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Mukherjee G, Orenstein E, Jain S, Hames N. 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. Pediatr Emerg Care 2023; 39:739-743. [PMID: 36727796 DOI: 10.1097/pec.0000000000002905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Gargi Mukherjee
- From the Department of Pediatrics, Emory University/Children's Healthcare of Atlanta, Atlanta, GA
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Hadhud M, Gross I, Hurvitz N, Ohana Sarna Cahan L, Ergaz Z, Weiser G, Ofek Shlomai N, Eventov Friedman S, Hashavya S. Serious Bacterial Infections in Preterm Infants: Should Their Age Be "Corrected"? J Clin Med 2023; 12:jcm12093242. [PMID: 37176683 PMCID: PMC10178985 DOI: 10.3390/jcm12093242] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/24/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Adjusting the chronological age of preterm infants according to their gestational age is a widely accepted practice in the field of neurodevelopment. It has been suggested for the assessment of preterm infants with suspected infection, but has been poorly validated. Correcting for chronological age is especially critical in infants with a chronological age above 3 months, but a corrected age below 3 months due to the differences in assessment protocols. This study assessed the difference in incidence of serious bacterial infection (SBI) according to chronological and corrected age in preterm infants. A retrospective analysis of pediatric emergency department (PED) presentations was conducted for all 448 preterm infants born in between January 2010 and August 2019. Of the 448 preterm infants, 204 (46%) presented at one of 3 PEDs in Jerusalem, Israel, during their first year of life. Overall, 141 (31.4%) presented with fever and were included in the study. The infants were divided into 3 age groups: 1-corrected age >3 months; 2-chronological age >3 months, but corrected age <3 months; 3-chronological and corrected age <3 months. SBI was diagnosed in 2.6%, 16.7%, and 33.3% of the infants in groups 1, 2 and 3, respectively; (p < 0.01, p = 0.17, p < 0.001). The incidence of SBI in the control group of 300 term infants <3 months presenting to the PED due to fever was 15.3%. Preterm infants with a corrected age <3 months are at increased risk for SBI, similarly to term infants <3 months of age. Age correction should thus be considered for preterm infants presenting with fever.
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Affiliation(s)
- Mohamad Hadhud
- Department of Pediatrics, Hadassa-Hebrew University Medical Center, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Itai Gross
- Department of Pediatric Emergency Medicine, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
- Department of Pediatrics, Hadassah Medical Center, Ein Kerem, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel
| | - Noa Hurvitz
- Department of Pediatrics, Hadassa-Hebrew University Medical Center, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Lea Ohana Sarna Cahan
- Department of Pediatric Emergency Medicine, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Zivanit Ergaz
- Department of Neonatology, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Giora Weiser
- Department of Pediatric Emergency Medicine and Shaare Zedek Medical Center, Jerusalem 91120, Israel
| | - Noa Ofek Shlomai
- Department of Neonatology, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Smadar Eventov Friedman
- Department of Neonatology, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Saar Hashavya
- Department of Pediatric Emergency Medicine, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
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Hallmaier-Wacker LK, Andrews A, Nsonwu O, Demirjian A, Hope RJ, Lamagni T, Collin SM. Incidence and aetiology of infant Gram-negative bacteraemia and meningitis: systematic review and meta-analysis. Arch Dis Child 2022; 107:988-994. [PMID: 35710719 PMCID: PMC9606543 DOI: 10.1136/archdischild-2022-324047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/26/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND One in six infant deaths worldwide are caused by invasive bacterial infections, of which a substantial but unquantified proportion are caused by Gram-negative bacteria. METHODS We conducted a systematic review of studies published from 31 May 2010 to 1 June 2020 indexed in MEDLINE, Embase