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Velasco R, Gomez B, Labiano I, Mier A, Ugedo A, Benito J, Mintegi S. Performance of Febrile Infant Algorithms by Duration of Fever. Pediatrics 2024; 153:e2023064342. [PMID: 38563061 DOI: 10.1542/peds.2023-064342] [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] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVES To analyze the performance of commonly used blood tests in febrile infants ≤90 days of age to identify patients at low risk for invasive bacterial infection (bacterial pathogen in blood or cerebrospinal fluid) by duration of fever. METHODS We conducted a secondary analysis of a prospective single-center registry that includes all consecutive infants ≤90 days of age with fever without a source evaluated at 1 pediatric emergency department between 2008 and 2021. We defined 3 groups based on caregiver-reported hours of fever (<2, 2-12, and ≥12) and analyzed the performance of the biomarkers and Pediatric Emergency Care Applied Research Network, American Academy of Pediatrics, and Step-by-Step clinical decision rules. RESULTS We included 2411 infants; 76 (3.0%) were diagnosed with an invasive bacterial infection. The median duration of fever was 4 (interquartile range, 2-12) hours, with 633 (26.3%) patients with fever of <2 hours. The area under the curve was significantly lower in patients with <2 hours for absolute neutrophil count (0.562 vs 0.609 and 0.728) and C-reactive protein (0.568 vs 0.760 and 0.812), but not for procalcitonin (0.749 vs 0.780 and 0.773). Among well-appearing infants older than 21 days and negative urine dipstick with <2 hours of fever, procalcitonin ≥0.14 ng/mL showed a better sensitivity (100% with specificity 53.8%) than that of the combination of biomarkers of Step-by-Step (50.0% and 82.2%), and of the American Academy of Pediatrics and Pediatric Emergency Care Applied Research Network rules (83.3% and 58.3%), respectively. CONCLUSIONS The performance of blood biomarkers, except for procalcitonin, in febrile young infants is lower in fever of very short duration, decreasing the accuracy of the clinical decision rules.
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Affiliation(s)
- Roberto Velasco
- Pediatric Emergency Unit, Hospital Universitari Parc Tauli, Institut d'Investigació i Innovació I3PT, Sabadell, Spain
- Department of Paediatrics & Child Health, University College Cork (UCC), Cork, Ireland
| | - Borja Gomez
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Ismael Labiano
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Ana Mier
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Alberto Ugedo
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
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Darishetty G, Kompally V, Nagajyothi VUV, Bukkapatnam SB, Gudi P, Alugoya A. Exploring Acute Febrile Illness in Children: Clinical Characteristics and Diagnostic Challenges. Cureus 2024; 16:e58315. [PMID: 38752054 PMCID: PMC11094522 DOI: 10.7759/cureus.58315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
Background Pediatric febrile illnesses are a major cause of hospital admissions and are often associated with significant morbidity and mortality. These illnesses pose a diagnostic challenge to both clinicians and laboratories. This study aims to explore the clinical characteristics of acute febrile illness in children and examine the effectiveness of various diagnostic techniques. Methods This prospective study was carried out at the Mahatma Gandhi Memorial Hospital, Warangal, India, from January 2020 to October 2022. It included children aged one month to 12 years. Results Out of 245 identified cases, 195 met the inclusion criteria. This study found that 18 patients (9.23%) suffered from serious bacterial infections (SBIs). In 63 patients (32.20%), the source of infection remained unidentified. Among those with SBI, UTIs were the most frequent. Bacteremia was identified in 2.5% of the patients. Conclusion SBIs were identified in 18 hospitalized children (9.23%), with UTIs being the most common SBI in children aged one to 36 months. Children in this age group presenting with toxic symptoms should be thoroughly evaluated for SBIs. The study also observed a higher prevalence of Gram-negative bacteremia compared to Gram-positive cases.
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Affiliation(s)
| | - Vasudev Kompally
- Department of Pediatrics, Kakatiya Medical College, Hanamkonda, IND
| | | | | | - Pratap Gudi
- Department of Pediatrics, Kakatiya Medical College, Hanamkonda, IND
| | - Arun Alugoya
- Department of Pediatrics, Kakatiya Medical College, Hanamkonda, IND
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Bernardi L, Bossù G, Dal Canto G, Giannì G, Esposito S. Biomarkers for Serious Bacterial Infections in Febrile Children. Biomolecules 2024; 14:97. [PMID: 38254697 PMCID: PMC10813546 DOI: 10.3390/biom14010097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Febrile infections in children are a common cause of presentation to the emergency department (ED). While viral infections are usually self-limiting, sometimes bacterial illnesses may lead to sepsis and severe complications. Inflammatory biomarkers such as C reactive protein (CRP) and procalcitonin are usually the first blood exams performed in the ED to differentiate bacterial and viral infections; nowadays, a better understanding of immunochemical pathways has led to the discovery of new and more specific biomarkers that could play a role in the emergency setting. The aim of this narrative review is to provide the most recent evidence on biomarkers and predictor models, combining them for serious bacterial infection (SBI) diagnosis in febrile children. Literature analysis shows that inflammatory response is a complex mechanism in which many biochemical and immunological factors contribute to the host response in SBI. CRP and procalcitonin still represent the most used biomarkers in the pediatric ED for the diagnosis of SBI. Their sensibility and sensitivity increase when combined, and for this reason, it is reasonable to take them both into consideration in the evaluation of febrile children. The potential of machine learning tools, which represent a real novelty in medical practice, in conjunction with routine clinical and biological information, may improve the accuracy of diagnosis and target therapeutic options in SBI. However, studies on this matter are not yet validated in younger populations, making their relevance in pediatric precision medicine still uncertain. More data from further research are needed to improve clinical practice and decision making using these new technologies.
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Affiliation(s)
| | | | | | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.B.); (G.B.); (G.D.C.); (G.G.)
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Grief MM, Yamamoto LG. Approach to the Febrile Infant (<3 Months). Pediatr Emerg Care 2023; 39:875-879. [PMID: 37902653 DOI: 10.1097/pec.0000000000003064] [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: 10/31/2023]
Abstract
ABSTRACT Evaluation and management of the febrile infant has long been an area of variability. Recent guidelines were released by the American Academy of Pediatrics in August 2021 to help provide evidence-based clinical guidelines to decrease variability and improve outcomes.1 These guidelines largely focus on management and treatment guidelines for 3 age groups: 8 to 21 days, 22 to 28 days, and 29 to 60 days. The inclusion criteria for these guidelines are previously healthy, term infants born at 37 weeks gestation or later, with a temperature of 100.4°F (38°C) or higher. The most significant changes to historical practice are in the 22- to 28-day and 29- to 60-day age groups. If initial laboratory work is reassuring, patients may not need cerebrospinal fluid studies, and patients may be monitored at home or at the hospital using shared decision-making with the family.
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Affiliation(s)
| | - Loren G Yamamoto
- Professor of Pediatrics, University of Hawai'i John A. Burns School of Medicine and Kapi'olani Medical Center For Women & Children, Honolulu, HI
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Guo BC, Chen YT, Chang YJ, Chen CY, Lin WY, Wu HP. Predictors of bacteremia in febrile infants under 3 months old in the pediatric emergency department. BMC Pediatr 2023; 23:444. [PMID: 37679686 PMCID: PMC10483716 DOI: 10.1186/s12887-023-04271-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023] Open
Abstract
INTRODUCTION Fever may serve as the primary indicator of underlying infection in children admitted to the pediatric emergency department (PED), especially in high-risk young infants. This study aimed to identify early clinical factors that could help predict bacteremia in young febrile infants. METHODS The study included infants under 90 days of age who were admitted to the PED due to fever. Patients were divided into two groups based on the presence or absence of bacteremia and further divided into three age groups: (1) less than 30 days, (2) 30 to 59 days, and (3) 60 to 90 days. Several clinical and laboratory variables were analyzed, and logistic regression and receiver operating characteristic (ROC) analyses were used to identify potential risk factors associated with bacteremia in young febrile infants. RESULTS A total of 498 febrile infants were included, of whom 6.4% were diagnosed with bacteremia. The bacteremia group had a higher body temperature (BT) at triage, especially in neonates, higher pulse rates at triage, longer fever subsidence time, longer hospital stays, higher neutrophil counts, and higher C-reactive protein (CRP) levels than those of the non-bacteremia group. ROC analysis showed that the best cut-off values for predicting bacteremia in infants with pyrexia were a BT of 38.7 °C, neutrophil count of 57.9%, and CRP concentration of 53.8 mg/L. CONCLUSIONS A higher BT at triage, increased total neutrophil count, and elevated CRP levels may be useful for identifying bacteremia in young febrile infants admitted to the PED.
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Affiliation(s)
- Bei-Cyuan Guo
- Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Yin-Ting Chen
- Division of Neonatology, Department of Pediatrics, Children Hospital, China Medical University, Taichung, Taiwan
| | - Yu-Jun Chang
- Laboratory of Epidemiology and Biostastics, Changhua Christian Hospital, Changhua, Taiwan
| | - Chun-Yu Chen
- Department of Emergency Medicine, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan
| | - Wen-Ya Lin
- Department of Pediatric Emergency Medicine, Department of Pediatrics, Taichung Veteran General Hospital, Taichung, Taiwan
| | - Han-Ping Wu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd, Puzi City, Taiwan.
