Management of fever without source in infants and children

Raising AWaRe-ness of Antimicrobial Stewardship Challenges in Pediatric Emergency Care: Results from the PERFORM Study Assessing Consistency and Appropriateness of Antibiotic Prescribing Across Europe

BACKGROUND

Optimization of antimicrobial stewardship is key to tackling antimicrobial resistance, which is exacerbated by overprescription of antibiotics in pediatric emergency departments (EDs). We described patterns of empiric antibiotic use in European EDs and characterized appropriateness and consistency of prescribing.

METHODS

Between August 2016 and December 2019, febrile children attending EDs in 9 European countries with suspected infection were recruited into the PERFORM (Personalised Risk Assessment in Febrile Illness to Optimise Real-Life Management) study. Empiric systemic antibiotic use was determined in view of assigned final "bacterial" or "viral" phenotype. Antibiotics were classified according to the World Health Organization (WHO) AWaRe classification.

RESULTS

Of 2130 febrile episodes (excluding children with nonbacterial/nonviral phenotypes), 1549 (72.7%) were assigned a bacterial and 581 (27.3%) a viral phenotype. A total of 1318 of 1549 episodes (85.1%) with a bacterial and 269 of 581 (46.3%) with a viral phenotype received empiric systemic antibiotics (in the first 2 days of admission). Of those, the majority (87.8% in the bacterial and 87.0% in the viral group) received parenteral antibiotics. The top 3 antibiotics prescribed were third-generation cephalosporins, penicillins, and penicillin/β-lactamase inhibitor combinations. Of those treated with empiric systemic antibiotics in the viral group, 216 of 269 (80.3%) received ≥1 antibiotic in the "Watch" category.

CONCLUSIONS

Differentiating bacterial from viral etiology in febrile illness on initial ED presentation remains challenging, resulting in a substantial overprescription of antibiotics. A significant proportion of patients with a viral phenotype received systemic antibiotics, predominantly classified as WHO Watch. Rapid and accurate point-of-care tests in the ED differentiating between bacterial and viral etiology could significantly improve antimicrobial stewardship.

Clinical and Microbiological Profiles of Urinary Tract Infections in Febrile Children Aged Six Months to Five Years Attending a Tertiary Care Hospital in India

Background Urinary tract infection (UTI) is one of the most common causes of fever in the pediatric age group. The study was designed to study the clinical profile, etiologic microorganisms, and antibiogram patterns. Methods The present study is a hospital-based cross-sectional study done over a study period of one and a half years. Results Females comprised a higher proportion of the study subjects. Increased urinary frequency and urgency were the most prevalent presenting symptoms in the study population, seen in 39 (39%) and 20 (20%) of the children, respectively. Escherichia coli was found to be the most common causative organism in 45 (45%) children followed by Klebsiella in 22 (22%) children. The organisms showed maximum sensitivity to linezolid (88%) followed by levofloxacin(78%), and piperacillin-tazobactam(76%). Cotrimoxazole(16%) and cefixime(9%) showed the maximum resistance. The outcome was favorable for the majority of the patients treated at par with the antibiogram. Eleven (11%) of the children were found to have anatomical abnormalities in their genitourinary system, and it was found to be significantly associated with recurrence (P value=0.05). Conclusions UTI as one of the leading causes of fever and has to be dealt with a high index of suspicion while evaluating for cases of fever without a focus on children. The antibiogram of the underlying organisms needs to be followed while treating cases of UTI to ensure prompt recovery and avoid the emergence of antimicrobial resistance. This also highlights the need for periodic surveillance of the local prevalence of organisms and their antimicrobial susceptibilities to tailor proper management. Children with anatomical abnormalities in their renal system need to be followed up carefully for chances of recurrence.

Impact on Emergency Department Interventions After Implementing a Guideline Based on the Pediatric Emergency Care Applied Research Network Prediction Rule for Identifying Low-Risk Febrile Infants 29 to 60 Days Old

BACKGROUND

The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule identifies febrile infants at low risk for serious bacterial infection (SBI). However, its impact on avoidable interventions in the emergency department remains unknown.

OBJECTIVE

To study the impact on lumbar puncture (LP) performance, empiric antibiotic use, and admissions after implementing a febrile infant clinical practice guideline for infants aged 29 to 60 days based on the PECARN prediction rule in the pediatric emergency department.

METHODS

This single center preintervention to postintervention study included infants 29 to 60 days old who presented with a chief complaint of fever from November 2018 to November 2021 and were assessed for SBI via blood culture and either urinalysis or urine culture. A new clinical practice guideline based on the PECARN prediction rule was implemented on December 2019. Lumbar puncture attempts, antibiotic administration, and admissions were compared preimplementation and postimplementation and in subgroups of low- and high-risk patients.

RESULTS

Of 1597 (PRE: 785, POST: 812) infants presenting with fever, 1032 (PRE: 500, POST: 532) met inclusion criteria. Adoption of guideline recommendations (measured as procalcitonin order rate) was 89.7% in eligible infants postimplementation. Overall, there was a significant decrease in LPs (PRE: 30.6%, POST: 22.6%, P < 0.05) and no significant change in antibiotics or admissions. Among low-risk infants, there was a significant reduction in LPs (PRE: 17.2%, POST: 4.4%, P < 0.05) and antibiotics (PRE: 14.5%, POST: 4.1%; P < 0.05). There was no change in missed SBI (PRE: 3, POST: 2, P = 0.65). No cases of missed meningitis preimplementation or postimplementation were observed.

CONCLUSIONS

After implementation of a guideline based on the PECARN prediction rule, we observed a reduction of LPs and antibiotics in low-risk infants. Overall, a decrease in LPs was observed, whereas antibiotic use and admissions remained unchanged.

Fever without a source in children: international comparison of guidelines

BACKGROUND

Fever without a source (FWS) in children poses a diagnostic challenge. To distinguish a self-limiting infection from a serious infection, multiple guidelines have been developed to aid physicians in the management of FWS. Currently, there is no comparison of existing FWS guidelines.

METHODS

This comparative review describes consistencies and differences in guideline definitions and diagnostic and therapeutic recommendations. A literature search was performed to include secondary care FWS guidelines of high-income countries, composed by national or regional pediatric or emergency care associations, available in English or Dutch.

RESULTS

Ten guidelines of five high-income countries were included, with varying age ranges of children with FWS. In children younger than one month with FWS, the majority of the guidelines recommended laboratory testing, blood and urine culturing and antibiotic treatment irrespective of the clinical condition of the patient. Recommendations for blood culture and antibiotic treatment varied for children aged 1-3 months. In children aged above three months, urine culture recommendations were inconsistent, while all guidelines consistently recommended cerebral spinal fluid testing and antibiotic treatment exclusively for children with a high risk of serious infection.

CONCLUSIONS

We found these guidelines broadly consistent, especially for children with FWS younger than one month. Guideline variation was seen most in the targeted age ranges and in recommendations for children aged 1-3 months and above three months of age. The findings of the current study can assist in harmonizing guideline development and future research for the management of children with FWS.

Etiology and clinical characteristics of pediatric acute fever among hospitalized children in an endemic malaria transmission area of Cameroon in Central Africa

Acute fever in the majority of children in resource-limited countries is attributable to malaria and often treated without laboratory evidence. The aim of the study was to characterize acute pediatric infectious fevers (APIF) in the pediatric department of the Douala Laquintinie Hospital. A cross-sectional study was conducted among children aged 2 months to 15 years who were admitted with an acute fever (anal temperature ≥ 37.5°C less than 5 days in infants and 7 days in adolescents). 200 children were included and followed up during their hospitalization. The mean age was 3.7 (IQ25-75: 1-4.6) years. More than 3 out of 5 patients (62.5%) came from another health facility and anemia accounted for 29% of the reasons for consultation associated with fever. The main symptoms were vomiting (28%), cough (26%), convulsions (21%) and diarrhea (20%). Skin-mucosal pallor (43.0%) and hepatosplenomegaly (26.0%) were the most common physical signs encountered. Among febrile children, 116/200 (58%) were infected with at least 1 pathogen, and 1/200 (0.5%) had a fever of unknown etiology. Malaria (53% vs 80.5% presumptive) associated with anemia (95.3% of cases) was the most common pathology associated with APIF, followed by pneumonia (19.5%), meningitis (11.5%) and urinary tract infections (10% vs 54.5% presumptive). Malaria was over-diagnosed on admission and over-treated as well as urinary tract infection. A better understanding of common pathogens carriage, a better capacity for improved diagnosis and a better applied clinical algorithm for febrile illnesses in children are needed.

