Evaluation of the infant with fever without source: an evidence based approach

Management of Pediatric Urinary Tract Infections: A Delphi Study

Urinary tract infection (UTI) is one of the most common infectious diseases in the pediatric population and represents a major cause of antibiotic consumption and hospitalization in children. Considering the ongoing controversies on the management of pediatric UTI and the challenges due to increasing antimicrobial resistance, the aim of the present study was to evaluate the level of agreement on UTI management in pediatric age in Emilia-Romagna Region, Italy, and to assess on the basis of recent studies whether there is the need to change current recommendations used by primary care pediatricians, hospital pediatricians, and pediatric surgeons in everyday clinical practice to possibly improve outcomes. This consensus provides clear and shared indications on UTI management in pediatric age, based on the most updated literature. This work represents, in our opinion, the most complete and up-to-date collection of statements on procedures to follow for pediatric UTI, in order to guide physicians in the management of the patient, standardize approaches, and avoid abuse and misuse of antibiotics. Undoubtedly, more randomized and controlled trials are needed in the pediatric population to better define the best therapeutic management in cases with antimicrobial resistance and real usefulness of long-term antibiotic prophylaxis.

Discrepancies Between the Management of Fever in Young Infants Admitted From Urban General Emergency Departments and Pediatric Emergency Departments

INTRODUCTION/OBJECTIVE

Most pediatric emergency visits occur in general emergency departments (GED). Our study aims to assess whether medical decision making regarding the management of febrile infants differs in GEDs from pediatric EDs (PED) and deviates from pediatric expert consensus.

METHODS

We conducted a retrospective chart review on patients younger than 60 days with fever admitted from 13 GEDs versus 1 PED to a children's hospital over a 3-year period. Adherence to consensus guidelines was measured by frequency of performing critical components of initial management, including blood culture, urine culture, attempted lumbar puncture, and antibiotic administration (<29 days old), or complete blood count and/or C-reactive protein, blood culture, and urine culture (29-60 days old). Additional outcomes included lumbar puncture, collecting urine specimens via catheterization, and timing of antibiotics.

RESULTS

A total of 176 patient charts were included. Sixty-four (36%) patients were younger than 29 days, and 112 (64%) were 29 to 60 days old. Eighty-eight (50%) patients were admitted from GEDs.In infants younger than 29 days managed in the GEDs (n = 32), 65.6% (n = 21) of patients underwent all 4 critical items compared with 96.9% (n = 31, P = 0.003) in the PED. In infants 29 to 60 days old managed in GEDs (n = 56), 64.3% (n = 36) patients underwent all 3 critical items compared with 91.1% (n = 51, P < 0.001) in the PED.

CONCLUSIONS

This retrospective study suggests that providers managing young infants with fever in 13 GEDs differ significantly from providers in the PED examined and literature consensus. Inconsistent testing and treatment practices may put young infants at risk for undetected bacterial infection.

Screening for dental focal infections in febrile patients with hematologic malignancies who received chemotherapy: a retrospective cohort study

Source of fever in chemotherapy patients is often unknown. Fever can also be fatal. No observational studies have determined the incidence of dental focal infection (DFI)-associated fever, despite oral cavity being a potential source of infection. We report the incidence of fever after chemotherapy in patients with hematological malignancies and their association with DFIs in 441 patients visiting our institution during a 6-year period. Dental treatments, including tooth extraction, were performed, and their oral and hematological profiles were monitored after chemotherapy. Fever was evident in 87 (38.5%) of 226 patients (≥ 38˚C) after the first cycle of chemotherapy. Sepsis due to DFIs (n = 4; 4.6%) was evaluated. Chemotherapy was delayed due to DFI in one case. Fever after chemotherapy should be differentiated from oral infections. Our study emphasizes the significance of DFI in patients with fever after chemotherapy and can help in improving the prognosis of patients.

A multicenter, randomized, open-label, active-comparator trial to determine the efficacy, safety, and pharmacokinetics of intravenous ibuprofen for treatment of fever in hospitalized pediatric patients

BACKGROUND

Oral antipyretics are commonly used to treat pediatric patients who develop fevers. However, patients presenting to the emergency department or undergoing surgery are frequently unable to tolerate oral antipyretics. Rectal formulations are available; however, this route of administration is unpredictable. The main objectives of this randomized controlled study was to evaluate the efficacy and safety of single or multiple doses of intravenous ibuprofen to acetaminophen (oral or suppository) in pediatric patients with fever and to assess plasma ibuprofen concentrations.

METHODS

This multi-center study was conducted in hospitalized patients, ≤ 16 years, with a new onset of fever ≥ 38.3°C. Patients were randomly assigned to receive either 10 mg/kg intravenous ibuprofen or acetaminophen. Study drug was administered at hour 0, and thereafter every 4 h as needed, up to 5 days. The primary outcome was to evaluate the effect of a single dose of intravenous ibuprofen compared to acetaminophen in reducing temperature in the first 2 h after administration. Data were compared using an analysis of variance model for continuous measurements and Cochran-Mantel-Haenszel test of general association for categorical data. A two-sided testing was used and a p-value ≤ 0.05 was considered significant.

RESULTS

A total of 103 patients received study medication. Intravenous ibuprofen resulted in a greater reduction in temperature as measured by the area under the change from baseline at 2 h (p = 0.005) and 4 h (<0.001); in a greater reduction in change from baseline temperature compared to treatment with acetaminophen, and it reduced fever throughout a 24 h dosing period. There were no differences in safety parameters or serious adverse events.

CONCLUSIONS

A single 10 mg/kg dose of intravenous ibuprofen provided a significant reduction of temperature for febrile pediatric patients compared to those that received 10 mg/kg acetaminophen at 2 h and 4 h post-treatment. A reduction in temperature was also demonstrated over 24 h; however the reduction was not considered statically significant. Intravenous ibuprofen provides an effective option for reducing fever in hospitalized pediatric patients.

TRIAL REGISTRATION

The study was registered on ClinicalTrials.gov on 26 October 2009, Study Identifier: NCT01002573.

Clinicians' overestimation of febrile child risk assessment

We aimed to estimate clinicians' based risk thresholds at which febrile children would be managed as serious bacterial infections (SBI) to determine influencing characteristics and to compare thresholds with prediction model (Feverkidstool) risk estimates. Twenty-one video vignettes of febrile children visiting the emergency department (ED) were assessed by 42 (40.4 %) international paediatricians/paediatric emergency clinicians. Questions were related to clinical risk scores of the child having SBI and SBI management decisions on visual analogue scales. Feverkidstool risk scores were based on clinical signs/symptoms and C-reactive protein. Amongst vignettes assigned to SBI management, the median risk was 60 % (interquartile range (IQR) 30.0-80.5) and 16.0 % (IQR 5.0-32.0) when vignettes were not managed as SBI. Ill appearance and aberrant circulatory signs were the most influencing factors, as age and duration of fever were the least influencing factors on SBI management decisions. Feverkidstool risk scores varied from 13 % (IQR 7.7-28.1) for SBI management to 7.3 % (IQR 5.7-16.3) for no SBI management.