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Lejarzegi A, Fernandez-Uria A, Gomez B, Velasco R, Benito J, Mintegi S. Febrile Urinary Tract Infection in Infants Less Than 3 Months of Age. Pediatr Infect Dis J 2023:00006454-990000000-00427. [PMID: 37171941 DOI: 10.1097/inf.0000000000003947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
INTRODUCTION Urinary tract infection (UTI) is the leading cause of bacterial infection in infants younger than 3 months of age with fever without a source. OBJECTIVE The objective of the study was to analyze the characteristics of emergency department presentations of febrile infants younger than 3 months of age with a UTI and identify risk factors for invasive bacterial infection (IBI) secondary to UTI. METHODS This was a secondary analysis of a prospective observational registry that includes infants younger than 3 months with fever without a source managed at a pediatric emergency department between 2003 and 2019. RESULTS Of the 2850 patients included, 592 (20.8%) were diagnosed with a UTI (524, 88.5%, for Escherichia coli). Infants with UTIs showed significant clinical differences when compared with those not diagnosed with a bacterial infection: patients with a UTI were more likely to have a history of renal/urological problems (8.3% vs. 3.5%), temperature ≥39ºC (38.3% vs. 29%) and poor feeding (13% vs. 8.7%). Yet, nearly half (285 of the 592, 48.1%) of the infants with febrile UTIs had none of these 3 risk factors. Thirty-six infants (6.1%) had a secondary IBI. We identified the following independent risk factors for secondary IBI: infants younger than 1 month of age, parent-reported irritability, procalcitonin >0.5 ng/mL, and C-reactive protein >60 mg/L. CONCLUSIONS History and physical examination do not allow us to safely rule out a UTI among young febrile infants. Age, parent-reported irritability, and biomarkers are useful in identifying patients at increased risk of secondary IBI.
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Affiliation(s)
- Ainara Lejarzegi
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
| | - Amaia Fernandez-Uria
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
| | - Borja Gomez
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
| | - Roberto Velasco
- Pediatric Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Javier Benito
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
| | - Santiago Mintegi
- From the Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU. Bilbao, Basque Country, Spain
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Karakaya D, Güngör T, Cakıcı EK, Yazılıtaş F, Celikkaya E, Bulbul M. Determining the effectiveness of the immature granulocyte percentage and systemic immune-inflammation index in predicting acute pyelonephritis. Postgrad Med 2023; 135:155-160. [PMID: 36472407 DOI: 10.1080/00325481.2022.2152970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM The most serious form of urinary tract infection (UTI) is acute pyelonephritis (APN), which can result in bacteremia and renal scarring. This study aims to show the roles that the systemic immune-inflammation index (SII) and the immature granulocyte (IG) percentage play in predicting APN in pediatric patients by comparing them with traditional infection markers. By illustrating a significant relationship between APN, the IG percentage, and the SII, the study's contributions to the differential diagnosis of UTI can promote a rapid and appropriate treatment of APN. MATERIAL AND METHODS The present study included 522 pediatric patients. The patients were divided into two groups: (I) an APN group (n = 236) and (II) a lower UTI group (n = 286). RESULTS The mean age of the sample was 5.05 ± 4.7 years. According to the most appropriate cutoff values, the findings showed that among all the parameters, C-reactive protein (CRP) and the IG percentage had the highest sensitivities, specificities, and predictive values for predicting APN. CONCLUSION This study emphasizes the support features of the IG percentage and the SII in the diagnosis of APN in pediatric patients, a topic that has recently attracted attention. The findings indicated that among all of the parameters behind CRP, the IG percentage and the SII had the highest sensitivities, specificities, and predictive values for forecasting APN. It is worth noting that these methods can be applied without additional costs or burdens to the patient.
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Affiliation(s)
- Deniz Karakaya
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Tülin Güngör
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Evrim Kargın Cakıcı
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Fatma Yazılıtaş
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Evra Celikkaya
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Mehmet Bulbul
- Department of Pediatric Nephrology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
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Ferreira M, Santos M, Rodrigues J, Diogo C, Resende C, Baptista C, Faria C. Epidemiology of bacteremia in a pediatric population - A 10-year study. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2023; 41:85-91. [PMID: 36759058 DOI: 10.1016/j.eimce.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/05/2021] [Indexed: 02/09/2023]
Abstract
INTRODUCTION With the widespread introduction of conjugate meningococcal and pneumococcal vaccines, the prevalence and etiology of invasive bacterial infections have changed. We aimed to review all cases of bacteremia in a level II pediatric department over a ten-year period in the post-pneumococcal conjugate vaccine era. METHODS We reviewed all positive blood cultures (BC) obtained in our department between 2007 and 2016. Results were classified as contaminants, potential pathogens or confirmed pathogens, based on species, number of positive BC in the episode and the patients' medical history. Demographic and clinical data were collected for patients with identified pathogens. RESULTS A total of 638 positive BC were identified (6.6% of total BC); 120 (1.2%) were considered to represent true bacteremia. The most frequently identified microorganism was Streptococcus pneumoniae (29.2%), with a decrease in the number of cases between 2008 and 2015. Staphylococcus aureus was the second most common organism (19.2%) being 21.7% of these methicillin-resistant. Escherichia coli was the most common isolate in children aged less than three months. CONCLUSION We found a rate of true bacteremia in children similar to recent studies. Although Streptococcus pneumoniae remains the most common microorganism, its prevalence may be declining. Monitoring microbiological data in children has implications in practice, particularly in local antibiotic prescription.
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Affiliation(s)
- Mariana Ferreira
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal.
| | - Mafalda Santos
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Jorge Rodrigues
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Clara Diogo
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Catarina Resende
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Cristina Baptista
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Cristina Faria
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
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Greenhow TL, Nguyen THP, Young BR, Alabaster A. Following Birth Hospitalization: Invasive Bacterial Infections in Preterm Infants Aged 7-90 Days. J Pediatr 2023; 252:171-176.e2. [PMID: 35970237 DOI: 10.1016/j.jpeds.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/20/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the incidence rate of invasive bacterial infections in preterm infants and compare invasive bacterial infection rates and pathogens between preterm and full-term infants at age 7-90 days. STUDY DESIGN This is a retrospective cohort study of the incidence rate of invasive bacterial infections among all infants born at Kaiser Permanente Northern California (KPNC), with blood and cerebrospinal fluid cultures collected between 7 and 90 days of chronological age from outpatient clinics, from emergency departments, and in the first 24 hours of hospitalization presenting for care between January 1, 2005, and December 31, 2017. Incidence rates of invasive bacterial infection by chronological age and postmenstrual age (PMA) and pathogens were compared between preterm and full-term infants. RESULTS Between January 1, 2005, and December 31, 2017, a total of 479 729 infants were born at KPNC, including 440 070 full-term infants and 39 659 preterm infants. There were 283 cases of bacteremia in 282 infants. The incidence rate of invasive bacterial infection was significantly higher for preterm infants compared with full-term infants. The highest incidence rates of invasive bacterial infection were in preterm infants at chronological age 7-28 days and/or 37-39 weeks PMA. There was a trend toward lower rates of invasive bacterial infection with increasing PMA in preterm infants aged 61-90 days. Preterm infants aged 29-60 days or at ≥40 weeks PMA and those aged 61-90 days or at ≥43 weeks PMA had a rate of invasive bacterial infection equivalent to the overall rate seen in full-term infants of the same chronological age group. The distribution of pathogens causing bacteremia and meningitis did not differ between preterm and full-term infants. CONCLUSION PMA and chronological age together were more useful than either alone in informing the incidence rate of invasive bacterial infection in preterm infants during the first 90 days of life.
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Affiliation(s)
- Tara L Greenhow
- Department of Pediatrics, Division Infectious Diseases, Kaiser Permanente Northern California, San Francisco, CA.
| | - Tran H P Nguyen
- Department of Pediatric Hospital Medicine, Kaiser Permanente Northern California, Roseville, CA
| | - Beverly R Young
- Department of Pediatric Hospital Medicine, Kaiser Permanente Northern California, Roseville, CA
| | - Amy Alabaster
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Li SY, Yin CH, Chen JS, Chen YS, Yang CC, Fang NW, Wang HP, Chiou YH. A nomogram for predicting the development of serious bacterial infections in febrile term neonates: A single medical center experience in Southern Taiwan. Pediatr Neonatol 2022; 63:605-612. [PMID: 36008242 DOI: 10.1016/j.pedneo.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/04/2022] [Accepted: 07/07/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Serious bacterial infections (SBIs) could lead to mortality or severe long-term sequelae in neonates and infants aged <3 months. Accordingly, the aim of this study was to develop a quantitative and accurate assessment tool for predicting the risk of SBIs in febrile neonates. METHODS This retrospective study enrolled 131 febrile term neonates (aged <30 days) who were hospitalized at Kaohsiung Veterans General Hospital between January 2005 and December 2020. These neonates were classified into SBI and nonbacterial infection (NBI) groups on the basis of microbiological laboratory reports. The clinical characteristics and routine blood tests of both groups at the time of admission were analyzed. Stepwise logistic regression was applied to create and validate the nomogram for SBI prediction. RESULTS Among the 131 febrile neonates, 38 and 93 developed SBIs and NBIs, respectively. At the time of admission, ill clinical appearance, serum myelocyte/metamyelocyte presence, C-reactive protein (CRP) > 2.5 mg/dL, and pyuria were associated with an increased risk of SBIs. Accordingly, these four factors were used to develop a nomogram for SBI prediction, which exhibited significantly high performance (area under curve = 0.848, p < 0.001) in predicting SBI risk. CONCLUSION We developed a nomogram combining clinical appearance, serum myelocyte/metamyelocyte presence, CRP, and pyuria for predicting SBI risk in febrile neonates. This tool can assist clinicians in making early diagnoses and delivering the appropriate treatment.
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Affiliation(s)
- Shin-Ying Li
- Division of Pediatric Neonatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chun-Hao Yin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Taiwan; Institute of Health Care Management, National Sun Yat-sen University, Taiwan
| | - Jin-Shuen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Taiwan
| | - Yao-Shen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Taiwan
| | - Chih-Chieh Yang
- Division of Pediatric Neonatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Nai-Wen Fang
- Division of Pediatric Nephrology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hsiao-Ping Wang
- Division of Pediatric Neonatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yee-Hsuan Chiou
- Division of Pediatric Nephrology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Medical Laboratory Science and Biotechnology, Fooyin University, Kaohsiung, Taiwan.