New insights into fever phobia: a pilot qualitative study with caregivers and their healthcare providers

Despite the availability of clinical guidelines on the correct symptomatic management of fever in children, several studies have reported inaccurate knowledge about this symptom and inappropriate management behaviours among caregivers. There is evidence that caregivers' management of fever is largely influenced by unrealistic and unwarranted concerns about the potential harm that elevated body temperature can cause, a phenomenon commonly referred to as fever phobia. Research on fever phobia has predominantly focused on the role of fever misconceptions in triggering anxiety and impeding a proper fever management, in terms of both concept and operationalization, with little attention to the influence of the relationship between caregivers and the healthcare team. The aim of this pilot study was to explore and describe fever-related knowledge, experience and behaviour among a sample of caregivers, paediatricians and their medical assistants in the Canton of Ticino, Switzerland. We used a qualitative study design with semi-structured, one-to-one interviews with paediatricians employed in private healthcare facilities, their medical assistants and caregivers with at least one child between the ages of 0 and 3 years. We conducted individual interviews either in person or by phone, according to participants' preferences, between October 2020 and February 2021. We performed an inductive-deductive analysis of the transcripts to identify the most meaningful themes from participants' reports. The analysis of the transcripts yielded three main themes. The first theme refers to participants' awareness of the emotional component in managing the child's fever and the challenges this component presents. The second theme refers to the risk of overtreating when the child's right to be sick is not recognized and respected. The third theme refers to the importance of the relational component, showing how a solid therapeutic alliance with the healthcare team helps caregivers develop self-confidence in managing the child's fever. This study contributes to advance our understanding of fever phobia and to a better conceptualization and operationalization of this phenomenon.

CONCLUSION

Our results point out to the importance of going beyond a knowledge gap paradigm and recognizing both the emotional and the relational component of fever phobia, the former being entrenched in latter, that is, the unique relationship caregivers establish with their child's paediatrician and the medical assistant.

WHAT IS KNOWN

• Research on fever phobia has predominantly focused on the role of fever misconceptions in triggering anxiety and impeding a proper fever management, in terms of both concept and operationalization, with little attention to the relational component of this phenomenon.

WHAT IS NEW

• Our results point out to the importance of recognizing the emotional component of fever phobia, beyond its declarative and procedural knowledge dimensions. They also suggest that overtreating is not necessarily and not only the result of a phobia but also of a particular conception of health and the relational component of this phenomenon, which is entrenched in the unique relationship caregivers establish with their child's paediatrician and the medical assistant.

Incidence, Characteristics, and Outcomes of Clinically Undetected Bacteremia in Children Discharged Home From the Emergency Department

BACKGROUND

Despite a recent decline in the rates of invasive infections, bacteremia in young children remains a significant challenge. We aimed to describe patient characteristics, microbial etiology, and outcomes of bacteremic, well-appearing children 3-36 months of age who were discharged home from the pediatric emergency department (PED) on their index visit.

METHODS

A retrospective cohort study in the PED of a tertiary children's hospital from 1 June 2015 until 30 June 2021. We included all well appearing, immunocompetent infants 3-36 months old evaluated for fever and discharged home from the PED after a blood culture was drawn. We extracted demographic, clinical and laboratory data from the patient's electronic medical records for the index visit and subsequent encounters.

RESULTS

During the study period, 17,114 children evaluated for fever met the inclusion criteria. Seventy-two patients (0.42%) had positive cultures for known pathogens. Thirty-six (50%) were male and 36 (50%) younger than 1 year. The most common isolates were S. pneumonia 26%. (n = 19), K. Kingae 25%. (n = 18) and Salmonella spp. 13.9% (n = 10). Sixty patients (85.7%) were recalled to the ED or had a scheduled appointment, 10 (14.3%) returned spontaneously and two were followed up by phone. The median time between visits was 28.7 hours (IQR 19.1-41.1). One patient was admitted to intensive care during the course of hospitalization. There were no deaths.

CONCLUSION

The rate of undetected true bacteremia in our study was low and our data suggest that significant clinical deterioration during the first 24 hours is rare.

Serious bacterial infections in young children with fever without source after discharge from emergency department: A National Health Insurance database cohort study

BACKGROUND

Well-appearing febrile young children discharged from the emergency department (ED) after medical assessment are still at risk for serious bacterial infections (SBI). The incidence of SBI and the effectiveness of laboratory tests in the pneumococcal conjugate vaccine era remain unknown.

METHODS

We conducted a study using Taiwan's National Health Insurance claims data from 2004 to 2014. Children aged 2-24 months discharged from the ED with a diagnosis compatible with fever without source (FWS) were enrolled.

RESULTS

The study identified 431,884 children from the ED with FWS. 13.53% of the children had revisits, 8.62% needed hospitalization and 1.57% developed SBI. Younger children had a higher SBI rate, but a lower revisit rate. The revisit rate was 12.22% for children aged 2-6 months, 13.61% for children aged 7-12 months and 13.77% for children aged 13-24 months (p < 0.0001). The SBI rate was 4.44% for children aged 2-6 months, 1.85% for children aged 2-6 months and 0.96% for children aged 13-24 months (p < 0.0001). Children with hemogram tests, compared to those without, had a higher revisit rate (16.30% vs. 13.15%, p < 0.0001), and a higher SBI rate in the children aged 13-24 months (1.30% vs. 0.92%, p < 0.0001); furthermore, children with urinalysis had a significantly higher revisit rate (14.42% vs. 13.24%, p < 0.0001) and higher SBI rate (2.10% vs. 1.40%, p < 0.0001).

CONCLUSION

Children with FWS aged 2-24 months who were discharged from ED after blood test and urinalysis were still at risk for SBI, especially those aged 2-6 months.

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.

Cost-effectiveness of procalcitonin for detection of serious bacterial infections in children presenting with fever without source

INTRODUCTION

Procalcitonin (PCT) offers better specificity than C-reactive protein (CRP) to detect SBI. However, their cost limited their use and routine application. The objective of this work is to determine the cost-effectiveness of PCT against CPR or Rochester scale in infants between 1 and 3 months from the perspective of the third payer in Colombia.

METHODS

A Monte Carlo simulation was performed with a hypothetical cohort of 10,000 patients with fever without focus (FWS) between 1 to 3 months, to estimate the number of cases correctly diagnosed for each test and the associated costs with each test.

RESULTS

The test with the highest number of correctly diagnosed cases was PCT 79%, followed by C-reactive protein 75%, and the Rochester scale 68%. The test with the lowest cost per patient was PCT $645 (95% CI US$646-US$645) followed by C-reactive protein U$ 653 (95% CI US$655-$645) and Rochester scale US$804 (95% CI US$807-US$804). This position of dominance of PCT eliminated the need to calculate an incremental cost effectiveness ratio.

CONCLUSIONS

PCT is the most cost-effective strategy for the detection of IBS in infants with FWS. These results should be interpreted within the clinical context of the patient and not as a single method for therapeutic decision-making.

Racial/Ethnic Disparities in Triage Scores Among Pediatric Emergency Department Fever Patients

OBJECTIVES

Emergency department (ED) triage scores are assigned to patients in a short period based on assessment of need for lifesaving measures, risk and pain levels, resource needs, and vital signs. Racial/ethnic disparities have been found across a number of outcomes but are not consistent across all studies. This study examines pediatric ED cases reporting fever, a commonly reported triage symptom, to explore racial/ethnic and age disparities in triage score assignment.

METHODS

This study uses the 2009-2015 National Hospital Ambulatory Medical Care Survey, an annual national sample of ED visits in the United States. Pediatric cases where fever is the sole reported reason for visit are analyzed for racial/ethnic disparities, controlling for sex, age, insurance status, body temperature, region, and hospital type.

RESULTS

Among all pediatric fever cases, temperature is the sole significant predictor of triage scores. However, non-Hispanic (NH) black pediatric patients older than 1 year have approximately 22% greater risk of being given a less urgent triage score relative to NH white patients.

