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Wang ML, Trehan I. Epidemiology and risk stratification of young infants presenting to the emergency department with hypothermia. J Am Coll Emerg Physicians Open 2024; 5:e13241. [PMID: 39035810 PMCID: PMC11258424 DOI: 10.1002/emp2.13241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/17/2024] [Accepted: 06/26/2024] [Indexed: 07/23/2024] Open
Abstract
Objective Hypothermic infants are presumed to be at high risk for a serious bacterial infection (SBI) or herpes simplex virus (HSV) infection. In contrast to febrile infants, the emergency department (ED) management of hypothermic infants is variable in the absence of consensus guidelines, potentially resulting in low-value care and missed diagnoses. We investigated the diagnostic workup conducted for hypothermic infants in our academic pediatric ED, the incidence of SBI and HSV infection, and risk factors associated with infection. Methods We conducted a single-center retrospective study of infants ≤90 days of age with a rectal temperature ≤36.5°C in the ED between 2013 and 2022. From their medical records, we abstracted the type(s) of testing each infant received in the ED and the diagnosis of SBI and HSV, analyzing characteristics associated with each. Results Of 1095 hypothermic infants identified, 402 (37%) underwent testing for SBI or HSV. Among these, 34/402 (8.5%) had an SBI or HSV. A minimum temperature below 36°C and hospital admission were characteristics associated with higher rates of infectious testing. Infants aged 29‒90 days, compared to 0‒28 days, were more likely to have a urinary tract infection (odds ratio 3.28, 95% confidence interval 1.47‒7.32). Conclusions Hypothermic infants have slightly lower rates of SBI or HSV than febrile infants, for whom infectious studies are widely recommended, but still high enough to warrant an infectious workup in most cases. Further research is required to risk stratify hypothermic infants in the ED to standardize care and improve outcomes while optimizing resource utilization.
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Affiliation(s)
| | - Indi Trehan
- Departments of Pediatrics, Global Health, and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
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Philips K, Silver AH. Entering the Icy Waters of Viral Testing and Infant Hypothermia. JOURNAL OF PEDIATRICS. CLINICAL PRACTICE 2024; 11:200103. [PMID: 38827479 PMCID: PMC11138250 DOI: 10.1016/j.jpedcp.2024.200103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Affiliation(s)
- Kaitlyn Philips
- Department of Pediatrics, Joseph M. Sanzari Children’s Hospital, Hackensack Meridian Children’s Health, Hackensack, NJ
| | - Alyssa H. Silver
- Department of Pediatrics, Joseph M. Sanzari Children’s Hospital, Hackensack Meridian Children’s Health, Hackensack, NJ
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Westphal K, Adib H, Doraiswamy V, Basiago K, Lee J, Banker SL, Morrison J, McCartor S, Berger S, Schmit EO, Van Meurs A, Mitchell M, Lee C, Wood JK, Tapp LG, Kunkel D, Halvorson EE, Potisek NM. Performance of Febrile Infant Decision Tools on Hypothermic Infants Evaluated for Infection. Hosp Pediatr 2024; 14:163-171. [PMID: 38312006 DOI: 10.1542/hpeds.2023-007525] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
BACKGROUND Given the lack of evidence-based guidelines for hypothermic infants, providers may be inclined to use febrile infant decision-making tools to guide management decisions. Our objective was to assess the diagnostic performance of febrile infant decision tools for identifying hypothermic infants at low risk of bacterial infection. METHODS We conducted a secondary analysis of a retrospective cohort study of hypothermic (≤36.0 C) infants ≤90 days of age presenting to the emergency department or inpatient unit among 9 participating sites between September 1, 2016 and May 5, 2021. Well-appearing infants evaluated for bacterial infections via laboratory testing were included. Infants with complex chronic conditions or premature birth were excluded. Performance characteristics for detecting serious bacterial infection (SBI; urinary tract infection, bacteremia, bacterial meningitis) and invasive bacterial infection (IBI; bacteremia, bacterial meningitis) were calculated for each tool. RESULTS Overall, 314 infants met the general inclusion criteria, including 14 cases of SBI (4.5%) and 7 cases of IBI (2.2%). The median age was 5 days, and 68.1% of the infants (214/314) underwent a full sepsis evaluation. The Philadelphia, Boston, IBI Score, and American Academy of Pediatrics Clinical Practice Guideline did not misclassify any SBI or IBI as low risk; however, they had low specificity and positive predictive value. Rochester and Pediatric Emergency Care Applied Research Network tools misclassified infants with bacterial infections. CONCLUSIONS Several febrile infant decision tools were highly sensitive, minimizing missed SBIs and IBIs in hypothermic infants. However, the low specificity of these decision tools may lead to unnecessary testing, antimicrobial exposure, and hospitalization.