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Jain PN, Lerer R, Choi J, Dunbar J, Eisenberg R, Hametz P, Nassau S, Katyal C. Discrepancies Between the Management of Fever in Young Infants Admitted From Urban General Emergency Departments and Pediatric Emergency Departments. Pediatr Emerg Care 2022; 38:358-362. [PMID: 35507367 DOI: 10.1097/pec.0000000000002740] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | | | - Jaeun Choi
- Albert Einstein College of Medicine, Bronx, NY
| | | | | | | | - Stacy Nassau
- Florida Center for Allergy and Asthma, Miami, FL
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Molyneaux ND, Liang TZ, Chao JH, Sinert RH. Rochester Criteria and Yale Observation Scale Score to Evaluate Febrile Neonates with Invasive Bacterial Infection. J Emerg Med 2022; 63:159-168. [PMID: 35691767 DOI: 10.1016/j.jemermed.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/26/2021] [Accepted: 10/12/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Febrile neonates undergo lumbar puncture (LP), empiric antibiotic administration, and admission for increased risk of invasive bacterial infection (IBI), defined as bacteremia and meningitis. OBJECTIVE Measure IBI prevalence in febrile neonates, and operating characteristics of Rochester Criteria (RC), Yale Observation Scale (YOS) score, and demographics as a low-risk screening tool. METHODS Secondary analysis of healthy febrile infants < 60 days old presenting to any of 26 emergency departments in the Pediatric Emergency Care Applied Research Network between December 2008 and May 2013. Of 7334 infants, 1524 met our inclusion criteria of age ≤ 28 days. All had fevers and underwent evaluation for IBI. Receiver operator characteristic (ROC) curve and transparent decision tree analysis were used to determine the applicability of reassuring RC, YOS, and age parameters as an IBI low-risk screening tool. RESULTS Of 1524 neonates, 2.9% had bacteremia and 1.5% had meningitis. After applying RC and YOS, 15 neonates were incorrectly identified as low risk for IBI (10 bacteremia, 4 meningitis, 1 bacteremia, and meningitis). Age ≤ 18 days was a statistically significant variable ROC (area under curve 0.63, p < 0.05). Incorporating age > 18 days as low-risk criteria with reassuring RC and YOS misclassified 7 IBI patients (6 bacteremia, 1 meningitis). CONCLUSION Thirty percent of febrile neonates met low-risk criteria, age > 18 days, reassuring RC and YOS, and could avoid LP and empiric antibiotics. Our low-risk guidelines may improve patient safety and reduce health care costs by decreasing lab testing for cerebrospinal fluid, empiric antibiotic administration, and prolonged hospitalization. These results are hypothesis-generating and should be verified with a randomized prospective study.
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Affiliation(s)
- Neh D Molyneaux
- State University of New York Downstate Medical Center, Brooklyn, New York; Kings County Hospital New York Health and Hospitals, Brooklyn, New York
| | - Tian Z Liang
- State University of New York Downstate Medical Center, Brooklyn, New York; Kings County Hospital New York Health and Hospitals, Brooklyn, New York
| | - Jennifer H Chao
- State University of New York Downstate Medical Center, Brooklyn, New York; Kings County Hospital New York Health and Hospitals, Brooklyn, New York
| | - Richard H Sinert
- State University of New York Downstate Medical Center, Brooklyn, New York; Kings County Hospital New York Health and Hospitals, Brooklyn, New York
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13
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Waterfield T, Lyttle MD, Munday C, Foster S, McNulty M, Platt R, Barrett M, Rogers E, Durnin S, Jameel N, Maney JA, McGinn C, McFetridge L, Mitchell H, Puthucode D, Roland D. Validating clinical practice guidelines for the management of febrile infants presenting to the emergency department in the UK and Ireland. Arch Dis Child 2022; 107:329-334. [PMID: 34531196 DOI: 10.1136/archdischild-2021-322586] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/03/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To report the performance of clinical practice guidelines (CPG) in the diagnosis of serious/invasive bacterial infections (SBI/IBI) in infants presenting with a fever to emergency care in the UK and Ireland. Two CPGs were from the National Institutes for Health and Care Excellence (NICE guidelines NG51 and NG143) and one was from the British Society for Antimicrobial Chemotherapy (BSAC). DESIGN Retrospective multicentre cohort study. PATIENTS Febrile infants aged 90 days or less attending between the 31 August 2018 to 1 September 2019. MAIN OUTCOME MEASURES The sensitivity, specificity and predictive values of CPGs in identifying SBI and IBI. SETTING Six paediatric Emergency Departments in the UK/Ireland. RESULTS 555 participants were included in the analysis. The median age was 53 days (IQR 32 to 70), 447 (81%) underwent blood testing and 421 (76%) received parenteral antibiotics. There were five participants with bacterial meningitis (1%), seven with bacteraemia (1%) and 66 (12%) with urinary tract infections. The NICE NG51 CPG was the most sensitive: 1.00 (95% CI 0.95 to 1.00). This was significantly more sensitive than NICE NG143: 0.91 (95% CI 0.82 to 0.96, p=0.0233) and BSAC: 0.82 (95% 0.72 to 0.90, p=0.0005). NICE NG51 was the least specific 0.0 (95% CI 0.0 to 0.01), and this was significantly lower than the NICE NG143: 0.09 (95% CI 0.07 to 0.12, p<0.0001) and BSAC: 0.14 (95% CI 0.1 to 0.17, p<0.0001). CONCLUSION None of the studied CPGs demonstrated ideal performance characteristics. CPGs should be improved to guide initial clinical decision making. TRIAL REGISTRATION NUMBER NCT04196192.
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Affiliation(s)
- Thomas Waterfield
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Charlotte Munday
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Steven Foster
- Emergency Department, Royal Hospital for Children, Glasgow, UK
| | - Marc McNulty
- Emergency Department, Royal Hospital for Children, Glasgow, UK
| | - Rebecca Platt
- Emergency Department, Barts Health NHS Trust, London, UK
| | - Michael Barrett
- Emergency Department, Children's Health Ireland at Crumlin, Crumlin, Ireland.,Women's and Children's Health, School of Medicine, University College Dublin, Dublin, Ireland
| | - Emma Rogers
- Emergency Department, Children's Health Ireland at Crumlin, Crumlin, Ireland
| | - Sheena Durnin
- Emergency Department, Children's Health Ireland at Tallaght, Dublin, Ireland.,Discipline of Paediatrics, Trinity College, University of Dublin, Dublin, Ireland
| | - Nida Jameel
- Emergency Department, Children's Health Ireland at Tallaght, Dublin, Ireland
| | - Julie-Ann Maney
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Claire McGinn
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Lisa McFetridge
- Mathematical Sciences Research Centre, Queen's University Belfast, Belfast, UK
| | - Hannah Mitchell
- Mathematical Sciences Research Centre, Queen's University Belfast, Belfast, UK
| | - Deepika Puthucode
- Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Damian Roland
- Department of Health Sciences, University of Leicester, Leicester, UK.,Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK
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14
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Outpatient and oral management is suitable for infants 60-90 days old with urinary tract infections at low risk of bacteremia. Eur J Pediatr 2022; 181:671-677. [PMID: 34519852 DOI: 10.1007/s00431-021-04224-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
One previous study recommended oral and outpatient management for those infants aged 60-90 days with urinary tract infection (UTI) meeting the low-risk criteria identified: to be well-appearing and to have a procalcitonin value of < 0.7 ng/mL. A retrospective study was conducted, including infants aged 29 to 90 days with UTI from 2014 to 2019, to validate these low-risk criteria identified and determine the adherence to the new algorithm for managing these patients at the Emergency Department. Two hundred one patients were included; 105 (52.2%) were aged 60 to 90 days. Twelve (6%, 95% CI 3.4-10.1%) had bacteremia. One hundred thirty-six (67.7%) infants met low-risk criteria; none had a positive blood culture (0%, 95% CI 0-2.7%). Overall protocol adherence was 90.6%. One hundred and forty-four (71.6%) infants were admitted to the hospital; all patients meeting high-risk criteria were hospitalized. Among the 57 (28.4%) infants initially sent home, 4 (7.0%) required later hospital admission.Conclusions: A prediction rule including general appearance and procalcitonin is highly accurate in identifying young infants with UTI at low risk for bacteremia. Outpatient management with appropriate follow-up is safe for these infants. What is Known: • Patients under 2-3 months of age with a presumptive urinary tract infection (UTI) are commonly hospitalized because of concerns regarding concomitant bacteremia. What is New: • A prediction rule including general appearance and procalcitonin is highly accurate in identifying young infants with UTI at low risk for bacteremia. Outpatient management with appropriate follow-up is safe for these infants.
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15
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Novel Biomarkers Differentiating Viral from Bacterial Infection in Febrile Children: Future Perspectives for Management in Clinical Praxis. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8111070. [PMID: 34828783 PMCID: PMC8623137 DOI: 10.3390/children8111070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/31/2021] [Accepted: 11/18/2021] [Indexed: 01/12/2023]
Abstract
Differentiating viral from bacterial infections in febrile children is challenging and often leads to an unnecessary use of antibiotics. There is a great need for more accurate diagnostic tools. New molecular methods have improved the particular diagnostics of viral respiratory tract infections, but defining etiology can still be challenging, as certain viruses are frequently detected in asymptomatic children. For the detection of bacterial infections, time consuming cultures with limited sensitivity are still the gold standard. As a response to infection, the immune system elicits a cascade of events, which aims to eliminate the invading pathogen. Recent studies have focused on these host–pathogen interactions to identify pathogen-specific biomarkers (gene expression profiles), or “pathogen signatures”, as potential future diagnostic tools. Other studies have assessed combinations of traditional bacterial and viral biomarkers (C-reactive protein, interleukins, myxovirus resistance protein A, procalcitonin, tumor necrosis factor-related apoptosis-inducing ligand) to establish etiology. In this review we discuss the performance of such novel diagnostics and their potential role in clinical praxis. In conclusion, there are several promising novel biomarkers in the pipeline, but well-designed randomized controlled trials are needed to evaluate the safety of using these novel biomarkers to guide clinical decisions.