CONCLUSIONS

Findings suggest racial disparities in the triage of NH black pediatric patients older than 1 year for fever. Although fever is a single and often non-life-threatening condition, especially after infancy, findings of racial disparities in triage scores suggests a need for further evaluation of the assignment of patient urgency in emergency medicine.

Febrile infants without respiratory symptoms or sick contacts: are chest radiographs or RSV/influenza testing indicated?

Background

Serious bacterial infection rates in febrile infants < 60 days are about 8–11%. Less than 1% of febrile infants with no respiratory symptoms will have pneumonia however, chest radiography (CXR) rates remain between 30 and 60%. Rapid Respiratory Syncytial Virus (RSV) and influenza (flu) testing is common, however, there is not enough data to determine if febrile infants without any respiratory symptoms should be tested. The goal of this study is to determine the rate of positive CXR and RSV/flu results in febrile infants with no respiratory symptoms and no sick contacts.

Methods

Well-appearing febrile infants between 7 and 60 days of age who presented to the pediatric emergency department (PED) from September 1st, 2015 through October 30th, 2017 were enrolled. Demographic data, respiratory symptoms, CXR findings and RSV/flu results were collected. SAS statistical software was used for analysis.

Results

129 infants met enrollment criteria. Of the 129 infants, 58 (45.0%) had no respiratory symptoms and no sick contacts. Of these 58, 36 (62.1%) received a CXR and none of them had any abnormal findings, 48 (82.8%) had RSV/flu testing, no patients tested positive for RSV and only one patient tested positive for flu. Costs of CXR and RSV/flu testing for this cohort was $19,788.

Conclusion

The absence of positive CXRs in this patient population reinforces the current recommendations that CXR is not indicated. The low incidence of RSV/flu indicate that routine testing may not be necessary in this population especially outside of the flu season. Reduced testing could decrease overall costs to the healthcare system as well as radiation exposure to this population.

Association of Bacteremia with Vaccination Status in Children Aged 2 to 36 Months

OBJECTIVE

To determine the association between bacteremia and vaccination status in children aged 2-36 months presenting to a pediatric emergency department.

STUDY DESIGN

Retrospective cohort study of children aged 2-36 months with blood cultures obtained in the pediatric emergency department between January 2013 and December 2017. The exposure of interest was immunization status, defined as number of Haemophilus influenzae type B (Hib) and Streptococcus pneumoniae vaccinations, and the main outcome positive blood culture. Subjects with high-risk medical conditions were excluded.

RESULTS

Of 5534 encounters, 4742 met inclusion criteria. The incidence of bacteremia was 1.5%. The incidence of contaminated blood culture was 5.0%. The relative risk of bacteremia was 0.79 (95% CI 0.39-1.59) for unvaccinated and 1.20 (95% CI 0.52-2.75) for undervaccinated children relative to those who had received age-appropriate vaccines. Five children were found to have S pneumoniae bacteremia and 1 child had Hib bacteremia; all of these subjects had at least 3 sets of vaccinations. No vaccine preventable pathogens were isolated from blood cultures of unvaccinated children. We found no S pneumoniae or Hib in children 2-6 months of age who were not fully vaccinated due to age (95% CI 0-0.13%) and the contamination rate in this group was high compared with children 7-36 months (6.6% vs 3.7%).

CONCLUSIONS

Bacteremia in young children is an uncommon event. Contaminated blood cultures were more common than pathogens. Bacteremia from S pneumoniae or Hib is uncommon and, in this cohort, was independent of vaccine status.

Epidemiology of COVID-19 infection in young children under five years: A systematic review and meta-analysis

INTRODUCTION

Emerging evidence suggests young children are at greater risk of COVID-19 infection than initially predicted. However, a comprehensive understanding of epidemiology of COVID-19 infection in young children under five years, the most at-risk age-group for respiratory infections, remain unclear. We conducted a systematic review and meta-analysis of epidemiological and clinical characteristics of COVID-19 infection in children under five years.

METHOD

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses , we searched several electronic databases (Pubmed, EMBASE, Web of Science, and Scopus) with no language restriction for published epidemiological studies and case-reports reporting laboratory-confirmed COVID-19 infection in children under five years until June 4, 2020. We assessed pooled prevalence for key demographics and clinical characteristics using Freeman-Tukey double arcsine random-effects model for studies except case-reports. We evaluated risk of bias separately for case-reports and other studies.

RESULTS

We identified 1,964 articles, of which, 65 articles were eligible for systematic review that represented 1,214 children younger than five years with laboratory-confirmed COVID-19 infection. The pooled estimates showed that 50% young COVID-19 cases were infants (95% CI: 36% - 63%, 27 studies); 53% were male (95% CI: 41% - 65%, 24 studies); 43% were asymptomatic (95% CI: 15% - 73%, 9 studies) and 7% (95% CI: 0% - 30%, 5 studies) had severe disease that required intensive-care-unit admission. Of 139 newborns from COVID-19 infected mothers, five (3.6%) were COVID-19 positive. There was only one death recorded.

DISCUSSION

This systematic review reports the largest number of children younger than five years with COVID-19 infection till date. Our meta-analysis shows nearly half of young COVID-19 cases were asymptomatic and half were infants, highlighting the need for ongoing surveillance to better understand the epidemiology, clinical pattern, and transmission of COVID-19 to develop effective preventive strategies against COVID-19 disease in young paediatric population.

Risk factors associated with serious bacterial infections among newborns with high body temperature

Introduction

Recognizing the importance of serious bacterial infections (SBIs), study aimed to identify factors associated with high body temperature in newborns.

Methods

A convenience sample of 54 newborns admitted to our hospital in Iran (March-July 2015) with rectal temperature > 38°C (100.4°F) were examined for clinical signs, blood cultures, complete blood counts, platelets, Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP), renal function, chest/abdominal x-rays, spinal tap, and history of maternal infections.

Results

Newborns had either fever due to infections, or hyperthermia due to dehydration and/or extreme warm environment. Bacterial infections (37%) included: sepsis (15%) (coagulase-positive or coagulase-negative Staphylococci, Enterobacter, Klebsiella, Escherichia coli), meningitis (13%), and 3.5% UTI, 3.5% pneumonia, 2% cellulitis, and 2% omphalitis. Degrees of dehydration experienced by 55.6% included 37% of cases associated with hyperthermia caused by warm clothing/environment, while in 18.6% dehydration was secondary to fever. Viral infections (11%) included upper respiratory infections, gastroenteritis, while in remaining 13% cause of high body temperature was unknown. The group with SBIs had higher chance of having history of PROM (premature rupture of membrane) (p = 0.023), positive CRP (p = 0.041), and abnormal platelets count (p = 0.021) comparing all others.

Conclusions

High body temperature in newborns needs careful evaluation to identify fever due to SBIs. In sepsis cases, antibiotics should cover prevalent bacteria including Staphylococci and Enterobacter. Dehydration was prevalent among newborns with high body temperature due to hyperthermia or secondary to infections. To avoid hyperthermia, parents should know how to clothe their newborns appropriate for environmental temperature. Newborns' SBIs associated with positive CRP, abnormal platelet count, and maternal PROM.

Risk factors for urinary tract infections in children aged 0-36months presenting with fever without source and evaluated for risk of serious bacterial infections

BACKGROUND

Children younger than 36 months with fever without a source (FWS) are at risk of serious bacterial infections (SBI). The risk of occult bacteremia (OB) has been greatly reduced in vaccinated children. The aim of this study is to describe the epidemiology of SBI in children with FWS in our setting and to evaluate the performance of our management algorithm.

METHODS

We designed a prospective cohort study. We included children aged 0-36 months presenting with FWS in our emergency unit. Demographic and clinical characteristics, investigations, and management procedures were recorded at the time of inclusion. Information on clinical evolution, final diagnosis, and immunization history were obtained after 10 days. Potential predictors of SBI were compared between patients with and without SBI.

RESULTS

Between October 2015 and September 2017, 173 children were recruited, with a median age of 4.4 months (2.1-1). Of these children, 166 (96%) were up to date with their vaccinations. A total of 47 children (27%) had a final diagnosis of SBI, which were all urinary tract infections (UTI). Presence of chills (odds ratio [OR] 5.6, 95% confidence interval [CI] 1.3-24.3), fever for>2 days (OR 29.1, 95% CI 3.5-243.5), and age<9 months (OR: 45.3, 95% CI: 4.9-415.7) were statistically significant predictors of UTI in a multivariate logistic regression. The sensitivity and specificity of our management algorithm were 100% (95% CI: 92.4-100%) and 21.4% (14.6-29.6%), respectively.