CONCLUSION

Clinicians assigned high risk scores to children who they would have managed as SBI, mostly influenced by ill appearance and aberrant circulation. In contrast to SBI risk assessment of the Feverkidstool, clinicians' appeared to apply a more stepwise assessment of the risk of presence/absence of SBI at different steps in the diagnostic and therapeutic process. Uniform risk thresholds at which one should start SBI management in febrile children remains unclear; risk thresholds at which we refrained from SBI management were more consistent.

WHAT IS KNOWN

•Only a small proportion of febrile children presenting to the emergency department will have serious bacterial infections (SBI) and uniform risk thresholds to start or withhold SBI treatment are not known. •The low prevalence of SBI and consequently the low exposure of clinicians to these infections make them rely more on alarming signs or clinical decision rules. What is New: •Previously identified model predictors for SBI appeared to be significantly influencing factors in clinicians' febrile child management in emergency care. •Clinicians' wielded higher risk thresholds regarding SBI febrile child management than reflected by the clinical prediction model while smaller differences in risk thresholds between clinical and model prediction were observed when clinicians refrained from SBI management.

Impact of a clinical decision model for febrile children at risk for serious bacterial infections at the emergency department: a randomized controlled trial

OBJECTIVES

To assess the impact of a clinical decision model for febrile children at risk for serious bacterial infections (SBI) attending the emergency department (ED).

METHODS

Randomized controlled trial with 439 febrile children, aged 1 month-16 years, attending the pediatric ED of a Dutch university hospital during 2010-2012. Febrile children were randomly assigned to the intervention (clinical decision model; n = 219) or the control group (usual care; n = 220). The clinical decision model included clinical symptoms, vital signs, and C-reactive protein and provided high/low-risks for "pneumonia" and "other SBI". Nurses were guided by the intervention to initiate additional tests for high-risk children. The clinical decision model was evaluated by 1) area-under-the-receiver-operating-characteristic-curve (AUC) to indicate discriminative ability and 2) feasibility, to measure nurses' compliance to model recommendations. Primary patient outcome was defined as correct SBI diagnoses. Secondary process outcomes were defined as length of stay; diagnostic tests; antibiotic treatment; hospital admission; revisits and medical costs.

RESULTS

The decision model had good discriminative ability for both pneumonia (n = 33; AUC 0.83 (95% CI 0.75-0.90)) and other SBI (n = 22; AUC 0.81 (95% CI 0.72-0.90)). Compliance to model recommendations was high (86%). No differences in correct SBI determination were observed. Application of the clinical decision model resulted in less full-blood-counts (14% vs. 22%, p-value < 0.05) and more urine-dipstick testing (71% vs. 61%, p-value < 0.05).

CONCLUSIONS

In contrast to our expectations no substantial impact on patient outcome was perceived. The clinical decision model preserved, however, good discriminatory ability to detect SBI, achieved good compliance among nurses and resulted in a more standardized diagnostic approach towards febrile children, with less full blood-counts and more rightfully urine-dipstick testing.

TRIAL REGISTRATION

Nederlands Trial Register NTR2381.

Urinary tract infections in children: EAU/ESPU guidelines

CONTEXT

In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign. Failure to identify patients at risk can result in damage to the upper urinary tract.

OBJECTIVE

To provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI.

EVIDENCE ACQUISITION

The recommendations were developed after a review of the literature and a search of PubMed and Embase. A consensus decision was adopted when evidence was low.

EVIDENCE SYNTHESIS

UTIs are classified according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria. A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In children with febrile UTI, antibiotic treatment should be initiated as soon as possible to eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reflux should be excluded. Antibacterial prophylaxis is beneficial. In toilet-trained children, bladder and bowel dysfunction needs to be excluded.

CONCLUSIONS

The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage.

PATIENT SUMMARY

In these guidelines, we looked at the diagnosis, treatment, and imaging of children with urinary tract infection. There are strong recommendations on diagnosis and treatment; we also advise exclusion of obstructive uropathy within 24h and later vesicoureteral reflux, if indicated.

Diagnostic findings in infants presenting to a pediatric emergency department for lethargy or feeding complaints

OBJECTIVES

Lethargy is a common complaint among infants in the pediatric emergency department (ED), yet there is little data to guide appropriate evaluation. The objectives of the study were (1) to determine the frequency of diagnoses requiring intervention/monitoring and (2) to identify predictors of these diagnoses.

METHODS

A retrospective chart review of patients aged 0 to 6 months with a chief complaint of lethargy or poor feeding from January 2004 to December 2009 was performed. Patients were excluded if they had a fever, hypothermia, a chronic medical condition, or a history of trauma. Charts were reviewed by a single investigator; 10% were reviewed by a second investigator for agreement. History, examination, laboratory and radiology results, ED and inpatient diagnoses, as well as return visits within 7 days were recorded. Frequencies of diagnoses and interventions were described, and history and examination findings associated with these categories were determined.

RESULTS

Two hundred seventy-two patients were included; 34 patients (12.5%; 95% confidence interval [CI], 8.8%-17%) required intervention/monitoring. These patients were classified into 6 categories. Eighteen had hematologic disorders (6.6%; 95% CI, 4.0%-10.3%), 8 had dehydration (2.9%; 95% CI, 1.3%-5.7%), 2 had intracranial bleeds (0.7%; 95% CI, 0.09%-2.6%), 3 had serious bacterial infections (1%; 95% CI, 0.2%-3.2%), 1 had a cardiac disorder (0.4%; 95% CI, 0.009%-2%), and 2 had neurologic disorders (0.7%; 95% CI, 0.9%-2.6%). Of the patients, 76% had conditions that were clinically evident (dehydration and hyperbilirubinemia requiring phototherapy). The patients with cardiac disorders, neurologic disorders, and intracranial bleeds all had abnormal examination findings in the ED. The 3 patients with serious bacterial infections were younger than 2 months of age and ill appearing; all had urinary tract infections.

CONCLUSIONS

Infants with lethargy or poor feeding who require an intervention are likely to have conditions that are clinically evident or focal examination findings that lead to the diagnosis. Well-appearing infants with normal findings in examinations are unlikely to have a condition requiring intervention and should receive minimal testing.

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

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.