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16
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Orfanos I, Alfvén T, Mossberg M, Tenland M, Sotoca Fernandez J, Eklund EA, Elfving K. Age- and sex-specific prevalence of serious bacterial infections in febrile infants ≤60 days, in Sweden. Acta Paediatr 2021; 110:3069-3076. [PMID: 34310741 DOI: 10.1111/apa.16043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/30/2021] [Accepted: 07/22/2021] [Indexed: 11/30/2022]
Abstract
AIM The aim of the study was to describe age- and sex-specific prevalence of serious bacterial infections (SBI: urinary tract infection, bacteraemia, meningitis) among febrile infants ≤60 days in Sweden. METHODS This is a retrospective study in 4 Pediatric Emergency Departments from 2014 to 2017, in previously healthy, full-term infants ≤60 days with fever without a source. RESULTS Of the 1,701 included infants, 214 (12.6%; 95% CI, 11.1-14.3) had an SBI. Urinary tract infection (UTI) was diagnosed in 196 (11.5%; 95% CI, 10.0-13.1) patients. In the ≤28 and 29-60 days age-groups, meningitis prevalence was 0.9% (95% CI, 0.3-2.0) and 0.3% (95% CI, 0.1-0.8), whereas bacteraemia prevalence was 3.2% (95% CI, 1.9-4.9) and 0.6% (95% CI, 0.2-1.3). The SBI prevalence was higher in boys 16.0% (95% CI, 13.8-18.5) than girls 8.0% (95% CI, 6.2-10.2; p<0.001), due to 2-fold higher UTI risk. The prevalence of meningitis in boys was 0.3% (95% CI, 0.1- 0.9) vs. 0.7% (95% CI, 0.2-1.6) in girls and of bacteraemia 1.8% (95% CI, 1.0-2.8) vs. 1.0% (95% CI, 0.4-2.0), respectively. CONCLUSIONS The total SBI prevalence was 12.6%, and UTI represented the vast majority. The prevalence of bacteraemia and meningitis was low, particularly in the 29-60 days age group, without significant difference between boys and girls.
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Affiliation(s)
- Ioannis Orfanos
- Department of Clinical Sciences Lund University Lund Sweden
- Department of Pediatrics Skåne University Hospital Lund Sweden
| | - Tobias Alfvén
- Department of Global Public Health Karolinska Institutet Stockholm Sweden
- Sachs’ Children and Youth Hospital Stockholm Sweden
| | - Maria Mossberg
- Department of Clinical Sciences Lund University Lund Sweden
- Department of Pediatrics Skåne University Hospital Lund Sweden
| | | | | | - Erik A. Eklund
- Department of Clinical Sciences Lund University Lund Sweden
- Department of Pediatrics Skåne University Hospital Lund Sweden
| | - Kristina Elfving
- Department of Pediatrics Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- School of Public Health and Community Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
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17
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Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, O'Leary ST, Okechukwu K, Woods CR. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics 2021; 148:peds.2021-052228. [PMID: 34281996 DOI: 10.1542/peds.2021-052228] [Citation(s) in RCA: 174] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This guideline addresses the evaluation and management of well-appearing, term infants, 8 to 60 days of age, with fever ≥38.0°C. Exclusions are noted. After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active investigators, 21 key action statements were derived. For each key action statement, the quality of evidence and benefit-harm relationship were assessed and graded to determine the strength of recommendations. When appropriate, parents' values and preferences should be incorporated as part of shared decision-making. For diagnostic testing, the committee has attempted to develop numbers needed to test, and for antimicrobial administration, the committee provided numbers needed to treat. Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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Affiliation(s)
- Robert H Pantell
- Department of Pediatrics, School of Medicine, University of California San Francisco, San Francisco, California
| | - Kenneth B Roberts
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - William G Adams
- Boston Medical Center/Boston University School of Medicine, Deparment of Pediatrics, Boston, Massachusetts
| | - Benard P Dreyer
- Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatric, School of Medicine, University of California, Davis School of Medicine, Sacramento, California
| | - Sean T O'Leary
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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18
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Ferreira M, Santos M, Rodrigues J, Diogo C, Resende C, Baptista C, Faria C. Epidemiology of bacteremia in a pediatric population - A 10-year study. Enferm Infecc Microbiol Clin 2021; 41:S0213-005X(21)00207-X. [PMID: 34275687 DOI: 10.1016/j.eimc.2021.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/28/2021] [Accepted: 06/05/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION With the widespread introduction of conjugate meningococcal and pneumococcal vaccines, the prevalence and etiology of invasive bacterial infections have changed. We aimed to review all cases of bacteremia in a level II pediatric department over a ten-year period in the post-pneumococcal conjugate vaccine era. METHODS We reviewed all positive blood cultures (BC) obtained in our department between 2007 and 2016. Results were classified as contaminants, potential pathogens or confirmed pathogens, based on species, number of positive BC in the episode and the patients' medical history. Demographic and clinical data were collected for patients with identified pathogens. RESULTS A total of 638 positive BC were identified (6.6% of total BC); 120 (1.2%) were considered to represent true bacteremia. The most frequently identified microorganism was Streptococcus pneumoniae (29.2%), with a decrease in the number of cases between 2008 and 2015. Staphylococcus aureus was the second most common organism (19.2%) being 21.7% of these methicillin-resistant. Escherichia coli was the most common isolate in children aged less than three months. CONCLUSION We found a rate of true bacteremia in children similar to recent studies. Although Streptococcus pneumoniae remains the most common microorganism, its prevalence may be declining. Monitoring microbiological data in children has implications in practice, particularly in local antibiotic prescription.
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Affiliation(s)
- Mariana Ferreira
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal.
| | - Mafalda Santos
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Jorge Rodrigues
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Clara Diogo
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Catarina Resende
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Cristina Baptista
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Cristina Faria
- Department of Pediatrics, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
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19
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Chen YT, Chang YJ, Liu BY, Lee EP, Wu HP. Severe bacterial infection in young infants with pyrexia admitted to the emergency department. Medicine (Baltimore) 2021; 100:e26596. [PMID: 34232210 PMCID: PMC8270585 DOI: 10.1097/md.0000000000026596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/18/2021] [Indexed: 01/04/2023] Open
Abstract
The objectives of this study were to understand the clinical presentations of febrile young infants with severe bacterial infection (SBI), and to investigate the pathogen variations throughout the vaccine era and after antenatal group B Streptococcus (GBS) screening.All infants < 90 days old with a body temperature of ≥38.0°C and admitted to the emergency department were retrospectively enrolled in our study. SBI was defined as a positive culture of urine, blood, or cerebrospinal fluid. All clinical variables were analyzed and compared between the SBI group and the non-SBI group, to identify the relevant risk factors for SBI in infants with pyrexia.A total of 498 infants were studied, 279 of whom (56%) had SBI. The body temperature at triage was higher in the SBI group, and the difference was highly obvious in the neonatal group. White blood cell count and C-reactive protein levels were both significantly higher in the SBI group (P < .05), whereas neutrophil percentage and band percentage demonstrated no significant differences. Escherichia coli was the most common pathogen and plasmid-mediated extended-spectrum lactamases were detected in up to 9.1%. GBS was detected in 16 cases of bacteremia (6 cases with concurrent meningitis).The body temperature at triage may provide a clue for differentiating sick babies, especially in the neonatal group. Complete serum analysis is required for infection survey, especially white blood cell and C-reactive protein. Escherichia coli is the most common pathogen, and clinician should raise awareness of drug resistance in some patients. The prevalence of GBS infection in the young infant group remains high after routine antenatal GBS screening.
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Affiliation(s)
- Yin-Ting Chen
- Division of Neonatology, Department of Pediatrics, Children Hospital, China Medical University, Taichung, Taiwan
- Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Yu-Jun Chang
- Laboratory of Epidemiology and Biostastics, Big Data Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Bang-Yan Liu
- Division of Neonatology, Department of Pediatrics, Children Hospital, China Medical University, Taichung, Taiwan
| | - En-Pei Lee
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Han-Ping Wu
- Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
- Department of Pediatric Emergency Medicine, Children Hospital, China Medical University, Taichung, Taiwan
- Department of Medical Research, Children's Hospital, China Medical University, Taichung, Taiwan
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20
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Burstein B, Sabhaney V, Bone JN, Doan Q, Mansouri FF, Meckler GD. Prevalence of Bacterial Meningitis Among Febrile Infants Aged 29-60 Days With Positive Urinalysis Results: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e214544. [PMID: 33978724 PMCID: PMC8116985 DOI: 10.1001/jamanetworkopen.2021.4544] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
IMPORTANCE Fever in the first months of life remains one of the most common pediatric problems. Urinary tract infections are the most frequent serious bacterial infections in this population. All published guidelines and quality initiatives for febrile young infants recommend lumbar puncture (LP) and cerebrospinal fluid (CSF) testing on the basis of a positive urinalysis result to exclude bacterial meningitis as a cause. For well infants older than 28 days with an abnormal urinalysis result, LP remains controversial. OBJECTIVE To assess the prevalence of bacterial meningitis among febrile infants 29 to 60 days of age with a positive urinalysis result to evaluate whether LP is routinely required. DATA SOURCES MEDLINE and Embase were searched for articles published from January 1, 2000, to July 25, 2018, with deliberate limitation to recent studies. Before analysis, the search was repeated (October 6, 2019) to ensure that new studies were included. STUDY SELECTION Studies that reported on healthy, full-term, well-appearing febrile infants 29 to 60 days of age for whom patient-level data could be ascertained for urinalysis results and meningitis status were included. DATA EXTRACTION AND SYNTHESIS Data were extracted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and used the Newcastle-Ottawa Scale to assess bias. Pooled prevalences and odds ratios (ORs) were estimated using random-effect models. MAIN OUTCOMES AND MEASURES The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with positive urinalysis results. The secondary outcome was the prevalence of bacterial meningitis, defined by CSF testing or suggestive history at clinical follow-up. RESULTS The parent search yielded 3227 records; 48 studies were included (17 distinct data sets of 25 374 infants). The prevalence of culture-proven meningitis was 0.44% (95% CI, 0.25%-0.78%) among 2703 infants with positive urinalysis results compared with 0.50% (95% CI, 0.33%-0.76%) among 10 032 infants with negative urinalysis results (OR, 0.74; 95% CI, 0.39-1.38). The prevalence of bacterial meningitis was 0.25% (95% CI, 0.14%-0.45%) among 4737 infants with meningitis status ascertained by CSF testing or clinical follow-up and 0.28% (95% CI, 0.21%-0.36%) among 20 637 infants with positive and negative urinalysis results (OR, 0.89; 95% CI, 0.48-1.68). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, the prevalence of bacterial meningitis in well-appearing febrile infants 29 to 60 days of age with positive urinalysis results ranged from 0.25% to 0.44% and was not higher than that in infants with negative urinalysis results. These results suggest that for these infants, the decision to use LP should not be guided by urinalysis results alone.
