a potentially useful tool in clinical management and epidemiological studies of paediatric pneumonia.
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Affiliation(s)
- Mohamed A Elemraid
- Department of Paediatric Infectious Disease and Immunology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne NE1 7RU, UK.
| | - Stephen P Rushton
- Biological, Clinical and Environmental Systems Modelling Group, School of Biology, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Matthew F Thomas
- Biological, Clinical and Environmental Systems Modelling Group, School of Biology, Newcastle University, Newcastle upon Tyne NE1 7RU, UK; Department of Respiratory Paediatrics, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
| | - David A Spencer
- Department of Respiratory Paediatrics, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
| | - Andrew R Gennery
- Department of Paediatric Infectious Disease and Immunology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Julia E Clark
- Department of Paediatric Infectious Disease, Royal Children's Hospital, Brisbane, Queensland 4029, Australia
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Kaya Z, Küçükcongar A, Vurallı D, Emeksiz HC, Gürsel T. Leukocyte populations and C-reactive protein as predictors of bacterial infections in febrile outpatient children. Turk J Haematol 2014; 31:49-55. [PMID: 24764729 PMCID: PMC3996630 DOI: 10.4274/tjh.2013.0057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 07/02/2013] [Indexed: 12/03/2022] Open
Abstract
Objective: Infections remain the major cause of unnecessary antibiotic use in pediatric outpatient settings. Complete blood count (CBC) is the essential test in the diagnosis of infections. C-reactive protein (CRP) is also useful for assessment of young children with serious bacterial infections. The purpose of the study was to evaluate leukocyte populations and CRP level to predict bacterial infections in febrile outpatient children. Materials and Methods: The values of CBC by Cell-DYN 4000 autoanalyzer and serum CRP levels were evaluated in 120 febrile patients with documented infections (n:74 bacterial, n:46 viral) and 22 healthy controls. Results: The mean CRP, neutrophil and immature granulocyte (IG) values were significantly higher in bacterial infections than in viral infections and controls (p<0.05). C-reactive protein was significantly correlated with neutrophil level in bacterial infections (r: 0.76, p<0.05). Specificity of IG was greatest at 93%, only a modest 56% for neutrophil and mild 18% for CRP, whereas 100% for combination of IG, neutrophil and CRP. Conclusion: Acute bacterial infection seems to be very unlikely in children with normal leukocyte populations and CRP values, even if clinically signs and symptoms indicate acute bacterial infections.
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Affiliation(s)
- Zühre Kaya
- Gazi University Medical School, The Pediatric Hematology Unit, Department of Pediatrics, Ankara, Turkey
| | - Aynur Küçükcongar
- Gazi University Medical School, The Pediatric Hematology Unit, Department of Pediatrics, Ankara, Turkey
| | - Doğuş Vurallı
- Gazi University Medical School, The Pediatric Hematology Unit, Department of Pediatrics, Ankara, Turkey
| | - Hamdi Cihan Emeksiz
- Gazi University Medical School, The Pediatric Hematology Unit, Department of Pediatrics, Ankara, Turkey
| | - Türkiz Gürsel
- Gazi University Medical School, The Pediatric Hematology Unit, Department of Pediatrics, Ankara, Turkey
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Lack of value of midregional pro-adrenomedullin and C-terminal pro-endothelin-1 for prediction of severe bacterial infections in infants with fever without a source. Eur J Pediatr 2013; 172:1441-9. [PMID: 23793138 DOI: 10.1007/s00431-013-2062-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 06/05/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED The study was performed to assess the usefulness of two new biomarkers, midregional pro-adrenomedullin (MR-pro-ADM) and C-pro-endothelin-1 (CT-pro-ET-1), in predicting bacterial infection (BI) and especially invasive bacterial infection (IBI) in well-appearing infants with fever without source (FWS). For this purpose, a multicenter prospective study was conducted between February 2008 and March 2009 including well-appearing infants less than 36 months of age with FWS. MR-pro-ADM, CT-pro-ET-1, procalcitonin (PCT), CRP, and WBC were measured and compared. Among the 1,035 infants included, a bacterial infection was diagnosed in 75 patients (7.2 %), and 16 (1.54 %) had an invasive bacterial infection (bacterial meningitis, 8; occult bacteremia, 6; and sepsis, 1). MR-pro-ADM and CT-pro-ET-1 levels were less reliable for diagnosis than the other biomarkers. The area under receiver operating characteristic curve for infants with BI and IBI was 0.59 (95 % confidence interval (CI) 0.52-0.67) and 0.63 (95 % CI 0.46-0.80) for MR-pro-ADM and 0.58 (95 % CI 0.51-0.66) and 0.62 (95 % CI 0.47-0.67) for CT-pro-ET-1, respectively. Multivariate analysis showed that PCT ≥ 0.5 ng/mL, CRP ≥ 40 mg/L, and CT-pro-ET-1 ≥ 105 pmol/mL were independent risk factors for having a BI (odds ratio (OR) 6.12, 3.61, and 2.84, respectively). PCT was the only independent risk factor for having an IBI (OR 17.53 if PCT ≥ 0.5 ng/mL). CONCLUSION Although baseline MR-pro-ADM and CT-pro-ET-1 levels are significantly elevated in well-appearing febrile infants with a bacterial infection, their overall performance as diagnostic markers is very poor.