Fever in the pediatric patient

Fever is the most common reason that children and infants are brought to emergency departments. Emergency physicians face the challenge of quickly distinguishing benign from life-threatening conditions. The management of fever in children is guided by the patient's age, immunization status, and immune status as well as the results of a careful physical examination and appropriate laboratory tests and radiographic views. In this article, the evaluation and treatment of children with fevers of known and unknown origin are described. Causes of common and dangerous conditions that include fever in their manifestation are also discussed.

Clinical prediction model to aid emergency doctors managing febrile children at risk of serious bacterial infections: diagnostic study

OBJECTIVE

To derive, cross validate, and externally validate a clinical prediction model that assesses the risks of different serious bacterial infections in children with fever at the emergency department.

DESIGN

Prospective observational diagnostic study.

SETTING

Three paediatric emergency care units: two in the Netherlands and one in the United Kingdom.

PARTICIPANTS

Children with fever, aged 1 month to 15 years, at three paediatric emergency care units: Rotterdam (n=1750) and the Hague (n=967), the Netherlands, and Coventry (n=487), United Kingdom. A prediction model was constructed using multivariable polytomous logistic regression analysis and included the predefined predictor variables age, duration of fever, tachycardia, temperature, tachypnoea, ill appearance, chest wall retractions, prolonged capillary refill time (>3 seconds), oxygen saturation <94%, and C reactive protein.

MAIN OUTCOME MEASURES

Pneumonia, other serious bacterial infections (SBIs, including septicaemia/meningitis, urinary tract infections, and others), and no SBIs.

RESULTS

Oxygen saturation <94% and presence of tachypnoea were important predictors of pneumonia. A raised C reactive protein level predicted the presence of both pneumonia and other SBIs, whereas chest wall retractions and oxygen saturation <94% were useful to rule out the presence of other SBIs. Discriminative ability (C statistic) to predict pneumonia was 0.81 (95% confidence interval 0.73 to 0.88); for other SBIs this was even better: 0.86 (0.79 to 0.92). Risk thresholds of 10% or more were useful to identify children with serious bacterial infections; risk thresholds less than 2.5% were useful to rule out the presence of serious bacterial infections. External validation showed good discrimination for the prediction of pneumonia (0.81, 0.69 to 0.93); discriminative ability for the prediction of other SBIs was lower (0.69, 0.53 to 0.86).

CONCLUSION

A validated prediction model, including clinical signs, symptoms, and C reactive protein level, was useful for estimating the likelihood of pneumonia and other SBIs in children with fever, such as septicaemia/meningitis and urinary tract infections.

Reduced use of occult bacteremia blood screens by emergency medicine physicians using immunization registry for children presenting with fever without a source

OBJECTIVES

This study examined whether utilization of the Florida State Health Online Tracking System (SHOTS) immunization registry to determine Haemophilus influenzae type B and heptavalent pneumococcal conjugate (PCV7) vaccine status impacts the protocolized decision to perform a screening blood draw for occult bacteremia (OB) in young children.

METHODS

A convenience sample of children 6 to 24 months of age presenting to the pediatric emergency department with fever of greater than 39°C without a source was enrolled. Physicians were trained to use the SHOTS immunization registry and reviewed the emergency department's fever protocol. A "preregistry" workup plan was documented for each patient based on clinical history, immunization status before accessing SHOTS, and physical examination. A "postregistry" workup plan was then documented based on the SHOTS record. Demographic and registry data were recorded.

RESULTS

Preregistry workup plans indicated OB screening blood draws for 100% (n = 91; 95% confidence interval [CI], 96-100) of patients with unconfirmed immunization status. Of those 91 children, 58% (n = 53; 95% CI, 55-61) were documented in SHOTS as having received their primary conjugate vaccine series at ages 2, 4, and 6 months. Registry access reduced the percentage of screening blood draws from 100% (n = 91) to 42% (n = 38; 95% CI, 37-53; P < 0.001).

CONCLUSIONS

The state immunization registry is an adjunctive tool to caregiver recall, which can be used by emergency medicine practitioners to confirm completion of the primary conjugate vaccine series before making the decision to perform blood screens for OB in children aged 6 to 24 months who present with fever without a source.

Diagnosis and management of urinary tract infection in children

A young child presents to their primary health provider with fever and irritability. How likely is a urinary tract infection? How should a urine sample be collected? How accurate are urinary dipsticks and microscopy compared with culture for the diagnosis? What route and type of antibiotics should be used? What imaging is indicated? Diagnosing and treating children with urinary tract infection presents many questions. This review summarises the most relevant recent primary studies, systematic reviews and guidelines.

Well appearing young infants with fever without known source in the emergency department: are lumbar punctures always necessary?

We included 685 consecutive previously healthy well appearing infants younger than 3 months with fever without known source admitted to an Emergency Department without routinely performing lumbar punctures (LP). LP was performed in 198 infants. Of these, 36 (18.1%) showed pleocytosis. Two infants less than 15 days were diagnosed with bacterial meningitis and 47 with aseptic meningitis (6.8%). LP was not performed in 487 infants. Of these, 69 were admitted to ward (46 had urinary tract infection) and 418 were discharged. In this group, we registered 38 unscheduled revisits to the Emergency Department (four aseptic meningitis). All infants did well. It is unnecessary to perform a LP routinely on infants over 1 month of age. The decision to perform the LP in previously healthy and well appearing infants with fever without known source attended by an experienced paediatric emergency physician can be individualized with no subsequent adverse outcomes. This approach may lead to under-diagnosing nonbacterial meningitis.

Evaluation, management, and outcome of focal bacterial infections (FBIs) in nontoxic infants under two months of age

BACKGROUND

Well-appearing young infants with focal bacterial infections present to the emergency department (ED) and are often admitted for a sepsis evaluation of blood, urine, and spinal fluid. However, the risk of concomitant systemic infections (CSI) in this population is not well reported, specifically comparing febrile to afebrile infants. We hypothesized that afebrile, well-appearing infants under two months of age with a defined focal bacterial infection on exam have a very low risk of CSI.

METHODS

This retrospective study was conducted at an urban, academic, tertiary care pediatric hospital ED on patients seen from January 2000-December 2005. Eligible infants were less than 60 days of age, well-appearing on exam, and with normal-for-age vital signs who presented with a focal bacterial infection on exam. Exclusion criteria included immunodeficiency, indwelling catheter, previous admission for bacterial infection, or current use of systemic antibiotics. Main study outcome was risk of CSI in febrile and afebrile groups.

RESULTS

One hundred ninety seven patients were included in the study population. Of these, 39 were febrile and 158 were afebrile. Four patients had a documented CSI: one case of S. pneumoniae bacteremia and three cases of E. coli urinary tract infection. Of these 4 infants, 3 were febrile (7.7% CSI risk) and 1 was afebrile (0.6%). Febrile infants had a significantly higher risk of CSI (OR 13.1, 95% CI 1.3, 129.5).