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Affiliation(s)
- Brett Burstein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Vikram Sabhaney
- Division of Pediatric Emergency Medicine, Department of Pediatrics, British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey N. Bone
- Department Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Quynh Doan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fahad F. Mansouri
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Garth D. Meckler
- Division of Pediatric Emergency Medicine, Department of Pediatrics, British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
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21
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Elgoibar B, Gangoiti I, Garcia‐Garcia JJ, Hernandez‐Bou S, Gomez B, Martinez Indart L, Mintegi S. Paediatric Escherichia coli bacteraemia presentations and high-risk factors in the emergency department. Acta Paediatr 2021; 110:1032-1037. [PMID: 32815584 DOI: 10.1111/apa.15549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/29/2020] [Accepted: 08/18/2020] [Indexed: 01/05/2023]
Abstract
AIM Escherichia coli (E coli) is a known cause of paediatric bacteraemia. The main objective was to characterise the emergency department (ED) presentations of paediatric E coli bacteraemia and secondarily to identify those related to greater severity. METHODS This was a sub-study of a multicentre cross-sectional prospective registry including all with E coli bacteraemia episodes between 2011 and 2016. We used multiple correspondence and cluster analysis to identify different patterns. RESULTS We included 291 patients and 43 met criteria for severe disease (14.3%, 95% confidence interval 11.2-19.3). We identified four types of paediatric E coli bacteraemia presentations. Two (178 patients, 61.2%) were related to well-appearing previously healthy infants with associated urinary tract infection (UTI). Well-appearing children older than 12 months old with underlying disease (n = 60, 20.6%) and non-well-appearing children of different ages (n = 53, 18.2%) corresponded to the other two types; these had associated UTI infrequently and higher severity rate (15% and 50.9%, respectively, higher when compared with the two previous types, P < .01), including the two patients who died. CONCLUSION There were four different types of ED paediatric E coli bacteraemia presentations with different severity. Febrile young children with associated UTI showed the best outcome.
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Affiliation(s)
- Borja Elgoibar
- Paediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao, Basque Country Spain
| | - Iker Gangoiti
- Paediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao, Basque Country Spain
| | | | | | - Borja Gomez
- Paediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao, Basque Country Spain
| | | | - Santiago Mintegi
- Paediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao, Basque Country Spain
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22
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Gatt D, Lendner I, Ben-Shimol S. Catheter-obtained, Enterococcus and Proteus positive urine cultures may represent mostly contamination or asymptomatic bacteriuria in infants <90 days. Infect Dis (Lond) 2021; 53:332-339. [PMID: 33620253 DOI: 10.1080/23744235.2021.1885731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Urinary tract infection (UTI) diagnosis in infants is often made by a positive urine culture result, regardless of urine dipstick findings. AIM To assess parameters that may affect positive urine culture results interpretation in infants, including dipstick performance, obtainment method, bacteria type, age and laboratory results. METHODS A retrospective, cohort study. Infants <90 days with urine dipstick and culture obtained through subrapubic aspiration (SPA) or catheter, 2015-2016, were included. RESULTS Overall, 19% (129/678) of cultures were positive. The dipstick sensitivity was 51% for all cultures; 66%, 47%, 15% and 10% for Escherichia coli (n= 71), Klebsiella (n= 19), Enterococcus (n= 34) and Proteus (n= 10), respectively (p<.001). Sensitivity was higher in SPA vs. catheter for all cultures (67% vs. 43%); E. coli (78% vs. 59%); and Klebsiella (88% vs. 18%). For Enterococcus, dipstick sensitivity was low in both SPA and catheter (0-16%). All Proteus episodes were catheter obtained. Positive culture with negative dipstick and Enterococcus episodes had lower C-reactive protein levels, and higher proportion of mixed infection compared with positive dipstick and E. coli episodes. CONCLUSIONS Urine cultures in infants should be obtained by SPA, since catheter-obtained, Enterococcus and Proteus positive cultures may represent contamination or asymptomatic bacteriuria, rather than true UTI.
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Affiliation(s)
- Dvir Gatt
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer Sheva, Israel.,Pediatric Pulmonary Unit, Soroka University Medical Center, Beer Sheva, Israel
| | - Idan Lendner
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer Sheva, Israel
| | - Shalom Ben-Shimol
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer Sheva, Israel
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Pediatric emergency medicine literature 2020. Am J Emerg Med 2021; 43:123-133. [PMID: 33561621 DOI: 10.1016/j.ajem.2021.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/06/2021] [Accepted: 01/09/2021] [Indexed: 11/22/2022] Open
Abstract
Most children are treated at general Emergency Departments (EDs) and not specialized pediatric EDs. Therefore, it is crucial for emergency medicine physicians to be aware of recent developments in pediatric emergency medicine. Often impactful articles on pediatric emergency medicine are not published in the journals regularly studied by general emergency medicine physicians. We selected ten studies that we found impactful, robust, and relevant for practicing general emergency physicians. This review includes studies of status epilepticus, cardiac arrest, asthma, infant fever, wound care, rapid sequence intubation, coronavirus, and trauma.
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Velasco R, Lejarzegi A, Gomez B, de la Torre M, Duran I, Camara A, de la Rosa D, Manzano S, Rodriguez J, González A, Lopes AA, Rivas A, Martinez I, Angelats CM, Moya S, Corral S, Alonso J, Del Rio P, Sancho E, Ruiz Del Olmo I, Nieto I, Vega B, Mintegi S. Febrile young infants with abnormal urine dipstick at low risk of invasive bacterial infection. Arch Dis Child 2020; 106:archdischild-2020-320468. [PMID: 33246922 DOI: 10.1136/archdischild-2020-320468] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/04/2020] [Accepted: 11/11/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop and validate a prediction rule to identify well-appearing febrile infants aged ≤90 days with an abnormal urine dipstick at low risk of invasive bacterial infections (IBIs, bacteraemia or bacterial meningitis). DESIGN Ambispective, multicentre study. SETTING The derivation set in a single paediatric emergency department (ED) between 2003 and 2017. The validation set in 21 European EDs between December 2017 and November 2019. PATIENTS Two sets of well-appearing febrile infants aged ≤90 days with an abnormal urine dipstick (either leucocyte esterase and/or nitrite positive test). MAIN OUTCOME Prevalence of IBI in low-risk infants according to the RISeuP score. RESULTS We included 662 infants in the derivation set (IBI rate:5.2%). After logistic regression, we developed a score (RISeuP score) including age (≤15 days old), serum procalcitonin (≥0.6 ng/mL) and C reactive protein (≥20 mg/L) as risk factors. The absence of any risk factor had a sensitivity of 96.0% (95% CI 80.5% to 99.3%), a negative predictive value of 99.4% (95% CI 96.4% to 99.9%) and a specificity of 32.9% (95% CI 28.8% to 37.3%) for ruling out an IBI. Applying it in the 449 infants of the validation set (IBI rate 4.9%), sensitivity, negative predictive value and specificity were 100% (95% CI 87.1% to 100%), 100% (95% CI 97.3% to 100%) and 29.7% (95% CI 25.8% to 33.8%), respectively. CONCLUSION This prediction rule accurately identified well-appearing febrile infants aged ≤90 days with an abnormal urine dipstick at low risk of IBI. This score can be used to guide initial clinical decision-making in these patients, selecting infants suitable for an outpatient management.
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Affiliation(s)
- Roberto Velasco
- Pediatric Emergency Unit, Rio Hortega University Hospital, Valladolid, Spain
| | - Ainara Lejarzegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces. University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Borja Gomez
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces. University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Mercedes de la Torre
- Pediatric Emergency Department, Hospital Infantil Universitario Nino Jesus, Madrid, Madrid, Spain
| | - Isabel Duran
- Pediatric Emergency Department, Hospital Regional Universitario de Malaga, Malaga, Spain
| | - Amaia Camara
- Pediatric Emergency Department, Donostia Ospitalea, Donostia, Spain
| | - Daniel de la Rosa
- Pediatric Emergency Department, Hospital Universitario Materno Infantil de Canarias, Las Palmas Gran Canaria, Spain
| | - Sergio Manzano
- Pediatric Emergency Department, Geneva University Hospital, Geneva, Switzerland
| | - Jose Rodriguez
- Pediatrics, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | | | - Anne-Aurelie Lopes
- Pediatric Emergency Department, Robert-Debré Mother-Child University Hospital. Sorbonne University, Paris, France
| | - Aristides Rivas
- Pediatric Emergency Department, Gregorio Marañón University Hospital, Madrid, Spain
| | - Isabel Martinez
- Pediatric Emergency Department, Virgen del Rocio University Hospital, Sevilla, Spain
| | | | - Sandra Moya
- Pediatric Emergency Department, Parc Taulí University Hospital, Sabadell, Spain
| | - Sonia Corral
- Pediatrics, Granollers General Hospital, Granollers, Spain
| | - Juan Alonso
- Pediatrics, Hospital San Agustín, Linares, Spain
| | | | - Elena Sancho
- Pediatrics, Hospital de San Jorge, Huesca, Spain
| | | | - Inmaculada Nieto
- Pediatrics, Hospital San Juan de Dios del Aljarafe, Sevilla, Spain
| | - Beatriz Vega
- Pediatrics, Hospital Comarcal de Laredo, Laredo, Spain
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces. University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
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Velasco R, Gomez B, Torre M, Benito J, Mintegi S. A positive nitrite test was an independent risk factor for invasive bacterial infections in infants under 90 days of age with fever without source. Acta Paediatr 2020; 109:2316-2323. [PMID: 32061143 DOI: 10.1111/apa.15230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/01/2020] [Accepted: 02/13/2020] [Indexed: 12/13/2022]
Abstract
AIM This study analysed the association between a positive nitrite dipstick test and an invasive bacterial infection (IBI) in infants younger than 90 days of age with fever without source (FWS). METHODS We performed a secondary analysis of data from a prospective multicentre study of infants up to 90 days of age with FWS undergoing care in 19 paediatric EDs between October 2011 and September 2013. Invasive bacterial infection was defined as a positive blood or cerebrospinal fluid culture. RESULTS The dipstick urinalysis was positive for nitrite or leucocyte esterase in 766 (22.5%) of the 3401 infants we studied, and 270 (35.2%) had a dipstick test that was just positive for nitrite. Overall, 107 were diagnosed with an IBI (3.1%). The IBI prevalence was 2.2% among patients with a normal urine dipstick, 4.4% if they had positive leucocyte esterase test results, 8.3% where the nitrite test was positive and 10.6% when both tests were positive. After multivariate analysis, a positive nitrite test remained an independent risk factor for IBI (odds ratio 2.7, 95% confidence interval 1.4-4.9). CONCLUSION In infants under 90 days of age with FWS, a positive nitrite urine dipstick test was an independent risk factor for IBI.