and Global Health databases. We performed meta-analyses of the incidence of Gram-negative bacteraemia and of individual Gram-negative species as proportions of all infant bacteraemia, stratified by onset (early vs late) and country income (low/middle vs high). RESULTS 152 studies from 54 countries were included, 60 in high-income countries (HIC) and 92 in low-income/middle-income countries (LMIC). Gram-negatives represented a higher proportion (53%, 95% CI 49% to 57%) of all infant bacteraemia in LMIC compared with HIC (28%, 95% CI 25% to 32%). Incidence of infant Gram-negative bacteraemia was 2.01 (95% CI 1.15 to 3.51) per 1000 live births; it was five times higher in LMIC (4.35, 95% CI 2.94 to 6.43) compared with HIC (0.73, 95% CI 0.39 to 7.5). In HIC, Escherichia coli was the leading Gram-negative pathogen, representing 19.2% (95% CI 15.6% to 23.4%) of early and 7.3% (95% CI 5.3% to 10.1%) of all late-onset bacteraemia; Klebsiella spp were the next most common cause (5.3%) of late-onset bacteraemia. In LMIC, Klebsiella spp caused 16.4% (95% CI 11.5% to 22.7%) of early and 15.0% (95% CI 10.1% to 21.8%) of late-onset bacteraemia, followed by E. coli (early-onset 7.50%, 95% CI 4.98% to 11.1%; late-onset 6.53%, 95% CI 4.50% to 9.39%) and Pseudomonas spp (early-onset 3.93%, 95% CI 2.04% to 7.44%; late-onset 2.81%, 95% CI 1.99% to 3.95%). CONCLUSION E. coli, Klebsiella and Pseudomonas spp cause 20%-28% of early-onset infant bacteraemia and 14% cases of infant meningitis worldwide. Implementation of preventive measures could reduce the high incidence of Gram-negative bacteraemia in LMIC. PROSPERO REGISTRATION NUMBER CRD42020191618.
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Affiliation(s)
- Luisa K Hallmaier-Wacker
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use, and Sepsis Division, UK Health Security Agency (UKHSA), London, UK
| | - Amelia Andrews
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use, and Sepsis Division, UK Health Security Agency (UKHSA), London, UK
| | - Olisaeloka Nsonwu
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use, and Sepsis Division, UK Health Security Agency (UKHSA), London, UK
| | - Alicia Demirjian
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use, and Sepsis Division, UK Health Security Agency (UKHSA), London, UK
- Evelina London Children's Hospital, London, UK
- Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Russell J Hope
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use, and Sepsis Division, UK Health Security Agency (UKHSA), London, UK
| | - Theresa Lamagni
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use, and Sepsis Division, UK Health Security Agency (UKHSA), London, UK
| | - Simon M Collin
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use, and Sepsis Division, UK Health Security Agency (UKHSA), London, UK
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Epidemiology of serious bacterial infection in febrile infants under 3 months of age and diagnostic management in Mayotte. Arch Pediatr 2021; 28:553-558. [PMID: 34400055 DOI: 10.1016/j.arcped.2021.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 04/06/2021] [Accepted: 06/13/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE This study aimed to determine the prevalence of serious bacterial infections (SBIs) in infants less than 90 days old presenting with fever on arrival at the emergency department (ED), and to assess the diagnostic management of febrile infants. DESIGN A retrospective study at Mamoudzou Hospital, Mayotte Island, French Department. SETTING General ED in the only pediatric hospital throughout the territory PATIENTS: We included infants less than 90 days old with a history of fever and bacterial investigation evaluated in the ED between 2016 and 2018. We excluded preterm infants (gestational age < 37 weeks) and those with known immunodeficiency or previous administration of antibiotics. RESULTS A total of 594 infants were included. In all, 105 infants (17.7%) were diagnosed with an SBI and 28 (4.7%) with an invasive bacterial infection of which 1.34% was meningitis. The most frequent SBI was pneumonia (n = 69, 11.6%) followed by urinary tract infection (UTI; n = 37, 6.2%). Predominant pathogens (excluding contaminants) were Escherichia coli (51.2% of the UTI cases), group B Streptococcus (62.5% of meningitis cases), and Staphylococcus aureus (61.5% of bacteremia cases). Seven