CONCLUSIONS

CSI is very uncommon in afebrile, well-appearing infants under 60 days of age with a focal bacterial infection.

Imaging of Chest Infections in Children

■ Imaging studies have limited value in the differentiation between viral and bacterial lower respiratory tract infections (moderate evidence).

■ CT provides more information than plain radiographs for complicated pulmonary infections with empyema, pleural effusion, or bronchopleural fistula (moderate evidence).

■ In immunocompromised patients, CT has been shown to characterize the type of infection better than plain radiographs (moderate evidence).

■ Ultrasound has an advantage over CT in the identification and characterization of complicated effusions (moderate evidence).

■ Early detection and therefore intervention for pleural complications of pneumonia are critical and can result in better outcomes (moderate evidence).

■ Early surgery (VATS) is more cost-effective than thoracotomy (without or with image guidance) in the treatment of empyemas in children (strong evidence).

Blood culture and bacteremia predictors in infants less than three months of age with fever without source

OBJECTIVES

(1) To assess the rate of bacteremia in febrile infants less than 3 months of age admitted to a pediatric emergency department at a tertiary hospital; (2) to describe the bacteria isolated; and (3) to analyze factors related to increased probability of having a positive blood culture.

METHODS

A retrospective, cross-sectional, 5-year descriptive study that includes all infants less than 3 months of age who presented with fever without source (FWS) and had a blood culture performed.

RESULTS

A blood culture was performed in 1018 (91.5%) of 1125 infants admitted, and a bacterial pathogen was grown in 23 (2.2%) of these; 8 were associated with a positive urine culture. The most frequently isolated pathogen was Escherichia coli (9), followed by Streptococcus pneumoniae (4). The risk factors detected by multivariate analysis were: (a) being classified as "not well-appearing" (12.5% vs. 1.8%; odds ratio: 8.37) and (b) leukocyturia and/or nitrituria in a urine dipstick test (5.6% vs. 1.6%; odds ratio: 3.73). C-reactive protein value was higher than white blood cell count and absolute neutrophil count in detecting bacteremia; a 70 g/L cut-off had a specificity of 93.8%, but sensitivity of only 69.6%.

CONCLUSIONS

A positive blood culture rate of 2.2% was found in infants less than 3 months of age with FWS. C-reactive protein, white blood cell count, and absolute neutrophil count were not good bacteremia predictors. We recommend obtaining a blood culture in infants less than 3 months of age with FWS, particularly those patients considered "not well-appearing" and those with leukocyturia and/or nitrituria.

Serious bacterial infection in recently immunized young febrile infants

OBJECTIVE

The objective of this study was to investigate the prevalence of serious bacterial infection (SBI) in febrile infants without a source aged 6-12 weeks who have received immunizations in the preceding 72 hours.

METHODS

The authors conducted a medical record review of infants aged 6-12 weeks with a fever of > or = 38.0 degrees C presenting to the pediatric emergency department (ED) over 88 months. Infants were classified either as having received immunizations within the 72 hours preceding the ED visit (recent immunization [RI]) or as not having received immunizations during this time period (no recent immunization [NRI]). Primary outcome of an SBI was based on culture results; only patients with a minimum of blood and urine cultures were studied.

RESULTS

A total of 1,978 febrile infants were studied, of whom 213 (10.8%) had received RIs. The overall prevalence of definite SBI was 6.6% (95% confidence interval [CI] = 5.5 to 7.7). The prevalence of definite SBI in NRI infants was 7.0% (95% CI = 5.9 to 8.3) compared to 2.8% (95% CI = 0.6 to 5.1) in the RI infants. The prevalence of definite SBI in febrile infants vaccinated in the preceding 24 hours decreased to 0.6% (95% CI = 0 to 1.9). The prevalence of definite SBI in febrile infants vaccinated greater than 24 hours prior to presentation was 8.9% (95 CI = 1.5 to 16.4). The relative risk of SBI with RI was 0.41 (95% CI = 0.19 to 0.90). All SBIs in the RI infants were urinary tract infections (UTI).

CONCLUSIONS

Among febrile infants, the prevalence of SBI is less in the initial 24 hours following immunizations. However, there is still a substantial risk of UTI. Therefore, urine testing should be considered in febrile infants who present within 24 hours of immunization. Infants who present greater than 24 hours after immunizations with fever should be managed similarly to infants without RIs.

Rapid influenza test in young febrile infants for the identification of low-risk patients

We included 381 febrile infants less than 3 months with a blood culture and a rapid influenza test done as part of study of fever. The prevalence of serious bacterial infections was significantly lower in patients in the positive rapid influenza test (RIT) group (3/113; 2.65%; 95% CI: 0-5.6) than in patients in the negative RIT group (47/268; 17.5%; 95% CI: 13-22.0). No patient with a positive RIT had a positive blood culture (vs. 8 in the negative RIT group, 2.98%, 95% CI: 0.9-5.0) The cerebrospinal fluid culture was positive in 5; all of them had a negative RIT. The use of RIT in the Emergency Department on previously well-appearing febrile young infants without a known source during influenza seasons can help to identify infants with a lower risk of developing serious bacterial infections. Routine blood culture may be no longer necessary in infants with a positive RIT.

Predictors of occult bacteremia in young febrile children in the era of heptavalent pneumococcal conjugated vaccine

BACKGROUND

Changes in the prevalence of pneumococcal occult bacteremia (PnOB) because of pneumococcal conjugated vaccine (PCV-7) may have altered the predictive value of the complete blood count (CBC) for selected patients at risk of having occult bacteremia (OB).

OBJECTIVE

To analyze the rate of OB in infants with high fever without source related to pneumococcal vaccination status and to study the yield of the CBC to identify children with OB in the era of PCV-7.

METHODS

Retrospective review of 1586 children of age 3-36 months admitted to a Pediatric Emergency Department with a CBC and a blood culture performed as part of their evaluation for fever. Patients with altered urinalysis were excluded.

RESULTS

Blood culture was positive in 15 (0.9%; pneumococcus 10, 0.6%). Of the 1586 children, 1040 (65.6%) showed less than 15,000 leukocytes/mm3 (2 PnOB, 0.19%). Of the 546 children with more than 15,000 leukocytes/mm3, eight had a PnOB (positive predictive value =1.46%, negative predictive value= 99.8%). Of the 1586 children, 1177 (74.2%) showed absolute neutrophil count less than 10,000/mm3 (3 PnOB, 0.25%). Of those 409 with more than 10,000 neutrophil/mm3, seven had a PnOB (positive predictive value= 1.71%, negative predictive value= 99.7%). Among the 429 children with at least two doses of PCV-7, one (0.23%) had a PnOB (vs. nine of 1090 - 0.82% - with no dose or one dose of PCV-7).