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Affiliation(s)
- Roberto Velasco
- Pediatric Emergency Department Rio Hortega Universitary Hospital Valladolid Spain
| | - Borja Gomez
- Pediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao Spain
| | - Mercedes Torre
- Pediatric Emergency Department Niño Jesús University Hospital Madrid Spain
| | - Javier Benito
- Pediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao Spain
| | - Santiago Mintegi
- Pediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao Spain
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Kim SG, Oh YN, Lee JK. Clinical implications of aminotransferase elevation in hospitalised infants aged 8‐90 days with respiratory virus detection. Influenza Other Respir Viruses 2020; 14:429-435. [PMID: 32157800 PMCID: PMC7298305 DOI: 10.1111/irv.12732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/15/2020] [Accepted: 02/16/2020] [Indexed: 11/30/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Sang Gyeom Kim
- Department of Pediatrics Chungbuk National University Hospital Cheongju South Korea
| | - Yu Na Oh
- Department of Pediatrics Chungbuk National University Hospital Cheongju South Korea
| | - Joon Kee Lee
- Department of Pediatrics Chungbuk National University Hospital Cheongju South Korea
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Manandhar SR, Basnet R. Micro-Erythrocyte Sedimentation Rate in Neonatal Sepsis of a Tertiary Hospital: A Descriptive Cross-sectional Study. ACTA ACUST UNITED AC 2020; 58:377-382. [PMID: 32788752 PMCID: PMC7580353 DOI: 10.31729/jnma.4984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Neonatal sepsis is the most important cause of morbidity and mortality among low birth weight and preterm babies in developing countries. The main objective of this study is to find the level of micro-Erythrocyte sedimentation rate in neonatal sepsis. METHODS This is a descriptive cross-sectional study conducted at the neonatal unit over six months period (November 2019 to April 2020). All preterm, term and post-term babies with neonatal sepsisdelivered at Kathmandu Medical College Teaching Hospital were enrolled. Ethical clearance was received from the Institutional Review Committee of Kathmandu Medical College (Ref: 181020191). Convenient sampling method was applied and statistical analysis was done with Statistical package for social sciences 19 version. RESULTS Out of 75 babies, confirm sepsis is 13 (17.3%), probable sepsis is 40 (53.4%) and suspected sepsis is 22 (29.2%). Micro-Erythrocyte sedimentation level is elevated (≥15mm in 1st hr) in 25 (33.3%) babies with a mean micro-Erythrocyte sedimentation level 9.32±5.4 (2-18) mm in 1st hr. The elevated micro- Erythrocyte sedimentation level was seen in relation to sepsis types and C-reactive protein. CONCLUSIONS The bedside micro-Erythrocyte sedimentation level aids in the diagnosis of neonatal sepsis.
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Affiliation(s)
- Sunil Raja Manandhar
- Neonatal Unit, Department of Paediatrics, Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal
| | - Rydam Basnet
- Neonatal Unit, Department of Paediatrics, Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal
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Lyons TW, Garro AC, Cruz AT, Freedman SB, Okada PJ, Mahajan P, Balamuth F, Thompson AD, Kulik DM, Uspal NG, Arms JL, Nigrovic LE. Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections. Pediatrics 2020; 145:peds.2019-3538. [PMID: 32205466 DOI: 10.1542/peds.2019-3538] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The ability of the decades-old Boston and Philadelphia criteria to accurately identify infants at low risk for serious bacterial infections has not been recently reevaluated. METHODS We assembled a multicenter cohort of infants 29 to 60 days of age who had cerebrospinal fluid (CSF) and blood cultures obtained. We report the performance of the modified Boston criteria (peripheral white blood cell count [WBC] ≥20 000 cells per mm3, CSF WBC ≥10 cells per mm3, and urinalysis with >10 WBC per high-power field or positive urine dip result) and modified Philadelphia criteria (peripheral WBC ≥15 000 cells per mm3, CSF WBC ≥8 cells per mm3, positive CSF Gram-stain result, and urinalysis with >10 WBC per high-power field or positive urine dip result) for the identification of invasive bacterial infections (IBIs). We defined IBI as bacterial meningitis (growth of pathogenic bacteria from CSF culture) or bacteremia (growth from blood culture). RESULTS We applied the modified Boston criteria to 8344 infants and the modified Philadelphia criteria to 8131 infants. The modified Boston criteria identified 133 of the 212 infants with IBI (sensitivity 62.7% [95% confidence interval (CI) 55.9% to 69.3%] and specificity 59.2% [95% CI 58.1% to 60.2%]), and the modified Philadelphia criteria identified 157 of the 219 infants with IBI (sensitivity 71.7% [95% CI 65.2% to 77.6%] and specificity 46.1% [95% CI 45.0% to 47.2%]). The modified Boston and Philadelphia criteria misclassified 17 of 53 (32.1%) and 13 of 56 (23.3%) infants with bacterial meningitis, respectively. CONCLUSIONS The modified Boston and Philadelphia criteria misclassified a substantial number of infants 29 to 60 days old with IBI, including those with bacterial meningitis.
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Affiliation(s)
- Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts;
| | - Aris C Garro
- Departments of Pediatrics and Emergency Medicine, Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Andrea T Cruz
- Sections of Pediatric Emergency Medicine and Pediatric Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital and Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pamela J Okada
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Fran Balamuth
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy D Thompson
- Departments of Pediatrics and Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Dina M Kulik
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Neil G Uspal
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Joseph L Arms
- Department of Pediatrics, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Yoon SH, Shin H, Lee KH, Kim MK, Kim DS, Ahn JG, Shin JI. Predictive factors for bacteremia in febrile infants with urinary tract infection. Sci Rep 2020; 10:4469. [PMID: 32161316 PMCID: PMC7066144 DOI: 10.1038/s41598-020-61421-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 02/26/2020] [Indexed: 11/24/2022] Open
Abstract
This study aimed to investigate the predictive factors of concomitant bacteremia occurring in febrile infants who initially presented with pyuria and fever, and were subsequently diagnosed with culture-proven urinary tract infection (UTI). We conducted a retrospective cohort study for January 2010–October 2018 that included infants younger than six months with febrile UTI at a tertiary hospital. The study included 463 patients, of whom 34 had a concomitant bacteremic UTI. Compared to those in the non-bacteremic urinary tract infection (UTI) group, the bacteremic UTI group had a lower mean age; higher levels of C-reactive protein (CRP), delta neutrophil index (DNI, reflects the fraction of immature granulocytes) and blood urea nitrogen (BUN); lower levels of hemoglobin (Hb) and albumin; and a lower platelet count. Vesicoureteral reflux (VUR) was detected nearly twice as often in patients with bacteremic UTI compared to those with non-bacteremic UTI (59.3% vs. 30.6%; P = 0.003). Univariate logistic analyses showed that age ≤90 days; higher DNI, CRP, and creatinine levels; lower Hb and albumin levels; and the presence of VUR were predictors for bacteremic UTI. On multivariate logistic regression analysis, age ≤90 days, higher DNI and CRP levels, and the presence of VUR were independent predictors of bacteremic UTI. The area under the receiver operating characteristic curve of the multivariate model was 0.859 (95% CI, 0.779–0.939; P < 0.001). Age ≤90 days, higher DNI and CRP values may help predict bacteremia of febrile infants younger than 6 months with UTI. Vesicoureteral reflux imaging is also recommended in infants with bacteremic UTI to evaluate VUR.
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Affiliation(s)
- Seo Hee Yoon
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752, Korea
| | - HyunDo Shin
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752, Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752, Korea.,Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, 03722, Korea.,Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, 03722, Korea
| | - Moon Kyu Kim
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752, Korea
| | - Dong Soo Kim
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752, Korea
| | - Jong Gyun Ahn
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752, Korea.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752, Korea. .,Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, 03722, Korea. .,Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, 03722, Korea.
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He Y, Chen J, Liu Z, Yu J. Efficacy and safety of applying a neonatal early-onset sepsis risk calculator in China. J Paediatr Child Health 2020; 56:237-243. [PMID: 31328848 DOI: 10.1111/jpc.14572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/28/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022]
Abstract
AIM To evaluate and compare the performance of the early-onset sepsis (EOS) risk calculator with procalcitonin (PCT), complete blood count (CBC) and C-reactive protein (CRP) for predicting neonatal EOS. METHODS This was a retrospective case-control study of neonates who were ≥34 weeks of gestation and ≤12 h of age at admission to our hospital between January 2017 and December 2018. Neonates with strictly defined EOS and those without evidence of infection were included in this study. We reviewed and collected the laboratory data and medical charts of the included neonates. The EOS risk scores for all neonates were calculated using the EOS risk calculator, and the results were analysed and compared with blood biomarkers. RESULTS A total of 501 neonates, including 353 infected and 148 uninfected infants, met the inclusion criteria for the study. Comparing these predictors, PCT had the best predictive value (sensitivity: 87.5%, specificity: 95.5%), closely followed by the EOS risk calculator (sensitivity: 81.16%, specificity: 93.92%). Multivariate logistic regression found that risk scores calculated by the EOS risk calculator had strong associations with EOS as an independent risk factor (odds ratio: 57.37, P < 0.05). The combination of the EOS risk calculator, PCT, CBC and CRP could increase the predictive value of the model and reach an area under the receiver operating characteristic curve of 0.987 for predicting EOS. CONCLUSIONS In this pilot study, applying the EOS calculator in China, the EOS risk calculator and PCT showed good predictive value compared to CBC and CRP. Risk scores from the EOS risk calculator strongly correlated with EOS, and the EOS risk calculator offered increased predictive value when used in combination with blood biomarkers.