CONCLUSIONS

In the setting of high vaccination coverage, we only identified SBI related to UTIs. We could not identify any OB. Our management algorithm was able to identify all SBI, but specificity was low. Refined criteria for screening of UTI could slightly increase this.

What matters when managing childhood fever in the emergency department? A discrete-choice experiment comparing the preferences of parents and healthcare professionals in the UK

BACKGROUND

Fever among children is a leading cause of emergency department (ED) attendance and a diagnostic conundrum; yet robust quantitative evidence regarding the preferences of parents and healthcare providers (HCPs) for managing fever is scarce.

OBJECTIVE

To determine parental and HCP preferences for the management of paediatric febrile illness in the ED.

SETTING

Ten children's centres and a children's ED in England from June 2018 to January 2019.

PARTICIPANTS

98 parents of children aged 0-11 years, and 99 HCPs took part.

METHODS

Nine focus-groups and coin-ranking exercises were conducted with parents, and a discrete-choice experiment (DCE) was conducted with both parents and HCPs, which asked respondents to choose their preferred option of several hypothetical management scenarios for paediatric febrile illness, with differing levels of visit time, out-of-pocket costs, antibiotic prescribing, HCP grade and pain/discomfort from investigations.

RESULTS

The mean focus-group size was 4.4 participants (range 3-7), with a mean duration of 27.4 min (range 18-46 min). Response rates to the DCE among parents and HCPs were 94.2% and 98.2%, respectively. Avoiding pain from diagnostics, receiving a faster diagnosis and minimising wait times were major concerns for both parents and HCPs, with parents willing-to-pay £16.89 for every 1 hour reduction in waiting times. Both groups preferred treatment by consultants and nurse practitioners to treatment by doctors in postgraduate training. Parents were willing to trade-off considerable increases in waiting times (24.1 min) to be seen by consultants and to avoid additional pain from diagnostics (45.6 min). Reducing antibiotic prescribing was important to HCPs but not parents.

CONCLUSIONS

Both parents and HCPs care strongly about reducing visit time, avoiding pain from invasive investigations and receiving diagnostic insights faster when managing paediatric febrile illness. As such, overdue advances in diagnostic capabilities should improve child and carer experience and HCP satisfaction considerably in managing paediatric febrile illness.

Using Machine Learning to Predict Bacteremia in Febrile Children Presented to the Emergency Department

Blood culture is frequently used to detect bacteremia in febrile children. However, a high rate of negative or false-positive blood culture results is common at the pediatric emergency department (PED). The aim of this study was to use machine learning to build a model that could predict bacteremia in febrile children. We conducted a retrospective case-control study of febrile children who presented to the PED from 2008 to 2015. We adopted machine learning methods and cost-sensitive learning to establish a predictive model of bacteremia. We enrolled 16,967 febrile children with blood culture tests during the eight-year study period. Only 146 febrile children had true bacteremia, and more than 99% of febrile children had a contaminant or negative blood culture result. The maximum area under the curve of logistic regression and support vector machines to predict bacteremia were 0.768 and 0.832, respectively. Using the predictive model, we can categorize febrile children by risk value into five classes. Class 5 had the highest probability of having bacteremia, while class 1 had no risk. Obtaining blood cultures in febrile children at the PED rarely identifies a causative pathogen. Prediction models can help physicians determine whether patients have bacteremia and may reduce unnecessary expenses.

Prevalence, Characterization, and Drug Resistance of Staphylococcus Aureus in Feces From Pediatric Patients in Guangzhou, China

Background: Staphylococcus aureus (S. aureus) is a major pathogen of human infections. Its fecal carriage serves as a risk factor for nosocomial transmission and disease development. However, the rate of S. aureus fecal carriage among Chinese children has not yet been reported. Therefore, we sought to investigate the prevalence, characterization, and drug resistance of S. aureus isolated from pediatric patients' feces in Southern China. Methods: Fecal samples (2059) from pediatric patients in three centers in Guangzhou were cultured. From which, 412 S. aureus isolates were identified via selective mediums and automated VITEK Mass Spectrometer analysis. Antibiotic susceptibility was determined and DNA sequencing of seven housekeeping genes were used for multilocus sequence typing analysis. Results: The fecal carriage rates were 20.0% for S. aureus and 4.5% for methicillin-resistant S. aureus (MRSA). Moreover, S. aureus fecal carriage was positively correlated with outpatient status and gastroenteritis diagnosis. Moreover, age-related patterns were observed with respect to prevalence of S. aureus. Besides, a total of 76 sequence types (STs) were identified, including 25 newly assigned STs and 28 clonal complexes (CCs). ST188, ST6, and ST15 were the most prevalent methicillin-sensitive S. aureus (MSSA) clones, while ST59 and ST45 were the major MRSA clones. S. aureus isolates also exhibited high rates of penicillin (84.2%), erythromycin (38.8%), and clindamycin (35.9%) resistance. Specifically, all ST30 and ST338 isolates were resistant to erythromycin and clindamycin, 61% of ST7 were resistant to tetracycline, and 84% of ST45 exhibited resistance and intermediate resistance to rifampicin. Also, CC59 (ST338 and ST59) and CC45 exhibited different antibiotic resistance patterns. Conclusion: These results demonstrate the colonization dynamics and molecular epidemiology of S. aureus in child feces in Southern China. Further, they suggest an urgency for strengthening the surveillance programs in China and provide important information for the prevention and treatment of S. aureus infection.

Etiology, Treatment, and Outcome of Children Aged 3 to 36 Months With Fever Without a Source at a Community Hospital in Southern Thailand

Background: Fever without a source (FWS) in young children can result from occult bacteremia, urinary tract infection (UTI), meningitis, or certain viral infections. In rural areas of Thailand, where bacterial cultures are not available in some community hospitals, the appropriate examination and management of FWS remain controversial. Methods: We retrospectively searched electronic medical records for medical diagnoses associated with FWS and evaluated the characteristics and clinical courses of children aged 3 to 36 months with FWS who were admitted to a community hospital in southern Thailand between January 2015 and December 2016. Results: Sixty-seven children aged 3 to 36 months with an initial diagnosis of FWS were enrolled. The median age was 11 months (interquartile range [IQR] 8-21 months). Complete blood counts, blood cultures, urine analysis results and urinary cultures were obtained from 67 (100.0%), 31 (46.3%), 47 (70.1%), and 7 (10.5%) patients, respectively. The most common empirical antibiotic administered to these patients was ceftriaxone (71.6%); however, 4 patients recovered without antibiotic administration. The median duration of intravenous antibiotic administration was 4 days (IQR 2-4 days). Intravenous antibiotics were replaced by oral antibiotics in 38 patients (62.3%). The median time to fever subsidence was 30 hours (IQR 12-60 hours). Regarding final diagnoses, 5 patients (7.5%) were diagnosed with culture-confirmed UTI, and 2 (3.0%) had bacteremia (due to contamination). The majority of the children (60, 89.6%) retained the diagnosis of FWS. Presentation at the hospital was significantly earlier in children with culture-confirmed UTI (median 1 day) than in those with culture-negative FWS (median 3 days) (P = .019). Discussion: We evaluated the characteristics and clinical courses of young children with FWS presenting at a community hospital and the treatment approaches utilized by physicians. Although all patients had good prognoses during the study period, we identified several areas for improvement in conducting proper examinations (especially assessments for UTI in children presenting within the first day of fever onset).

Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway

BACKGROUND AND OBJECTIVES

Significant variation in management of febrile infants exists both nationally and within our institution. Risk stratification can be used to identify low-risk infants who can be managed as outpatients without lumbar puncture (LP) or antibiotics. Our objective was to reduce invasive interventions for febrile infants aged 29 to 60 days at low risk for serious bacterial infection (SBI) through implementation of a clinical pathway supported by quality improvement (QI).