CONCLUSION

In the era of PCV-7, rate of PnOB is related to the pneumococcal vaccination status. The yield of the CBC is lower than in the prevaccinal era. Decisions based on CBC must be reconsidered.

Serious bacterial infections in febrile infants in the post-pneumococcal conjugate vaccine era

OBJECTIVES

The objective was to identify the epidemiology of serious bacterial infections (SBI) and the current utility of obtaining routine complete blood counts (CBC) and blood cultures to stratify infants at risk of SBI, in the study population of febrile infants in the post-heptavalent pneumococcal conjugate vaccine (PCV7) era.

METHODS

A cohort study with nested case-controls was undertaken at a tertiary care military hospital emergency department (ED) from December 2002 through December 2003. Irrespective of clinical findings at the initial encounter, patients were included if they were under 3 months of age and had a home or ED temperature of >or=100.4 degrees F or if they were between 3 and 24 months of age with a temperature of >or=102.3 degrees F. Data abstracted included age, temperature, peripheral white blood cell (WBC) count, and discharge diagnosis. Culture (blood, urine, and cerebrospinal fluid [CSF]) and chest radiograph (CXR) results were obtained through review of the electronic hospital archives. SBI was defined as pneumonia, urinary tract infection (UTI), meningitis, or bacteremia.

RESULTS

A total of 985 children aged 0 to 24 months were enrolled. Fifty-five percent were male, the median age was 12 months (interquartile range = 8-17 months), and 79% had received at least one PCV7. A total of 132 cases of SBI were identified in 129 infants (13.1%): 82 pneumonias, 45 UTI, five bacteremias, and no cases of bacterial meningitis. The frequency of bacteremia was 0.7%. No statistical difference was detected in the WBC count between the SBI and non-SBI groups (13.8 +/- 5.8 and 11.7 +/- 5.6, respectively; p = 0.055). No readily available WBC cutoff on the receiver operating characteristic (ROC) curve proved to be an accurate predictor of SBI. No statistical difference was detected in mean temperature between the SBI and non-SBI groups (103.3 +/- 1.2 and 103.2 +/- 1.2 degrees F, respectively; p = 0.26), nor was there a difference noted when groups were broken down by age or height of fever.

CONCLUSIONS

The WBC count and height of fever were not found to be accurate predictors of SBI in infants age 3 to 24 months. UTI and pneumonias made up the vast majority of SBI in this population of infants. The overall bacteremia frequency was well below 1%. This calls into question the continued utility of obtaining routine complete cell counts and blood cultures in the febrile infant in the post-PCV7 era.

Streptococcus pneumoniae bacteraemia in children

Occult bacteraemia is the most frequent invasive disease caused by Streptococcus pneumoniae in children less than 3 years of age. Despite the relative frequency of this infection, its management is still a challenging task for paediatricians because fever is often the only symptom and a considerable overlap exists in the clinical presentation of children with fever without a focus due to viral illness and children with occult bacteraemia. Management protocols take into account the age of the patient, the clinical score for severity and the results of laboratory tests such as the white blood cell count, the C-reactive protein and the blood procalcitonin level in order to define accurately who will benefit from an antibiotic treatment. Despite appropriate healthcare facilities and access to care the case fatality rate in developed countries is around 9% in children aged less than 1 year. Prevention with the 7-valent conjugate vaccine against S. pneumoniae will decrease morbidity and mortality associated with invasive disease due to these bacteria. However, replacement by non-vaccine serotypes has been noted in countries where the vaccine is widely used and this concern needs to be monitored carefully over the next few years.

Randomized trial of a clinical decision support system: impact on the management of children with fever without apparent source

OBJECTIVE

To assess compliance with a clinical decision support system (CDSS) for diagnostic management of children with fever without apparent source and to study the effects of application of the CDSS on time spent in the emergency department (ED) and number of laboratory tests.

DESIGN

The CDSS was used by ED nursing staff to register children presenting with fever. The CDSS identified children that met inclusion criteria (1-36 months and fever without apparent source (FWS)) and provided patient-specific diagnostic management advice. Children at high risk for serious bacterial infection were randomized for the 'intervention' (n = 74) or the 'control' (n = 90) group. In the intervention group, the CDSS provided the advice to immediately order laboratory tests and in the control group the ED physician first assessed the children and then decided on ordering laboratory tests.

RESULTS

Compliance with registration of febrile children was 50% (683/1,399). Adherence to the advice to order laboratory tests was 82% (61/74). Children in the intervention group had a median (25(th)-75(th) percentile) length of stay at the ED of 138 (104-181) minutes. The median length of stay at the ED in the control group was 123 (83-179) minutes. Laboratory tests were significantly more frequently ordered in the intervention group (82%) than in the control group (44%, p < 0.001, chi(2) test).

CONCLUSION

Implementation of a CDSS for diagnostic management of young children with fever without apparent source was successful regarding compliance and adherence to CDSS recommendations, but had unexpected effects on patient outcome in terms of ED length of stay and number of laboratory tests. The use of the current CDSS was discontinued.

Pneumococcal bacteremia in febrile infants presenting to the emergency department before and after the introduction of the heptavalent pneumococcal vaccine

STUDY OBJECTIVE

Fever is among the most common presenting complaints of infants and children younger than 3 years who present to the emergency department (ED). The evaluation and management of the febrile child is evolving rapidly. We compare the proportion of pneumococcal bacteremia between febrile infants and children younger than 3 years who had and had not received the heptavalent pneumococcal vaccine and who had received blood culture tests in our ED.

METHODS

We performed a non-concurrent prospective observational cohort study, with a standardized medical record review to collect data of patients treated in the ED of a tertiary care military hospital during 24 months. Patients were eligible if they were younger than 36 months and had a temperature greater than or equal to 100.4 degrees F (38 degrees C). A data collection sheet was used to abstract age, temperature, and whether CBC count and blood cultures were obtained. Heptavalent pneumococcal vaccine status and blood culture results were obtained through review of the computerized medical record. Descriptive analysis was used for comparing the 2 groups. Group size analysis was based on the prevalence of occult bacteremia caused by Pneumococcus before the introduction of heptavalent pneumococcal vaccine. Interobserver variation was assessed by independent review of 10% of abstracted records. The main outcome measure was the proportion of positive pneumococcal blood cultures in infants and children younger than 3 years who had received at least 1 vaccination of heptavalent pneumococcal vaccine versus those who had not.