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Abstract
Fever is one of the most common reasons for a visit to the primary care provider or the emergency department. Traditionally, clinicians have used various risk-stratification strategies to identify serious bacterial infections (SBI) without an obvious source in febrile children, because missed bacterial infections in such children can result in meningitis, sepsis, and death; therefore, early and accurate identification of SBIs is critical. Infants aged less than 60 to 90 days are at greatest risk of SBI. The epidemiology of SBI continues to evolve, especially after the successful introduction of conjugate vaccines against Streptococcus pneumoniae and Haemophilus influenzae.
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Affiliation(s)
- Rajan Arora
- Division of Emergency Medicine, Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Boulevard, Detroit, MI 48201, USA
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Markic J, Jeroncic A, Polancec D, Bosnjak N, Markotic A, Mestrovic J, Culic VC. CD15s is a potential biomarker of serious bacterial infection in infants admitted to hospital. Eur J Pediatr 2013; 172:1363-9. [PMID: 23728509 DOI: 10.1007/s00431-013-2047-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 05/15/2013] [Indexed: 10/26/2022]
Abstract
Early recognition of serious bacterial infection (SBI) in children is essential for better treatment outcome. Flow cytometry analysis of neutrophil surface molecules has been more frequently utilized as a tool for diagnosis of infection. The infants (n = 105) under 6 months of age presenting to the pediatric emergency department with fever without apparent source who were hospitalized with suspicion of having SBI were enrolled in this prospective study. Sixty-nine infants were included into the training pool and were classified into bacterial or viral infection group. Validation pool consisted of 36 infants. The values of white blood cells counts, absolute neutrophil count (ANC), C-reactive protein (CRP), procalcitonin (PCT), neutrophil CD11b, CD15s and CD64 expression, and the percentage (%CD15s+) and absolute count (AC-CD15s+) of CD15s+ neutrophils were determined. In infants with SBI, %CD15s+ was 10.5 times more likely to be higher than the cut-off value. ANC, CRP, PCT, CD64, and AC-CD15s+ were also found as useful biomarkers for differentiation between bacterial and viral infection. The best fit multivariate logistic regression model included CRP, PCT, and %CD15s+ as strong predictors of SBI. The model's sensitivity (87 %) and specificity (83 %) indicated high model's accuracy. After validation on independent dataset, model's accuracy maintained high: 86 % sensitivity and 93 % specificity, confirming its reliability and supporting CRP, PCT, and %CD15s+ as real predictors. The findings of this study support assumption made in the literature on significance of CD15s in inflammation processes. Also, this study demonstrated for the first time that CD15s is potentially valuable biomarker of SBI in infants.
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Affiliation(s)
- Josko Markic
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital of Split, Spinciceva 1, 21000, Split, Croatia,
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Abstract
Early recognition of sepsis and septic shock in children relies on obtaining an attentive clinical history, accurate vital signs, and a physical examination focused on mental status, work of breathing, and circulatory status. Laboratory tests may support the diagnosis but are not reliable in isolation. The goal of septic shock management is reversal of tissue hypoperfusion. The therapeutic end point is shock reversal. Mortality is significantly better among children when managed appropriately. Every physician who cares for children must strive to have a high level of suspicion and keen clinical acumen for recognizing the rare but potentially seriously ill child.
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Affiliation(s)
- Patrick J Maloney
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver Health Medical Center, 660 Bannock Street, MC 0108, Denver, CO 80204, USA.
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Rödöö P, Ridefelt P, Aldrimer M, Niklasson F, Gustafsson J, Hellberg D. Population-based pediatric reference intervals for HbA1c, bilirubin, albumin, CRP, myoglobin and serum enzymes. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:361-7. [DOI: 10.3109/00365513.2013.783931] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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