METHODS

The evidence-based clinical pathway was developed and implemented by a multidisciplinary team with continuous-process QI to sustain use. Low-risk infants who underwent LP, received antibiotics, and were admitted to the hospital were compared pre- and postpathway implementation with SBI in low-risk infants and appropriate care for high-risk infants as balancing measures.

RESULTS

Of 350 included patients, 220 were pre- and 130 were postpathway implementation. With pathway implementation in July 2016, invasive interventions decreased significantly in low-risk infants, with LPs decreasing from 32% to 0%, antibiotic administration from 30% to 1%, and hospital admission from 17% to 2%. Postimplementation, there were 0 SBIs in low-risk infants versus 29.2% in high-risk infants. The percentage of high-risk patients receiving care per pathway remained unchanged. Improvement was sustained for 12 months through QI interventions, including order-set development and e-mail reminders.

CONCLUSIONS

Implementation of a clinical pathway by using QI methods resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs. Clinical pathways and QI can be key strategies in the delivery of evidence-based care for febrile infants.

Assessment of blood enterovirus PCR testing in paediatric populations with fever without source, sepsis-like disease, or suspected meningitis: a prospective, multicentre, observational cohort study

Background

Enteroviruses are the most frequent cause of acute meningitis and are seen increasingly in sepsis-like disease and fever without source in the paediatric population. Detection of enterovirus in cerebrospinal fluid (CSF) specimens by PCR is the gold standard diagnostic test. Our aim was to assess a method of detecting enterovirus in blood specimens by PCR.

Methods

We did a prospective, multicentre, observational study at 35 French paediatric and emergency departments in 16 hospitals. We recruited newborn babies (aged ≤28 days) and infants (aged >28 days to ≤2 years) with fever without source, sepsis-like disease, or suspected meningitis, and children (aged >2 years to ≤16 years) with suspected meningitis, who were admitted to a participating hospital. We used a standardised form to obtain demographic, clinical, and laboratory data, which were anonymised. Enterovirus PCR testing was done in blood and CSF specimens.

Findings

Between June 1, 2015, and Oct 31, 2015, and between June 1, 2016, and Oct 31, 2016, we enrolled 822 patients, of whom 672 had enterovirus PCR testing done in blood and CSF specimens. Enterovirus was detected in 317 (47%) patients in either blood or CSF, or both (71 newborn babies, 83 infants, and 163 children). Detection of enterovirus was more frequent in blood samples than in CSF specimens of newborn babies (70 [99%] of 71 vs 62 [87%] of 71; p=0·011) and infants (76 [92%] of 83 vs 62 [75%] of 83; p=0·008), and was less frequent in blood samples than in CSF specimens of children (90 [55%] of 163 vs 148 [91%] of 163; p<0·0001). Detection of enterovirus was more frequent in blood samples than in CSF specimens of infants aged 2 years or younger with fever without source (55 [100%] of 55 vs 41 [75%] of 55; p=0·0002) or with sepsis-like disease (16 [100%] of 16 vs nine [56%] of 16; p=0·008). Detection of enterovirus was less frequent in blood than in CSF of patients with suspected meningitis (165 [67%] of 246 vs 222 [90%] of 246; p<0·0001).

Interpretation

Testing for enterovirus in blood by PCR should be an integral part of clinical practice guidelines for infants aged 2 years or younger. This testing could decrease the length of hospital stay and reduce exposure to antibiotics for low-risk patients admitted to the emergency department with febrile illness.

Funding

University Hospital Clermont-Ferrand.

Predictive power of a single body temperature at different cutoff values for neonates in the nursery transferring to special care nursery

The aim of this study was to identify the clinical parameters indicative of serious etiology of neonatal hyperthermia and to determine the appropriate cutoff value of body temperature (BT) for predicting the need to transfer the newborn to the special care (SC) nursery.The nursery records of newborns diagnosed with hyperthermia between 2007 and 2013 were retrospectively reviewed. The clinical characteristics of newborns with hyperthermia remained in the nursery were compared with those transferred to the SC nursery. In addition, the receiver operating characteristic analysis was used to determine the appropriate cutoff BT for predicting further septic workup in the SC nursery.Among the 92 newborns with hyperthermia evaluated, 30 (32.6%) were transferred to the SC nursery and 62 (67.4%) remained in the nursery. Clinical characteristics associated with transfer to the SC nursery included the highest BT, BT at first measurement during hyperthermia, frequency of hyperthermia, duration of hyperthermia, irritable crying, decreased appetite, poor activity, vomiting with abdominal distension, tachypnea, and tachycardia (all P < .05). BT for predicting the need for transferring newborns with hyperthermia to the SC nursery had an area under the curve of 0.976 (P < .001). A BT of 38 °C was determined as the optimal cutoff value for predicting the need to monitoring for suspicious clinical symptoms (sensitivity (Sn), 93%; specificity (Sp), 87%). Furthermore, BT≥38.2 °C (Sn, 70%; Sp 100%) and BT≤37.8 °C (Sn, 100%; Sp, 61%) respectively were determined as the cutoff values for transferring newborns to the SC nursery or allowing them to remain in the regular nursery.Our results suggest a BT of 38 °C represents the optimal cutoff indicating newborns for close monitoring for suspicious clinical presentations including irritable crying, decreased appetite, poor activity, vomiting with abdominal distension, tachypnea, and tachycardia. Newborns with BT < 37.8 °C may remain in the nursery but should be transferred to the SC nursery for septic workup and empiric antibiotics if the BT is above 38.2 °C.

Dynamics of Severe and Non-severe Invasive Pneumococcal Disease in Young Children in Israel Following PCV7/PCV13 Introduction

BACKGROUND

The introduction of the pneumococcal conjugated vaccines (PCVs) resulted in a substantial reduction of invasive pneumococcal disease (IPD) rates. However, impact on nonsevere IPD (mostly occult bacteremia) has not yet been fully elucidated. We assessed severe and nonsevere IPD (SIPD and NSIPD, respectively) rate dynamics in children < 5 years in Israel before and after PCV7/PCV13 implementation.

METHODS

A prospective, population-based, nationwide surveillance. All IPD episodes recorded from 1999 through 2015 were included. NSIPD was defined as IPD episodes without meningitis, pneumonia or mastoiditis in a child with a favorable outcome (not hospitalized or hospitalized in a nonintensive care unit < 5 days, without mortality). Three subperiods were defined: pre-PCV (1999-2008), PCV7 (2010-2011) and PCV13 (2013-2015). Incidence rate ratios (IRRs) were calculated.

RESULTS

Overall, 4,457 IPD episodes were identified; 3,398 (76.2%) SIPD, 1,022 (22.9%) NSIPD and 37 (0.8%) unknown. In 90% of NSIPD episodes, no focus was identified. In the PCV7 period, NSIPD rates significantly declined by 52%, while SIPD rates declined less prominently by 24%. Following PCV13 introduction, compared with the PCV7 period, NSIPD rates declined nonsignificantly by 17% while SIPD rates declined significantly further by an additional 53%. These trends resulted in overall reductions (comparing PCV13 and pre-PCV periods) of NSIPD and SIPD of 60% (IRR = 0.4; 0.32-0.51) and 64% (IRR = 0.36; 0.32-0.42), respectively.

CONCLUSIONS

Following PCV7/PCV13 introduction, SIPD and NSIPD rates substantially declined, with differences in rate-dynamics, alluding to differences in serotype distribution between the 2 groups. Future surveillance is warranted when considering modification in treatment protocols for suspected occult bacteremia/NSIPD cases.

Invasive bacterial infections in young afebrile infants with a history of fever

OBJECTIVE

To determine the prevalence of invasive bacterial infections (IBI, pathogenic bacteria in blood or cerebrospinal fluid) in infants less than 90 days old with fever without a source related to the presence or absence of fever on arrival to the emergency department (ED).

DESIGN

Prospective registry-based cohort study.

SETTING

Paediatric ED of a tertiary teaching hospital.

PATIENTS

We included infants less than 90 days old with a history of fever evaluated in the ED from 2003 to 2016.

MAIN OUTCOMES AND MEASURES

The prevalence of IBI in patients with a history of fever who were febrile and afebrile on arrival to the ED.