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Affiliation(s)
- Yi He
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Pediatric Research Institute, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
| | - Jie Chen
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Pediatric Research Institute, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
| | - Zhenqiu Liu
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Pediatric Research Institute, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
| | - Jialin Yu
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Pediatric Research Institute, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Pediatric Research Institute, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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A Retrospective Review of Neonatal Sepsis among GBS-Colonized Women Undergoing Planned Cesarean Section after Labor Onset or Rupture of Membranes. Infect Dis Obstet Gynecol 2020; 2020:4365259. [PMID: 32148387 PMCID: PMC7056999 DOI: 10.1155/2020/4365259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/22/2019] [Accepted: 12/30/2019] [Indexed: 11/17/2022] Open
Abstract
Background Sepsis is a leading cause of mortality and morbidity in neonates, with group B streptococcus (GBS) remaining the most frequent pathogen isolated from term infants. Surveillance data showed that the majority of cases of early-onset GBS disease were neonates born to women who either received no or suboptimal intrapartum antibiotic prophylaxis with a notable portion of those women having a missed opportunity to receive ≥4 hours of chemoprophylaxis. Women planning delivery by cesarean section who present in labor or rupture of membranes prior to their scheduled surgery are unlikely to receive optimal GBS chemoprophylaxis and thus their neonates are at risk of having sepsis. Materials and Methods. A retrospective cohort study of women-infant dyads was extracted from the Consortium on Safe Labor dataset. Women who had an unlabored cesarean section at ≥37 + 0 week gestation were selected and divided into four groups based on GBS status and timing of cesarean section with respect to onset of labor or rupture of membranes. The rate of neonatal sepsis and the patterns of intrapartum antibiotic chemoprophylaxis were determined. Results The sepsis rate (4.5%) among neonates of GBS-colonized women having their unlabored cesarean section after onset of labor or rupture of membranes was significantly higher than that in any other group in this study. In this group, 9.4% of women received chemoprophylaxis for ≥4 hours, while 31% had a missed opportunity to receive ≥4 hours of chemoprophylaxis. Conclusion This study suggests that neonates of GBS-colonized women having a planned cesarean section after onset of labor or rupture of membranes are at increased risk of having a sepsis diagnosis. This finding suggest the need for additional studies to assess the risk of sepsis among neonates of women in this group.
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Epidemiology of Serious Bacterial Infections in Infants Less Than 90 Days in a Military Health System Cohort. Pediatr Infect Dis J 2019; 38:849-853. [PMID: 31220044 DOI: 10.1097/inf.0000000000002346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management of suspected serious bacterial infections (SBIs) in infants less than 3 months old is challenging. Understanding the epidemiology of SBI is necessary to inform management decisions. Recent publications have challenged the previously accepted distribution of infections by specimen source and pathogen. We sought to describe the burden of SBIs in previously healthy infants less than 90 days old. METHODS We conducted a retrospective analysis of the Military Health System database to identify SBI cases among term infants less than 90 days of age from 2005 to 2015. We defined an SBI case as any previously healthy infant with positive cultures for a likely pathogen from blood, urine or cerebrospinal fluid. RESULTS Of 467,462 live births between January 2005 and September 2015, 3421 infants had positive cultures. After excluding 1781 episodes with isolates considered nonpathogenic or ICD-9 codes for chronic conditions, the overall incidence of SBI was 3.1 cases/1000 live births. The SBI rate dropped from 5.0 cases/1000 live births in 2005 to 2.0 cases/1000 live births in 2015 (P < 0.001 for trend). The most common pathogen was Escherichia coli (51.3%). CONCLUSIONS In this retrospective review of 467,462 live births, the incidence of SBI decreased from 5.0/1000 to 2.0/1000 live births over time. We identified no cases of Listeria monocytogenes. These data can help inform decisions related to treatment and management of infants with suspected bacterial infections.
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Huggard D, Powell J, Kirkham C, Power L, O'Connell NH, Philip RK. Time to positivity (TTP) of neonatal blood cultures: a trend analysis over a decade from Ireland. J Matern Fetal Neonatal Med 2019; 34:780-786. [PMID: 31072183 DOI: 10.1080/14767058.2019.1617687] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background and aims: Blood culture (BC) remains gold standard for the evaluation and diagnosis of neonatal sepsis. Time when BC becomes positive and the type of microorganism isolated are crucial in deciding the antimicrobial management. Likely pathogenicity of organisms growing in BC could potentially be predicted based on the "time to positivity" (TTP). We aimed to estimate the predictive value of isolating a likely pathogenic organism depending on TTP; evaluate the aetiological trend and neonatal mortality rate due to culture-proven neonatal sepsis for over a decade and verify whether the application of a "36 hour rule" to discontinue empiric antibiotics in well newborn infants with negative BC would be safe.Methods: Retrospective review of BC results over a 14-year period from a regional neonatal unit in Ireland. Laboratory data were independently extracted in relation to BC results from the laboratory information management system (LIMS-iLAB). Neonatal mortality data were collected from multiple sources. Statistical analysis included logistic regression, chi-square, and Mann-Whitney U-test.Results: Over a 14-year period 11,432 neonatal BC specimens were incubated of which 605 (5.3%) turned positive. Overall, the commonest organism grown was coagulase-negative Staphylococcus (CoNS), 416 (68.8%). Main pathogenic organisms were Staphylococcus aureus 23 (3.8%), Enterococcus spp. 22 (3.6%), E.coli 21 (3.5%), group B Streptococcus (GBS) 18 (3.0%), and Klebsiella species 9 (1.5%). Gram-negative organisms had the shortest TTP, with Klebsiella spp. having a median TTP of 10 h and E. coli 11 h. For Gram-positives, GBS had a median TTP of 12 h, Enterococcus species 14 h, with S. aureus growing at a median time of 15 h. All of the Klebsiella spp. and other Coliforms were detected within 24 h, with, 95.2% of E.coli, 94.4% of GBS, 95.5% of Enterococci, and 95.7% of S. aureus, flagging positive in 24 h. Using logistic regression the omnibus test of the coefficients in the resulting model was significant (p < .001). Our observed coefficient (β) for TTP was 0.144; shorter the TTP higher was the likelihood of isolating a pathogenic organism, with an odds ratio (OR) of 1.155. We also report a relatively low blood culture proven sepsis-specific neonatal mortality rate of 0.403/1000 live births and in all such instances observed TTP was less than 24 h.Conclusion: Duration of this study exceeds that of most of the neonatal blood culture TTP analysis published to-date. A shorter TTP is an important adjunct to suggest the growth of a pathogenic organism while managing suspected neonatal sepsis. TTP if < 24 h per se would not necessarily confirm the growth of a highly pathogenic organism; however, if a positive growth is likely to happen for a significant neonatal pathogen, in more than 98% the TTP would be within 24 h. This offers the clinician more of negative predictive value than a positive one; when there is no growth in BC. Our observation on TTP reiterate the National Institute of Health and Care Excellence (NICE) guideline of discontinuation of empiric antibiotics after 36 h in and clinically well and BC negative newborn infants.
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Affiliation(s)
- D Huggard
- Division of Neonatology, Department of Paediatrics, University Maternity Hospital Limerick (UMHL), Limerick, Ireland
| | - J Powell
- Department of Clinical Microbiology, University Hospital Limerick (UHL), Limerick, Ireland
| | - C Kirkham
- Research Department, Rotunda Hospital, Dublin, Ireland
| | - L Power
- Department of Clinical Microbiology, University Hospital Limerick (UHL), Limerick, Ireland
| | - N H O'Connell
- Department of Clinical Microbiology, University Hospital Limerick (UHL), Limerick, Ireland.,Graduate Entry Medical School (GEMS), University of Limerick, Limerick, Ireland
| | - R K Philip
- Division of Neonatology, Department of Paediatrics, University Maternity Hospital Limerick (UMHL), Limerick, Ireland.,Graduate Entry Medical School (GEMS), University of Limerick, Limerick, Ireland
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Abstract
A 3-month-old baby is brought to the paediatric emergency department by their parents because of a fever. You decide to check their inflammatory markers. Their C-reactive protein (CRP) level comes back as 20 mg/L. Does this affect whether or not you start antibiotic therapy? Does it influence your decision to admit or discharge the patient? CRP is a commonly used biochemical test and yet its use is constantly debated and challenged. We look at the current evidence and suggest the best way to use this test in clinical practice.