RESULTS

Three thousand five hundred seventy-one patients met entry criteria; 1,428 had blood cultures obtained, and 833 of them received at least 1 immunization of heptavalent pneumococcal vaccine. All groups were similar in age, sex, and temperature. Positive blood culture results, including probable contaminants, were obtained for 4.2% (58/1,383) of the patients. In the heptavalent pneumococcal vaccine group, there were 0 of 833 (0%) positive pneumococcal blood cultures compared with 13 of 550 (2.4%) in the unimmunized group (P<.001; 95% confidence interval 1.4% to 3.3%).

CONCLUSION

Pneumococcal bacteremia was found to be lower in our patients who had received the heptavalent pneumococcal vaccine than in the patients who had not.

Clinical and consumer guidelines related to the management of childhood fever

Background: The majority of childhood fever episodes are considered part of normal childhood development. However, febrile children frequently present to hospital and general practitioners. Health providers and parents therefore require knowledge on how to manage childhood fever, how to recognise which febrile children are likely to become seriously ill and when to seek urgent medical advice. This information is frequently provided in the form of clinical and/or consumer guidelines.

Aim: The aim of this systematic review was to identify and assess clinical and consumer guidelines related to the management of childhood fever.

Methods: A comprehensive search strategy included searching electronic clinical databases, guideline databases, Internet searching, contacting paediatric hospitals across the UK, and experts and researchers. Application of inclusion criteria, quality assessment and data extraction were independently conducted by two reviewers. Data is presented in tabular format with narrative discussion.

Results: A total of 22 guidelines were identified and included in the review. Five were clinical guidelines and 17 guidelines designed for parents/carers. The results highlight that key markers cannot be identified to help predict which febrile children might become seriously ill. Because childhood fever guidelines also lack comprehensive evidence and offer conflicting recommendations, parents and carers are unlikely to be able to identify such markers.

Conclusions: Current clinical and consumer guidelines related to childhood fever are not evidence-based and appear to be produced as consensus statements summarising current care provision. Healthcare workers need to ensure when undertaking the development and dissemination of patient information that they follow appropriate processes to incorporate the most appropriate evidence.

Current guidelines fail to provide information on key markers to enable early recognition of seriously ill children. This review also demonstrates that alternative search strategies can prove effective in identifying guidelines for care.

Acute otitis media in infants less than three months of age: clinical presentation, etiology and concomitant diseases

OBJECTIVE

Acute otitis media (AOM) in the neonatal period can be difficult to diagnose. This infection can be isolated and localized, or it may be associated with serious bacterial infections or other illnesses. The objectives of this study were to determine the clinical presentation, etiology, susceptibility pattern, and frequency of bacteremia, meningitis and other serious bacterial infections associated with the first episode of AOM in young infants.

METHODS

From July 2002 to August 2004, infants less than 12 weeks of age with confirmed AOM underwent tympanocentesis with culture of the middle ear fluid. Sepsis work-up was performed in all infants, and they were admitted to the pediatric department. Parenteral antibiotic therapy with a combination of ampicillin and gentamicin was initiated.

RESULTS

Sixty-eight infants were diagnosed with AOM. The median age was 43+/-17 days, 17 infants (25%) were less than 4 weeks of age. Fever was present in 45 (66%) of the patients. Meningitis or bacteremia was not diagnosed in any of the cases. Concomitant urinary tract infection was diagnosed in six (8.8%) cases and broncholitis in seven (10.4%). Forty-seven bacterial pathogens were isolated from the middle-ear fluid. Streptococcus pneumoniae was the leading pathogen with 18 isolates (38%), followed by non-typable Haemophilus influenzae with nine (19%). Fourteen of the S. pneumoniae (78%) isolates were susceptible to penicillin and the other four (22%) were intermediately resistant. Three (33%) of the nine H. influenzae isolates were beta-lactamase producers.

CONCLUSIONS

In our study, AOM in infants less than 3 months of age is a localized infection and it is not associated with severe bacterial infections. S. pneumoniae and H. influenzae are the leading pathogens. In our region, most of S. pneumoniae strains are still susceptible to penicillin. Although only small number of patients were under 4 weeks of age, the results of the present study raise the question of whether the current policy of a full sepsis work-up in neonates with AOM is relevant.

Antibiotic resistance trends in paediatric uropathogens

The antimicrobial susceptibility patterns of paediatric uropathogens to six of the most common antibiotics in use for urinary tract infections were determined. The bacterial isolates came from the urine of children presenting as outpatients to participating US hospitals between April 2002 and May 2004. Strains of the six most common uropathogens were included in the analysis. Results were stratified by paediatric age group. In total, 11174 female and 1557 male positive cultures were analysed. The overall resistance rates for females and males, respectively, were as follows: ampicillin 44.3% and 44.6%; sulphamethoxazole/trimethoprim 24.5% and 36.7%; amoxicillin/clavulanic acid 12.4% and 27.5%; cefazolin 10.9% and 27.1%; ciprofloxacin 0.9% and 2.4%; and nitrofurantoin 4.4% and 11.0%. Uropathogen resistance to commonly used antibiotics in the paediatric population was high.

Hyperpyrexia among infants younger than 3 months

OBJECTIVE

To determine the prevalence of serious bacterial infection in infants younger than 3 months with fever > or =40 degrees C.

METHODS

We retrospectively identified all infants younger than 3 months with fever who presented to a pediatric emergency department. The medical records were reviewed. The prevalence of serious bacterial infection (SBI) among those patients with hyperpyrexia was compared with febrile infants with lower fever.

RESULTS

5279 infants younger than 3 months with fever were reviewed. Ninety-eight patients (1.7%) had triage temperature > or =40 degrees C rectally. Median age, temperature, and white blood count for those with hyperpyrexia were 58 days (interquartile range [IQR] 36-78 days), 40.2 degrees C (IQR, 40.0-40.4 degrees C), and 10,800/mm3 (IQR, 7900-14,600/mm3), respectively. Diagnostic studies included blood culture (100%), urine culture (100%), lumbar puncture (100%), chest radiographs (34%), and stool cultures (11%). SBI was found in 38% infants with hyperpyrexia: urinary tract infection was the most common SBI (71%). Among patients with hyperpyrexia, patients with SBI had similar mean white blood cell counts (14,000 vs. 10,200 cells/mm3) and age (54 vs. 53 days) as those with hyperpyrexia but no SBI. The prevalence of SBI among febrile infants with temperatures > or =40.0 degrees C was 38% (95% CI 27-48%) compared with those with fever < or =40 degrees C: 8.8% (95% CI 8.1-9.5%).

CONCLUSION

Hyperpyrexia is rare among febrile infants younger than 3 months. One-third of infants with temperature > or =40.0 degrees C had SBI. Future management algorithms might include hyperpyrexia as a risk factor for serious infection.