infants presented with bacterial pneumonia due to Staphylococcus aureus with Panton-Valentine leucocidin (PVL) exotoxin production. Ill-appearing infants, clinical signs of SBI and complex chronic condition were associated with a risk of SBI (respective odds ratio [OR]: 4.6, 95% confidence interval [CI]: 3-6.9; OR: 4.2, 95% CI: 2.8-6.4; and OR: 3.2, 95% CI: 1.2-8.5). The median age for SBI was 42 days (5-90). Fever without source (FWS) occurred more often in infants under 21 days of age (48.5% vs. 31.3% in older infants, p < 0.001). The median duration of fever at home was 24 h (6-96). Concerning management, in infants aged under 21 days, there were more lumbar punctures (58.3% vs. 23% in older infants, p < 0.001) and more frequent initiation of empiric antibiotics (62.6% vs. 42.7%, p < 0.001). Length of stay was also longer in this age range (5 days vs. 3 days, p = 0.037). CONCLUSION Delay in medical consultation in the case of fever, the risk of SBI regardless of age, and unusual epidemiology with many IBI due to Staphylococcus aureus with PVL exotoxin production are specific characteristics observed in our study. Knowledge of the current epidemiology of SBI in Mayotte would be useful for setting up a risk-stratified protocol in this population in the future.
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Liu CE, Pan YM, Du ZL, Wu C, Hong XY, Sun YH, Li HF, Liu J. Composition characteristics of the gut microbiota in infants and young children of under 6 years old between Beijing and Japan. Transl Pediatr 2021; 10:790-806. [PMID: 34012829 PMCID: PMC8107842 DOI: 10.21037/tp-20-376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The composition of intestinal flora in Chinese and Japanese has been reported in many studies but that in infants aged 0-6 years old has not been studied yet. METHODS The distribution characteristics of the fecal flora of infants in Beijing (n=84) and Japan (n=53) were analyzed using 16S rRNA gene sequencing analysis. RESULTS This study showed the higher relative abundance of Erysipelotrichaceae_ UCG-003 and Anaerostipes in male group that of Ruminiclostridium, Eubacterium, Senegalimassilia and Senegalimassilia in female group, especially Senegalimassilia, which was not detected in male group. Defecation trait groups indicated significantly higher relative abundance of Bifidobacterium in abnormal bowel trait group than that in the normal group (P<0.05). The feeding groups' analysis showed significantly higher relative abundance of Bifidobacterium and Enterococcus and lower abundance of Bacteroides and Lacetospirillaceae in the breast-feeding group than that in the formula feeding and mixed-feeding groups. The relative abundance of Parasutterella and Ruminococcaceae_UCG-003 in the halitosis group was significantly higher than that in the normal group. The comparison of cold and fever group and normal group indicated significantly higher relative abundance of Erysipelatoclostridium and lower relative abundance of Lachnospiraceae _UCG-001 in the fever and cold group than that in the normal group (P<0.05). The regional comparison of intestinal flora of Beijing and Japan showed significant increase in the relative abundance of Bacillus, Lactobacillus, Prevotella, megamonas and Veillonella in the intestinal flora of 0-6 years old infants in Beijing. CONCLUSIONS These findings improve the understanding of intestinal bacterial and viral communities of infants from the two Asian countries.
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Affiliation(s)
- Chang-E Liu
- Department of Nutrition, the Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yuan-Ming Pan
- Department of Gastroenterology, the Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhen-Lan Du
- Department of Hematology and Oncology, Faculty of Pediatrics, Chinese PLA General Hospital, Beijing, China
| | - Cong Wu
- Department of Nutrition, the Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiao-Yang Hong
- Department of Critical Care Medicine, Faculty of Pediatrics, Chinese PLA General Hospital, Beijing, China
| | - Yan-Hui Sun
- Department of Nutrition, the Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hai-Feng Li
- Department of Health Services, the Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jie Liu
- Department of Laboratory, the Seventh Medical Center of PLA General Hospital, Beijing, China
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