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Affiliation(s)
- Kathryn Westphal
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Hania Adib
- Department of Pediatrics, Keck School of Medicine of USC, Children's Hospital Los Angeles, Los Angeles, California
| | - Vignesh Doraiswamy
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Kevin Basiago
- Department of Pediatrics, Keck School of Medicine of USC, Children's Hospital Los Angeles, Los Angeles, California
| | - Jennifer Lee
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, New York
| | - Sumeet L Banker
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, New York
| | - John Morrison
- Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Saylor McCartor
- Department of Pediatrics, University of South Carolina School of Medicine Greenville, Prisma Health Children's Hospital-Upstate, Greenville, South Carolina
| | - Stephanie Berger
- Department of Pediatrics, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Erinn O Schmit
- Department of Pediatrics, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Annalise Van Meurs
- Department of Pediatrics, Oregon Health and Science University, Doernbecher Children's Hospital, Portland, Oregon
| | - Meredith Mitchell
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Clifton Lee
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Julie K Wood
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lauren G Tapp
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Deborah Kunkel
- School of Mathematical and Statistical Sciences, Clemson University, Clemson, South Carolina
| | - Elizabeth E Halvorson
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Nicholas M Potisek
- Department of Pediatrics, University of South Carolina School of Medicine Greenville, Prisma Health Children's Hospital-Upstate, Greenville, South Carolina
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Potisek NM, Morrison J, St Ville ME, Westphal K, Wood JK, Lee J, Combs MD, Berger S, Lee C, Van Meurs A, Halvorson EE. Time to Positive Blood and Cerebrospinal Fluid Cultures in Hypothermic Young Infants. Hosp Pediatr 2024; 14:e6-e12. [PMID: 38062772 DOI: 10.1542/hpeds.2023-007391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2024]
Abstract
BACKGROUND AND OBJECTIVE Hypothermia in young infants may be secondary to an invasive bacterial infection. No studies have explored culture time-to-positivity (TTP) in hypothermic infants. Our objective was to compare TTP of blood and cerebrospinal fluid (CSF) cultures between pathogenic and contaminant bacteria in hypothermic infants ≤90 days of age. METHODS Secondary analysis of a retrospective cohort of 9 children's hospitals. Infants ≤90 days of age presenting to the emergency department or inpatient setting with hypothermia from September 1, 2017, to May 5, 2021, with positive blood or CSF cultures were included. Differences in continuous variables between pathogenic and contaminant organism groups were tested using a 2-sample t test and 95% confidence intervals for the mean differences reported. RESULTS Seventy-seven infants met inclusion criteria. Seventy-one blood cultures were positive, with 20 (28.2%) treated as pathogenic organisms. Five (50%) of 10 positive CSF cultures were treated as pathogenic. The median (interquartile range [IQR]) TTP for pathogenic blood cultures was 16.8 (IQR 12.7-19.2) hours compared with 26.11 (IQR 20.5-48.1) hours for contaminant organisms (P < .001). The median TTP for pathogenic organisms on CSF cultures was 34.3 (IQR 2.0-53.7) hours, compared with 58.1 (IQR 52-72) hours for contaminant CSF organisms (P < .186). CONCLUSIONS Our study is the first to compare the TTP of blood and CSF cultures between pathogenic and contaminant bacteria in hypothermic infants. All pathogenic bacteria in the blood grew within 36 hours. No difference in TTP of CSF cultures between pathogenic and contaminant bacteria was detected.
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Affiliation(s)
- Nicholas M Potisek
- Department of Pediatrics, University of South Carolina School of Medicine Greenville, Prisma Health Children's Hospital-Upstate, Greenville, South Carolina
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - John Morrison
- Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Kathryn Westphal
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie K Wood
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Jennifer Lee
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, New York
| | - Monica D Combs
- Department of Pediatrics, Keck School of Medicine of USC, Children's Hospital Los Angeles, Los Angeles, California
| | - Stephanie Berger
- Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, Alabama
| | - Clifton Lee
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Annalise Van Meurs
- Department of Pediatrics, Oregon Health and Science University, Doernbecher Children's Hospital, Portland, Oregon
| | - Elizabeth E Halvorson
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Ramgopal S, Graves C, Aronson PL, Cruz AT, Rogers A. Clinician Management Practices for Infants With Hypothermia in the Emergency Department. Pediatrics 2023; 152:e2023063000. [PMID: 38009075 DOI: 10.1542/peds.2023-063000] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND Young infants with serious bacterial infections (SBI) or herpes simplex virus (HSV) infections may present to the emergency department (ED) with hypothermia. We sought to evaluate clinician testing and treatment preferences for infants with hypothermia. METHODS We developed, piloted, and distributed a survey of ED clinicians from 32 US pediatric hospitals between December 2022 to March 2023. Survey questions were related to the management of infants (≤60 days of age) with hypothermia in the ED. Questions pertaining to testing and treatment preferences were stratified by age. We characterized clinician comfort with the management of infants with hypothermia. RESULTS Of 1935 surveys distributed, 1231 (63.6%) were completed. The most common definition of hypothermia was a temperature of ≤36.0°C. Most respondents (67.7%) could recall caring for at least 1 infant with hypothermia in the previous 6 months. Clinicians had lower confidence in caring for infants with hypothermia compared with infants with fever (P < .01). The proportion of clinicians who would obtain testing was high in infants 0 to 7 days of age (97.3% blood testing for SBI, 79.7% for any HSV testing), but declined for older infants (79.3% for blood testing for SBI and 9.5% for any HSV testing for infants 22-60 days old). A similar pattern was noted for respiratory viral testing, hospitalization, and antimicrobial administration. CONCLUSIONS Testing and treatment preferences for infants with hypothermia varied by age and frequently reflected observed practices for febrile infants. We identified patterns in management that may benefit from greater research and implementation efforts.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher Graves
- Pediatric Emergency Medicine Associates (PEMA), LLC
- Division of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Andrea T Cruz
- Divisions of Pediatric Emergency Medicine and Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Alexander Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan
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