Quality of evidence-based pediatric guidelines

OBJECTIVE

To identify evidence-based pediatric guidelines and to assess their quality.

METHODS

We searched Medline, Embase, and relevant Web sites of guideline development programs and national pediatric societies to identify evidence-based pediatric guidelines. A list with titles of identified guidelines was sent to 51 leading pediatricians in the Netherlands, who were asked to select the 5 most urgent topics for guideline development. Three pediatrician reviewers appraised the available guidelines on the 10 most frequently mentioned topics with the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument.

RESULTS

A total of 215 evidence-based pediatric guidelines were identified; of these, 17 guidelines on the 10 most frequently mentioned topics were appraised. The AGREE instrument rates guidelines among 6 domains. For the scope and purpose domain, the mean score was 84% of the maximal mark. For stakeholder involvement, the mean score was 42%, with 12 guidelines (71%) scoring <50%. For rigor of development, the mean score was 54%, with 5 guidelines (29%) scoring <50%. For clarity and presentation, the mean score was 78%, with 4 guidelines (24%) scoring <50%. For applicability and editorial independence, performance was poor, with mean scores of 19% and 40%, respectively. Low scores were partly attributable to poor reporting. After considering all domain scores, the reviewers recommended 14 of 17 guidelines (82%) to be used in local practice.

CONCLUSIONS

The current volume of pediatric guidelines categorized as evidence based in popular databases is large. Overall, these guidelines scored well, compared with other studies on guideline quality in fields outside pediatrics, when assessed for quality with the AGREE instrument. This holds especially for guidelines published or endorsed by the American Academy of Pediatrics or registered in the National Guideline Clearinghouse.

Fever after Immunization: Current Concepts and Improved Future Scientific Understanding

Fever is a common clinical complaint in adults and children with a variety of infectious illnesses, as well as a frequently reported adverse event following immunization. Although the level of measured temperature indicative of a "fever" was first defined in 1868, it remains unclear what role fever has as a physiologic reaction to invading substances, how best to measure body temperature and compare measurements from different body sites, and, consequently, how to interpret fever data derived from vaccine safety trials or immunization safety surveillance. However, even with many aspects of the societal, medical, economic, and epidemiologic meanings of fever as an adverse event following immunization (AEFI) still elusive, it is a generally benign--albeit common--clinical sign. By standardizing the definition and means of assessment of fever in vaccine safety studies, thereby permitting comparability of data, we hope to arrive at an improved understanding of its importance as an AEFI.

Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections

BACKGROUND

The evaluation of young febrile infants is controversial, in part because it is unclear whether clinical evidence of a viral infection significantly reduces the risk of serious bacterial infections (SBIs). Specifically, it remains unclear whether the risk of SBI is altered in a meaningful way in the presence of respiratory syncytial virus (RSV) infections.

OBJECTIVE

The objective of this study was to determine the risk of SBI in young febrile infants who are infected with RSV compared with those without RSV infections.

METHODS

We conducted a 3-year multicenter, prospective, cross-sectional study. All febrile (> or =38 degrees C) infants who were < or =60 days of age and presented to any of 8 pediatric emergency departments from October through March 1998-2001 were eligible. General clinical appearance was evaluated using the Yale Observational Scale. We determined RSV status by antigen testing of nasopharyngeal secretions. We defined bronchiolitis as either wheezing alone or chest retractions in association with an upper respiratory infection. We evaluated infants with blood, urine, cerebrospinal fluid, and stool cultures. Urinary tract infection (UTI) was defined by single pathogen growth of > or =5 x 10(4) cfu/mL, or > or =10(4) cfu/mL in association with a positive urinalysis in a catheterized specimen, or > or = 10(3) cfu/mL in a suprapubic aspirate. Bacteremia, bacterial meningitis, and bacterial enteritis were defined by growth of a known bacterial pathogen. SBI was defined as any of the above-mentioned 4 bacterial infections.

RESULTS

We enrolled 1248 patients, including 269 (22%) with RSV infections. The overall SBI status could be determined in 1169 (94%) of the 1248 patients, and the rate of SBIs was 11.4% (133 of 1169; 95% confidence interval [CI]: 9.6%-13.3%). The rate of SBIs in the RSV-positive infants was 7.0% (17 of 244; 95% CI: 4.1%-10.9%) compared with 12.5% (116 of 925; 95% CI: 10.5%-14.8%) in the RSV-negative infants (risk difference: 5.5%; 95% CI: 1.7%-9.4%). The rate of UTI in the RSV-positive infants was 5.4% (14 of 261; 95% CI: 3.0%-8.8%) compared with 10.1% (98 of 966; 95% CI: 8.3%-12.2%) in the RSV-negative infants (risk difference: 4.7%; 95% CI: 1.4%-8.1%). The RSV-positive infants had a lower rate of bacteremia than the RSV-negative infants (1.1% vs 2.3%; risk difference: 1.2%; 95% CI: -0.4% to 2.7%). No RSV-positive infant had bacterial meningitis (0 of 251; 95% CI: 0%-1.2%); however, the differences between the 2 groups with regard to bacteremia and bacterial meningitis did not achieve statistical significance.

CONCLUSIONS

Febrile infants who are < or =60 days of age and have RSV infections are at significantly lower risk of SBI than febrile infants without RSV infection. Nevertheless, the rate of SBIs, particularly as a result of UTI, remains appreciable in febrile RSV-positive infants.

Bedside procalcitonin and C-reactive protein tests in children with fever without localizing signs of infection seen in a referral center

OBJECTIVE

To assess the value of bedside tests for predicting the occurrence of severe bacterial infections (SBIs) in children with fever without source.

METHODS

We conducted a prospective study of 99 children, aged 7 days to 36 months, who were seen for fever >38 degrees C and no localizing sign of infection at the emergency department of the University Children's Hospital of Geneva. Blood procalcitonin (PCT), C-reactive protein (CRP), and interleukin-6 (IL-6) values were determined using rapid tests and were compared with the total white blood cell (WBC) count with differential and clinical score. Specificity, sensitivity, predictive values, and multilevel likelihood ratios (LRs) with posttest probabilities of disease were calculated.

RESULTS

Twenty-nine (29%) children received a diagnosis of having an SBI. PCT had the best sensitivity (93%) and negative predictive value (96%). Band count had the best specificity (93%), but its positive predictive value was only 38%. Multilevel LRs revealed that a PCT concentration <0.5 ng/mL (LR: 0.093) almost ruled out SBI (posttest probability of disease: 3.7%) in 54 (54%) subjects, whereas a value >2 ng/mL (LR: 5.2) increased the probability of SBI to 68% in 19 (19%) children. For CRP, values <40 mg/L (LR: 0.263) and >100 mg/L (LR: 14.483) generated posttest probabilities for SBI of 9.7% (61 subjects) and 86.5% (14 subjects), respectively. For WBC count, the posttest probabilities of SBI were modestly changed from the pretest prevalence.