RESULTS

We included 2470 infants: 678 afebrile and 1792 febrile when evaluated in the ED. Fifty-nine (2.4%) were diagnosed with an IBI (bacteraemia 46, meningitis 7 and sepsis 6): 16 in the group of afebrile infants with a history of fever (2.4%, 95% CI 1.4 to 3.8 vs 43 in the febrile group, 2.4%, 95% CI 1.8 to 3.2). Of the 16 afebrile infants with a history of fever diagnosed with an IBI, 14 were well appearing. The rate of non-IBI (pathogenic bacteria in urine or stools) was similar in both groups (15.5% and 16.7%).

CONCLUSIONS

The prevalence of IBI in infants ≤90 days with a history of fever is similar regardless of the presence of fever on the arrival at the ED. The approach to infants with a history of fever who are afebrile in the ED should not differ from that recommended for infants who are febrile in the ED.

Diagnostic Value of PCT and CRP for Detecting Serious Bacterial Infections in Patients With Fever of Unknown Origin: A Systematic Review and Meta-analysis

BACKGROUND

It is vital to recognize the cause of an infection to enable earlier treatment. Studies have shown that procalcitonin (PCT) and C-reactive protein (CRP) have very high sensitivity and specificity for diagnosing serious bacterial infections (SBIs), with PCT performing better than CRP.

METHODS

Multiple databases were searched for relevant studies, and full-text articles involving diagnosis with PCT and CRP were reviewed. All meta-analyses were conducted with Review Manager 5.0. Sensitivity and bias analyses were performed to evaluate the quality of articles. In addition, a funnel plot and Egger test were used to assess possible publication bias.

RESULT

A total of 17 articles met the criteria for inclusion. The concentrations of both PCT and CRP were higher in the SBI group than in the nonbacterial infection group. Sensitivity for differentiating bacterial infections from nonbacterial infections was higher for PCT compared with CRP, whereas there was no significant difference in specificity. The area under the summary receiver operating characteristic curve for PCT was larger than that for CRP.

CONCLUSION

Both PCT and CRP are useful markers and should be used to evaluate SBIs with fever of unknown origin.

Refined Lab-score, a Risk Score Predicting Serious Bacterial Infection in Febrile Children Less Than 3 Years of Age

BACKGROUND

The identification of serious bacterial infection (SBI) in children with fever without source remains a challenge. A risk score called Lab-score, based on C-reactive protein, procalcitonin and urinary dipstick results was derived to predict SBI. However, all biomarkers were initially dichotomized, leading to weak statistical reliability and lack of transportability across diverse settings. We aimed to refine and validate this risk-score algorithm.

METHODS

The Lab-score was refined using a secondary analysis of a multicenter cohort study of children with fever without source via multilevel regression modeling. The external validation was conducted on data from a Canadian cohort study.

RESULTS

Eight hundred seventy-seven children (24% SBI) were included for the derivation study, and 347 (16% SBI) for validation. Only C-reactive protein, procalcitonin, age and urinary dipstick remained independently associated with SBI. The model achieved an area under the receiver operating characteristic (ROC) curve of 0.94 (95% confidence interval [CI]: 0.93-0.96), which was significantly higher than any other isolated biomarker (P < 0.0001), and the original Lab-score (P < 0.0001). According to a decision curve analysis, the model yielded a better strategy than those based on independently considered biomarkers, or on the original Lab-score. The threshold analysis led to a cutoff that yielded 96% (95% CI: 92-98) sensitivity and 73% (95% CI: 70-77) specificity. The external validation found similar predictive abilities: 0.96 area under the ROC curve (95% CI: 0.93-0.99), 95% sensitivity (95% CI: 85-99) and 87% specificity (95% CI: 83-91).

CONCLUSION

The refined Lab-score demonstrated higher prediction ability for SBI than the original Lab-score, with promising wider applicability across settings. These results require validation in additional populations.

Rotavirus infection as a frequent cause of neonatal fever

BACKGROUND

Fever rather than diarrhea or vomiting was the most common symptom of neonatal rotavirus (RV) infection in our previous study. We investigated whether RV infection is a major cause of neonatal fever and compared the clinical characteristics of bacterial infection, viral infection and unknown causes of neonatal fever.

METHOD

We reviewed the electronic medical records of 48 newborns aged ≤28 days who were admitted to the Special Care Nursery of Hanyang University Guri Hospital for fever (≥38°C) from 2005 to 2009. All the newborns underwent complete blood count, urinalysis, C-reactive protein, cultures of blood, urine, and cerebrospinal fluid as well as stool RV enzyme-linked immunosorbent assay. Respiratory virus polymerase chain reaction for cough or rhinorrhea, and stool culture for diarrhea were also done.

RESULTS

All the babies were term, with mean age 13 ± 8 days and peak body temperature 38.5 ± 0.5°C. The causes of neonatal fever were viral (44%), bacterial (10%) and unknown (46%). The viral infections included RV (n = 12), enterovirus (n = 6), respiratory syncytial virus (n = 2), and rhinovirus (n = 1). All the rotavirus genotypes were G4P[6]. Only three of 12 RV-infected febrile newborns had diarrhea. The bacterial infections included three cases of urinary tract infection (Escherichia coli, n = 2; Klebsiella pneumoniae, n = 1), and two cases of sepsis complicated with meningitis (all Streptococcus agalactiae).

CONCLUSIONS

RV infection is the most common single cause of neonatal fever. It may be necessary to include stool RV tests for febrile newborns.

Diagnostic accuracy of urinary biomarkers in infants younger than 3 months with urinary tract infection

Purpose

The aim of this study was to evaluate the diagnostic accuracy of urinary biomarkers, such as neutrophil gelatinase-associated lipocalin (uNGAL) and β-2 microglobulin (uB2MG), in early detection of urinary tract infection (UTI) in infants aged <3 months with fever.

Methods

A total of 422 infants aged <3 months (male:female=267:155; mean age, 56.4 days), who were admitted for fever, were retrospectively included in this study. We compared uNGAL and uB2MG between the UTI and non-UTI groups at the time of admission. The sensitivity, specificity, accuracy, and area under the curve (AUC) of uNGAL and uB2MG for use in diagnosing UTI were assessed.

Results

Among 422 patients, 102 (24.2%) were diagnosed with UTI. Levels of uNGAL were higher in the UTI group than in the non-UTI group (366.6 ng/mL vs. 26.9 ng/mL, P<0.001). Levels of uB2MG were not different between the 2 groups. Multivariate analysis revealed that uNGAL was an independent predictive factor for UTI (P=0.033). The sensitivity, specificity, and accuracy were 90.2%, 92.5%, and 91.9% for uNGAL, and 48.0%, 43.8%, and 44.8% for uB2MG, respectively. AUC of uNGAL was 0.942 and that of uB2MG was 0.407.

Conclusion

Accuracy of uNGAL in the diagnosis of UTI is high in febrile infants aged <3 months. uNGAL can help in the early diagnosis and treatment of UTI in infants.

Incidence of Fever and Positive Bacterial Cultures in Neonates Receiving Prostaglandin

Prostaglandin E (PGE₁) is necessary to maintain ductus arteriosus patency in many newborns with congenital heart disease. Because PGE₁ therapy commonly leads to fever, and given this population's fragile state, a complete sepsis workup is often performed in febrile, but otherwise asymptomatic, patients. This practice of liberal evaluation with bacterial cultures, empiric antibiotic treatment, and delays in essential surgical intervention may result in poor resource utilization and lead to increased iatrogenic morbidity. This study sought to determine the incidence of fever and culture-positive infection in patients receiving PGE₁, and identify diagnostic variables that predict culture-positive infection. The study included a single-center retrospective review of all neonates receiving PGE₁ between 2011 and 2014. Logistic regression and receiver operator characteristic analysis were used to identify significant predictors of positive bacterial cultures. Among 435 neonates, 175 (40%) had fevers (≥ 38.3 °C) while concurrently receiving PGE₁, but only 9 (2%) had culture-positive infection and 1 (< 1%) had culture-positive bacteremia. Among 558 cultures collected, only 16 (3%) had bacterial growth. Multivariable analysis revealed age (p = 0.049, AUC 0.604), hospital length of stay (p = 0.002, AUC 0.764) and hypoxemia (p = 0.044, AUC 0.727) as the only significant predictors of positive cultures. Fever (p = 0.998, AUC 0.424) was not a significant predictor. In conclusion, given that fever occurs frequently in neonates receiving PGE₁ and it is a very non-specific marker and not a predictor of positive cultures, the common practice of complete sepsis workup should be re-examined in febrile patients at low risk of bacterial illness.

C-reactive protein concentrations can help to determine which febrile infants under three months should receive blood cultures during influenza seasons

AIM

We explored whether C-reactive protein (CRP) concentrations could indicate which infants with fever without source (FWS) should receive undergo blood culture tests during influenza seasons.

METHODS

This retrospective study focused on patients under three months of age with FWS who had received blood culture tests at the West China Second University Hospital Paediatric Emergency Department during the influenza seasons from June 2013 to January 2015. The statistical analysis comprised specificity, sensitivity, multilevel likelihood ratios (LRs), receiver operating characteristic analysis and a multivariate logistic regression model.

RESULTS

We enrolled 592 febrile patients and 7.1% had bacteraemia, with levels falling with increasing age. According to the receiver operating characteristic analysis, the optimum threshold of CRP was 30.5 mg/L, and when the CRP level was higher than 30.5 mg/L, the positive LR of bacteraemia was 2.32. In patients aged 29-90 days, when the CRP level was higher than 5 mg/L, the negative LR of bacteraemia was 0.38. In the neonatal group, a CRP level of ≥30.5 mg/L had a positive LR of bacteraemia of 3.55.

CONCLUSION

We found that CRP concentrations could indicate which febrile children under three months of age should undergo blood culture tests during influenza seasons.

Prevalence of Inconsistencies in the Recorded Outcomes of Clinical Evaluations

OBJECTIVES

The aims of the study were to determine the prevalence of variations in the recorded outcomes of clinical evaluations by 2 different physicians during a single patient visit and to comment on observations of physician practices regarding history taking and physical examination.

METHODS

Structured interviews were conducted with both junior and supervising physicians after they had evaluated patients in a pediatric emergency department who presented with complaints of fever (temperature, >100.4°F) in infants younger than 3 months, fever (temperature, >102.2°F) in infants aged 3 to 12 months, headache in patients older than 5 years, abdominal pain in patients older than 5 years, and head injury in patients younger than 18 years. Data were analyzed with descriptive statistics.

RESULTS

Most of the data reported by both junior and supervising physicians showed response disagreement. The questions on fever (temperature, >102.2°F) in infants aged 3 to 12 months showed 29% (10/34) disagreement on fever duration and 45% (5/11) on fever height. Questions on abdominal pain in children older than 5 years showed 24% (24/100) disagreement on reporting right lower quadrant pain and 10% (11/106) on right lower quadrant tenderness on examination; however, the discrepancy rates were 56% (56/100) when considering less than complete agreement on all painful sites and 53% (56/106) on all tender sites. Supervising physicians questioned and examined patients presenting with abdominal pain more often than those presenting with other complaints.

CONCLUSIONS

There are significant variations in the recorded outcome of clinical evaluations by 2 different physicians during a single patient visit. Supervising physicians are more cautious to question and examine patients presenting with abdominal pain compared with other chief complaints.

Bacteremia in Children 3 to 36 Months Old After Introduction of Conjugated Pneumococcal Vaccines

BACKGROUND AND OBJECTIVES

In June 2010, Kaiser Permanente Northern California replaced all 7-valent pneumococcal conjugate vaccine (PCV7) vaccines with the 13-valent pneumococcal conjugate vaccine (PCV13). Our objectives were to compare the incidence of bacteremia in children 3 to 36 months old by 3 time periods: pre-PCV7, post-PCV7/pre-PCV13, and post-PCV13.

METHODS

We designed a retrospective review of the electronic medical records of all blood cultures collected on children 3 to 36 months old at Kaiser Permanente Northern California from September 1, 1998 to August 31, 2014 in outpatient clinics, in emergency departments, and in the first 24 hours of hospitalization.

RESULTS

During the study period, 57 733 blood cultures were collected in the population of children 3 to 36 months old. Implementation of routine immunization with the pneumococcal conjugate vaccine resulted in a 95.3% reduction of Streptococcus pneumoniae bacteremia, decreasing from 74.5 to 10 to 3.5 per 100 000 children per year by the post-PCV13 period. As pneumococcal rates decreased, Escherichia coli, Salmonella spp, and Staphylococcus aureus caused 77% of bacteremia. Seventy-six percent of all bacteremia in the post-PCV13 period occurred with a source.

CONCLUSIONS

In the United States, routine immunizations have made bacteremia in the previously healthy toddler a rare event. As the incidence of pneumococcal bacteremia has decreased, E coli, Salmonella spp, and S aureus have increased in relative importance. New guidelines are needed to approach the previously healthy febrile toddler in the outpatient setting.

Facing the ongoing challenge of the febrile young infant

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2017. Other selected articles can be found online at http://ccforum.com/series/annualupdate2017 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .

Role of PET/CT in Workup of Fever without a Source

Fever without source is a febrile illness without localizing signs or initial obvious cause. Early workup will often include chest radiography and computed tomography (CT) of the abdomen and pelvis, with or without CT of the chest. To evaluate localizing signs or symptoms or to further evaluate findings from initial studies, targeted imaging according to body part can be performed by using radiography, ultrasonography, CT, or magnetic resonance (MR) imaging. Nuclear medicine studies can provide imaging of the whole body and may be helpful when the clinical and conventional imaging workup findings are negative or equivocal in identifying a source of fever. Nuclear medicine studies can be used to detect pathologic changes early in a disease course, even in the absence of an anatomic abnormality. Gallium 67 scintigraphy, indium 111- and technetium 99m-labeled leukocyte scintigraphy, and fluorine 18 fluorodeoxyglucose positron emission tomography (PET)/CT studies are all useful in the evaluation of fever, but the radiopharmaceutical cost for PET/CT is much lower than that for radiolabeled leukocyte studies. The increased use of bundled payments for inpatient admissions requires updated cost evaluations for the preferred nuclear medicine study. For inpatients in whom the findings from the initial clinical workup and imaging studies are nondiagnostic, PET/CT examination may be preferable to radiolabeled leukocyte studies because of its high sensitivity and lower cost. Negative findings at PET/CT can be helpful in excluding a suspected site of infection, and positive findings at PET/CT can be helpful in confirming a suspected site of infection or in identifying an unexpected cause of fever. (©)RSNA, 2016.

Time to Positivity of Blood Cultures in Infants 0 to 90 Days Old Presenting to the Emergency Department: Is 36 Hours Enough?

BACKGROUND

Continuous monitoring blood culture systems (CMBCS) now allow for more rapid detection of microbial growth. We aimed to determine whether a 36-hour period was sufficient to detect all blood cultures positive for pathogenic bacteria in infants 0 to 90 days old undergoing a septic workup in the emergency department of a tertiary care pediatric center.

METHODS

We performed a retrospective study of all positive blood cultures collected in these infants over a 5-year time period (from March 13, 2008 to July 29, 2013). Bottles were incubated in a CMBCS. The time to positivity (TTP) was calculated from time of blood culture registration into the laboratory system to time of Gram stain. Medical charts were reviewed for relevant clinical information. Cultures were classified as pathogenic or contaminant using microorganism type and clinical presentation.

RESULTS

Three thousand five hundred fifty-nine blood cultures were collected. Of these, 98 (2.8%) were positive. Fifty-two (53.1%) were deemed pathogenic and 46 (46.9%) were deemed contaminant, for a true prevalence of bacteremia of 1.5%. At 24, 36, 48, and 50 hours, 87.8% (86 of 98), 96.9% (95 of 98), 99% (97 of 98), and 100% (98 of 98) of all cultures were positive. Considering only pathogenic organisms, 96.1% (50 of 52) and 100% (52 of 52) were positive at 24 and 36 hours. Mean TTP for pathogens and contaminants was 14.40 and 23.18 hours, respectively (P < .001).

CONCLUSIONS

An incubation period of 36 hours is sufficient to detect 100% of blood cultures positive for a pathogenic organism in our population.

Epidemiologic and Microbiologic Characteristics of Occult Bacteremia Among Febrile Children in Southern Israel, Before and After Initiation of the Routine Antipneumococcal Immunization (2005-2012)

BACKGROUND

Little is known about the incidence and dynamics of occult bacteremia (OB) among infants/young children following the introduction of pneumococcal conjugate vaccines (PCVs) into the national immunization program in Israel in 2009-2010. The aim of this study was to characterize the epidemiologic and microbiologic picture of OB among febrile infants/children aged 3-36 months in southern Israel, before and after PCVs introduction.