CONCLUSIONS

PCT and CRP performed better than IL-6, WBC, and/or band count in predicting the occurrence of SBI. PCT and CRP bedside tests may be useful tools for emergency and private practice doctors and should be considered in the initial work-up of children with fever without source.

Approach to the febrile child: A challenge bridging the gap between the literature and clinical practice

The approach to the febrile child is always concerning for any physician despite the fact that most fevers are viral in origin. However, in rare cases, a missed bacterial infection can have serious consequences. How can fevers of viral origin be differentiated from those of bacterial origin? Do all febrile children with no obvious infection site need a blood culture? Should antibiotics be administered before the results of the blood culture have been received? In the past 30 years, there has been an overabundance of recommendations, advice, opinions and suggested treatments on this subject. The purpose of this review is to present the evidence that is known at this time concerning the management of the febrile child and to present one approach used in a large urban paediatric emergency department.

[Diagnostic test in emergency departments for bacterial infections in infants younger than 12 months]

OBJECTIVE

To evaluate clinical and analytic numeric data that may help the emergency departments to identify bacterial infections in infants.

PATIENTS AND METHODS

A retrospective study of 430 infants with bacterial growth in cultures (culture from blood, 30; urine, 207; stools, 193, and/or cerebrospinal fluid, n 25) was performed. These patients were compared with a control group (n 430), randomly selected from patients aged less than 12 months with negative cultures who were hospitalized with suspected infection. Neonates and surgical patients were excluded from both groups. Statistical analysis was performed using Student's t-test for independent samples, Levene's test for the study of equality of variances, bivariate correlation and one-factor ANOVA, and receiver-operating characteristic (ROC) curves and odds ratios were calculated when statistically significant (p < 0.05) results were obtained. These analyses were performed using the SPSS 10.0 statistical software package.

RESULTS

Of the infants admitted to the pediatric unit, 11.7 % had at least one positive bacterial culture. Temperature (p 0.005), leucocyte count (p 0.003), percentage of neutrophils (p < 0.0001) and C-reactive protein (p < 0.0001) were significantly higher in infants with positive cultures. In invasive infections significant differences were found in sex (more frequent in males) (p 0.03), heart rate (p < 0.0001) and respiratory rate (p 0.003). In the ROC curves, the best diagnostic yield was obtained for C-reactive protein (0.93 for a cutoff value of 29 mg/l, 86 % specificity and 91 % sensitivity).

CONCLUSION

C-reactive protein is essential for diagnosis of bacterial infection in infants in the emergency department.

Acute otitis media in infants younger than two months of age: microbiology, clinical presentation and therapeutic approach

BACKGROUND

Information on the causative agents of acute otitis media (AOM) in infants <2 months of age is limited.

OBJECTIVES OF THE STUDY

To analyze the etiology, pathogen susceptibility patterns, clinical presentation and frequency of serious bacterial infections in infants <2 months of age with AOM and to determine the relationship between the organisms isolated systemically and those isolated from the middle ear fluid in the patients with serious bacterial infections in the presence of AOM.

METHODS

The medical records of 137 infants <2 months of age with AOM who underwent tympanocentesis in the emergency room of Soroka University Medical Center between January 1, 1995, and May 30, 1999, were reviewed. The main variables analyzed included demography, frequency of serious bacterial infections, bacteriologic results, susceptibility patterns of the pathogens and clinical presentation.

RESULTS

Median age was 38.7 +/- 13 days; 112 of 137 (82%) infants were hospitalized. Six (4%), 27 (20%), 46 (34%) and 58 (42%) episodes were recorded at age 0 to 2, 3 to 4, 5 to 6 and 7 to 8 weeks, respectively. Fever (temperature >38 degrees C) was present in 96 (70%) of the cases. Culture-negative (bacterial) meningitis was diagnosed in 3 cases. Blood and urine cultures were positive in 1 and 6 infants, respectively. None of the afebrile infants developed serious bacterial infection. One hundred twenty-two bacterial pathogens were isolated from the middle ear fluid of 109 of 137 (80%) patients: Streptococcus pneumoniae in 56 (46%), Haemophilus influenzae in 41 (34%), group A Streptococcus in 12 (10%), enteric gram-negative bacilli in 9 (7%), Moraxella catarrhalis in 3 (2%) and Streptococcus faecalis in 1 (1%). Eleven (20%) of the 56 S. pneumoniae isolates were nonsusceptible to penicillin. Serious bacterial infections were diagnosed in 6 of 137 (4%) patients. Whereas blood and urine grew pathogens typical for blood and urinary tract infections, the middle ear fluid isolates represented different pathogens usually isolated in AOM without any correlation between these 2 groups of pathogens.

CONCLUSIONS

(1) Most cases of AOM in infants <2 months of age are caused by pathogens similar to those causing AOM in older children; (2) antibiotic resistance may already be present at early age and should be considered in the empiric treatment of AOM in infants <2 months of age; (3) the presence of AOM does not predict a higher risk for serious bacterial infections in afebrile and febrile infants <2 months of age.

Effects of a pediatric emergency department febrile infant protocol on time to antibiotic therapy

The purpose of this study was to examine the effect of an Emergency Department (ED) protocol to reduce time to antibiotic administration in the febrile infant less than 3 months of age with a rectal temperature > or =38.0 degrees C. We conducted a before-after study of a febrile infant quality improvement initiative in an urban pediatric ED with approximately 35,000 patient visits per year. Records of infants less than 3 months of age presenting with a rectal temperature > or =38.0 degrees C, who underwent a full septic work-up (blood, urine, and cerebrospinal fluid studies, and possibly chest radiography), were identified by using daily ED logs. This review was performed in the month before and then 12 months after institution of the "Septic Infant Work-up Sheet" and a set of interventions (Febrile Infant Protocol) designed to streamline care of the febrile infant and to reduce the time to antibiotic administration. Data were analyzed by using the Kaplan-Meier survival estimate and the log-rank test. Patient demographic characteristics and severity of illness were similar across months; however, ED process of care was significantly changed. Initial analysis revealed a median time to antibiotics of 142 min. Subsequent analysis after implementation of the Febrile Infant Protocol revealed a median time to antibiotics of 105 min. This represents an overall time reduction of 25% from time of presentation to antibiotic administration. In conclusion, a guideline-based ED febrile infant protocol changed clinical practice and improved time to antibiotics.