METHODS

Retrospective study enrolling all infants/young children attending the emergency room of a tertiary medical center in southern Israel with fever without source, discharged, and reported with a positive blood culture.

RESULTS

Of 453 true bacteremias, 89 (19.6%) were defined as OB. OB rate was 0.22%; a significant decrease was recorded in OB rates, with the highest rate during 2005 (0.34%) and the lowest during 2011 (0.15%). OB cases decreased in post-PCV (2010-2012) versus prevaccination period (2005-2009) from 66/22,256 cases (0.3%) to 23/13,213 cases (0.17%; p = 0.03). Most frequent single OB pathogens were Streptococcus pneumoniae, Streptococcus viridans spp., and Kingella kingae (39.3%, 10.1%, and 9.0%, respectively); Enterobacteriaceae spp. were isolated in 10 cases (11.2%). No changes were recorded in S. pneumoniae-OB cases; K. kingae-OB decreased significantly (p = 0.047). None of the S. pneumoniae serotypes isolated during 2011-2012 belonged to 13-valent PCV (PCV13). An increase in non PCV13 serotypes was recorded during 2011-2012 (3/3, 100% vs. 7/32, 21.9%, p = 0.01).

CONCLUSION

OB rates decreased significantly following the introduction of PCVs. S. pneumoniae was the most frequent isolated pathogen in OB, but in lower percentages compared with the medical literature. No PCV13 serotypes were detected as a cause of OB during 2011-2012.

Lack of Accuracy of Biomarkers and Physical Examination to Detect Bacterial Infection in Febrile Infants

OBJECTIVES

The aim of this study was to analyze the usefulness of physical examination, C-reactive protein (CRP), procalcitonin (PCT), white blood cell (WBC) count, and absolute neutrophils counts (ANCs) for the diagnosis of invasive bacterial infections (IBIs) and potentially serious bacterial infections in infants younger than the age of 3 months presenting with fever without source (FWS) to the emergency department (ED).

METHODS

A descriptive retrospective study that includes all infants aged younger than 3 months who presented with FWS to the ED between July 2008 and January 2012. We evaluated diagnostic performance for each test by receiver operating characteristic curve analysis. Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were also calculated.

RESULTS

Three hundred eighteen patients met the inclusion criteria. Eleven bacteremia (3.5%) and 76 urinary tract infections (23.9%) were diagnosed. To detect IBI, the areas under the curve for the different tests were as follows: PCT, 0.77 (95% confidence interval [CI], 0.57-0.96); CRP, 0.54 (95% CI, 0.36-0.73); ANC, 0.53 (95% CI, 0.34-0.71); and WBC, 0.42 (0.24-0.61). To detect potentially serious bacterial infections, the areas under the curve were as follows: PCT, 0.66 (95% CI, 0.59-0.74); CRP, 0.68 (0.60-0.76); ANC, 0.64 (0.56-0.71); and WBC, 0.66 (0.58-0.72).

CONCLUSIONS

Procalcitonin is better than CRP, WBC, and ANC to confirm or dismiss the presence of an IBI in infants aged younger than 3 months presenting with FWS to the ED. However, it could not identify almost 30% of infants with IBI. Most patients diagnosed with IBI (10 of 11) presented abnormal values in at least one of the analytical parameters and/or physical appearance. Four of 5 patients with IBI and well appearing presented abnormal results in at least one of the analytical parameters. Therefore, the development of tools combining different tests including the new biomarkers could increase the reliability of the tests for the diagnosis of IBI in these patients.

[Cost-effectiveness of diagnostic strategies of severe bacterial infection in infants with fever without a source]

INTRODUCTION

Serious bacterial infections in infants under 2-years-of-age with fever without a source remains, despite advances in vaccination, a matter of concern for both physicians and parents. Having cost-effectiveness information is relevant to guide decision making in clinical practice in this scenario. Objective: To determine the cost-effectiveness of four different strategies of screening in Argentina for serious bacterial infection in children presenting with fever without a source. Materials and methods: We designed a decision tree to model a hypothetical cohort of 10,000 children with fever without a source. We compared the incremental cost-effectiveness of four strategies to detect serious bacterial infection: Rochester criteria + C reactive protein test, Rochester criteria + procalcitonin test, Rochester criteria, and expectant observation. Results: Rochester criteria + C reactive protein test was the most cost-effective strategy with USD$ 784 for each correctly diagnosed case versus USD$ 839 of Rochester criteria + procalcitonin test, USD$ 1,116 of expectant observation or USD$ 1,193 of Rochester criteria. When the probability of serious bacterial infections was equal or less than 14%, the strategy of choice was expectant observation. Conclusions: The Rochester criteria + C reactive protein test was the most cost-effective strategy to detect serious bacterial infection in one to three months old children with fever without a source. However, in low risk settings for such infection, the strategy of choice is expectant observation.

The Epidemiologic, Microbiologic and Clinical Picture of Bacteremia among Febrile Infants and Young Children Managed as Outpatients at the Emergency Room, before and after Initiation of the Routine Anti-Pneumococcal Immunization

We described the occult bacteremia (OB) and bacteremia with diagnosed focus (BwF) picture among children managed as outpatients at the pediatric emergency room (PER) in southern Israel, before and after the introduction of pneumococcal conjugate vaccines (PCVs) introduction in a retrospective study enrolling all three- to 36-month-old patients with fever >38.0 °C during 2005–2014. Of 511 (0.82% of all febrile patients) true bacteremias, 230 (45%) were managed as outpatients; 96 of 230 (41.7%) had OB and 134 (3.59%) had BwF. OB and BwF rates were 0.22% and 3.02%, respectively. A significant decrease was noted in OB and BwF rates (p = 0.0008 and p = 0.02, respectively). S. pneumoniae (SP, 37.5%), K. kingae (11.4%) and Brucella spp. (8.7%) were the most common OB pathogens and SP (29.8%), S. viridans (13.4%), and Brucella spp. (12.7%) were the most common in BwF patients. PCV13 serotypes were not found among the serotypes isolated post-PCV13 introduction. During 2010–2014 there was an increase in non-PCV13 serotype isolation (p = 0.005). SP was the main pathogen isolated among patients with pneumonia, acute otitis media (AOM) and periorbital cellulitis (62.5%, 33.3% and 60%, respectively). OB and BwF decreased following the introduction of PCVs and SP was the main pathogen in both conditions. Vaccine-SP serotypes were not isolated in OB after PCV13 introduction and non-vaccine serotypes increased significantly.

National Survey on the Impact of Viral Testing for the ED and Inpatient Management of Febrile Young Infants

OBJECTIVE

Well-appearing febrile infants with viral illnesses cannot be distinguished from those with occult life-threatening infections. Infants with respiratory viruses are less likely to have serious bacterial infections; however, current risk-stratification criteria predate widespread viral testing and there are limited data to safely inform physician management with this now common diagnostic tool. This study sought to explore the possible impact of respiratory virus testing on clinical decision-making for the management of febrile young infants<6 weeks old.

METHODS

A scenario-based survey was sent to emergency department (ED) and inpatient physicians at all 16 Canadian tertiary pediatric centers. Participants were asked questions regarding management decisions with and without results of respiratory virus testing.

RESULTS

Response rate was 78% (n=330; 190 ED, 140 inpatient). Detection of a respiratory virus reduced admission rates among 3-week-old (83% vs 95%, P<.001) and 5-week-old infants (36% vs 52%, P<.001). Similarly, empirical antibiotic treatment was decreased by detection of a respiratory virus for 3-week-old (65% vs 92%, P<.001) and 5-week-old infants (25% vs 39%, P<.001). Management of 5-week-old infants differed between ED and inpatient physicians, both in the presence and absence of a respiratory virus. There was no consensus among inpatient physicians regarding admission duration for well infants with a detectable respiratory virus and otherwise negative workup.

CONCLUSIONS

Respiratory virus testing appears to influence clinical decision-making for febrile infants<6 weeks, reducing both rates of admission and antimicrobial treatment. Important work is needed to better understand how to safely incorporate viral testing for the management of this vulnerable patient population.