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Affiliation(s)
| | - Thomas Waterfield
- Queen's University Belfast School of Medicine Dentistry and Biomedical Sciences, Belfast, UK
| | - Hannah Baynes
- King's College London School of Medical Education, London, UK
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Pruitt CM, Neuman MI, Shah SS, Shabanova V, Woll C, Wang ME, Alpern ER, Williams DJ, Sartori L, Desai S, Leazer RC, Marble RD, McCulloh RJ, DePorre AG, Rooholamini SN, Lumb CE, Balamuth F, Shin S, Aronson PL. Factors Associated with Adverse Outcomes among Febrile Young Infants with Invasive Bacterial Infections. J Pediatr 2019; 204:177-182.e1. [PMID: 30297292 PMCID: PMC6309646 DOI: 10.1016/j.jpeds.2018.08.066] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/21/2018] [Accepted: 08/24/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine factors associated with adverse outcomes among febrile young infants with invasive bacterial infections (IBIs) (ie, bacteremia and/or bacterial meningitis). STUDY DESIGN Multicenter, retrospective cohort study (July 2011-June 2016) of febrile infants ≤60 days of age with pathogenic bacterial growth in blood and/or cerebrospinal fluid. Subjects were identified by query of local microbiology laboratory and/or electronic medical record systems, and clinical data were extracted by medical record review. Mixed-effect logistic regression was employed to determine clinical factors associated with 30-day adverse outcomes, which were defined as death, neurologic sequelae, mechanical ventilation, or vasoactive medication receipt. RESULTS Three hundred fifty infants met inclusion criteria; 279 (79.7%) with bacteremia without meningitis and 71 (20.3%) with bacterial meningitis. Forty-two (12.0%) infants had a 30-day adverse outcome: 29 of 71 (40.8%) with bacterial meningitis vs 13 of 279 (4.7%) with bacteremia without meningitis (36.2% difference, 95% CI 25.1%-48.0%; P < .001). On adjusted analysis, bacterial meningitis (aOR 16.3, 95% CI 6.5-41.0; P < .001), prematurity (aOR 7.1, 95% CI 2.6-19.7; P < .001), and ill appearance (aOR 3.8, 95% CI 1.6-9.1; P = .002) were associated with adverse outcomes. Among infants who were born at term, not ill appearing, and had bacteremia without meningitis, only 2 of 184 (1.1%) had adverse outcomes, and there were no deaths. CONCLUSIONS Among febrile infants ≤60 days old with IBI, prematurity, ill appearance, and bacterial meningitis (vs bacteremia without meningitis) were associated with adverse outcomes. These factors can inform clinical decision-making for febrile young infants with IBI.
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Affiliation(s)
- Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL.
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Samir S Shah
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH; Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Veronika Shabanova
- Department of Pediatrics and Yale Center for Analytical Sciences, Yale School of Medicine, New Haven, CT
| | - Christopher Woll
- Section of Pediatric Emergency Medicine, Department of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Marie E Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Derek J Williams
- Division of Hospital Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Laura Sartori
- Pediatric Emergency Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Sanyukta Desai
- Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Rianna C Leazer
- Division of Hospital Medicine, Children's Hospital of The King's Daughters, Norfolk, VA
| | - Richard D Marble
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Adrienne G DePorre
- Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | | | - Catherine E Lumb
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Fran Balamuth
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sarah Shin
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Department of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Vos-Kerkhof ED, Gomez B, Milcent K, Steyerberg EW, Nijman RG, Smit FJ, Mintegi S, Moll HA, Gajdos V, Oostenbrink R. Clinical prediction models for young febrile infants at the emergency department: an international validation study. Arch Dis Child 2018; 103:1033-1041. [PMID: 29794106 DOI: 10.1136/archdischild-2017-314011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 03/28/2018] [Accepted: 04/10/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the diagnostic value of existing clinical prediction models (CPM; ie, statistically derived) in febrile young infants at risk for serious bacterial infections. METHODS A systematic literature review identified eight CPMs for predicting serious bacterial infections in febrile children. We validated these CPMs on four validation cohorts of febrile children in Spain (age <3 months), France (age <3 months) and two cohorts in the Netherlands (age 1-3 months and >3-12 months). We evaluated the performance of the CPMs by sensitivity/specificity, area under the receiver operating characteristic curve (AUC) and calibration studies. RESULTS The original cohorts in which the prediction rules were developed (derivation cohorts) ranged from 381 to 15 781 children, with a prevalence of serious bacterial infections varying from 0.8% to 27% and spanned an age range of 0-16 years. All CPMs originally performed moderately to very well (AUC 0.60-0.93). The four validation cohorts included 159-2204 febrile children, with a median age range of 1.8 (1.2-2.4) months for the three cohorts <3 months and 8.4 (6.0-9.6) months for the cohort >3-12 months of age. The prevalence of serious bacterial infections varied between 15.1% and 17.2% in the three cohorts <3 months and was 9.8% for the cohort >3-12 months of age. Although discriminative values varied greatly, best performance was observed for four CPMs including clinical signs and symptoms, urine dipstick analyses and laboratory markers with AUC ranging from 0.68 to 0.94 in the three cohorts <3 months (ranges sensitivity: 0.48-0.94 and specificity: 0.71-0.97). For the >3-12 months' cohort AUC ranges from 0.80 to 0.89 (ranges sensitivity: 0.70-0.82 and specificity: 0.78-0.90). In general, the specificities exceeded sensitivities in our cohorts, in contrast to derivation cohorts with high sensitivities, although this effect was stronger in infants <3 months than in infants >3-12 months. CONCLUSION We identified four CPMs, including clinical signs and symptoms, urine dipstick analysis and laboratory markers, which can aid clinicians in identifying serious bacterial infections. We suggest clinicians should use CPMs as an adjunctive clinical tool when assessing the risk of serious bacterial infections in febrile young infants.
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Affiliation(s)
- Evelien de Vos-Kerkhof
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Borja Gomez
- Paediatric Emergency Department, Cruces University Hospital, Bilbao, Spain.,University of the Basque Country, Bilbao, Spain
| | - Karen Milcent
- AP-HP Department of Paediatrics, Hôpitaux Universitaires Paris Sud-Antoine Béclère, Clamart, France
| | - Ewout W Steyerberg
- Department of Public Health and Clinical Decision Making, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ruud Gerard Nijman
- Department of Paediatric Accident and Emergency, St Mary's Hospital, Imperial College-NHS Healthcare Trust, Rotterdam, The Netherlands
| | - Frank J Smit
- Department of General Paediatrics, Maasstad Hospital, Rotterdam, The Netherlands
| | - Santiago Mintegi
- Paediatric Emergency Department, Cruces University Hospital, Bilbao, Spain.,University of the Basque Country, Bilbao, Spain
| | - Henriette A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Vincent Gajdos
- Université Paris-Saclay, Université Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Giannoni E, Agyeman PKA, Stocker M, Posfay-Barbe KM, Heininger U, Spycher BD, Bernhard-Stirnemann S, Niederer-Loher A, Kahlert CR, Donas A, Leone A, Hasters P, Relly C, Riedel T, Kuehni C, Aebi C, Berger C, Schlapbach LJ. Neonatal Sepsis of Early Onset, and Hospital-Acquired and Community-Acquired Late Onset: A Prospective Population-Based Cohort Study. J Pediatr 2018; 201:106-114.e4. [PMID: 30054165 DOI: 10.1016/j.jpeds.2018.05.048] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/09/2018] [Accepted: 05/30/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To assess the epidemiology of blood culture-proven early- (EOS) and late-onset neonatal sepsis (LOS). STUDY DESIGN All newborn infants admitted to tertiary care neonatal intensive care units in Switzerland and presenting with blood culture-proven sepsis between September 2011 and December 2015 were included in the study. We defined EOS as infection occurring <3 days after birth, and LOS as infection ≥3 days after birth. Infants with LOS were classified as having community-acquired LOS if onset of infection was ≤48 hours after admission, and hospital-acquired LOS, if onset was >48 hours after admission. Incidence was estimated based on the number of livebirths in Switzerland and adjusted for the proportion of admissions at centers participating in the study. RESULTS We identified 444 episodes of blood culture-proven sepsis in 429 infants; 20% of cases were EOS, 62% hospital-acquired LOS, and 18% community-acquired LOS. The estimated national incidence of EOS, hospital-acquired LOS, and community-acquired LOS was 0.28 (95% CI 0.23-0.35), 0.86 (0.76-0.97), and 0.28 (0.23-0.34) per 1000 livebirths. Compared with EOS, hospital-acquired LOS occurred in infants of lower gestational age and was more frequently associated with comorbidities. Community-acquired LOS was more common in term infants and in male infants. Mortality was 18%, 12%, and 0% in EOS, hospital-acquired LOS, and community-acquired LOS, and was higher in preterm infants, in infants with septic shock, and in those requiring mechanical ventilation. CONCLUSIONS We report a high burden of sepsis in neonates with considerable mortality and morbidity. EOS, hospital-acquired LOS, and community-acquired LOS affect specific patient subgroups and have distinct clinical presentation, pathogens and outcomes.
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Affiliation(s)
- Eric Giannoni
- Clinic of Neonatology, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland; Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Stocker
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Klara M Posfay-Barbe
- Pediatric Infectious Diseases Unit, Children's Hospital of Geneva, University Hospitals of Geneva, Geneva, Switzerland
| | - Ulrich Heininger
- Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Basel, Switzerland
| | - Ben D Spycher
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | | | - Alex Donas
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Antonio Leone
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Paul Hasters
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Christa Relly
- Division of Infectious Diseases, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Thomas Riedel
- Department of Pediatrics, Cantonal Hospital Graubuenden, Chur, Switzerland
| | - Claudia Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Christoph Aebi
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Berger
- Division of Infectious Diseases, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Luregn J Schlapbach
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Faculty of Medicine, The University of Queensland, Brisbane, Australia; Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, Brisbane, Australia; Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Children's Health Queensland, Brisbane, Australia
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Snelson E, Ramlakhan S. Which observed behaviours may reassure physicians that a child is not septic? An international Delphi study. Arch Dis Child 2018; 103:864-867. [PMID: 29545408 DOI: 10.1136/archdischild-2017-314339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 02/22/2018] [Accepted: 02/25/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE In an attempt to improve the diagnosis of sepsis in children, diagnostic aids have concentrated on clinical features that suggest that sepsis is present. Clinicians need to be able to clinically rule out sepsis as well as rule it in. Little is known about which features are consistent with wellness and/or absence of sepsis. Guidelines are therefore likely to improve sensitivity without preserving specificity. We aimed to gather expert opinion on which (if any) features would make clinicians consider a child to be unlikely to have sepsis. DESIGN We undertook a modified two-round international Delphi study, where clinicians were asked for features they believed were indicators of wellness in an ill child. PARTICIPANTS One hundred and ninety-five clinicians (predominantly physicians) who routinely assessed unwell children and had been doing so for most of their careers. RESULTS Over 90% of respondents rated age-appropriate verbalisation, playing, smiling and activity as reassuring that a child was unlikely to have sepsis. Eating, spontaneous interaction and normal movement were also agreed to be reassuring by over 70% of participants. Consolability and showing fear of the clinician were not felt to be adequately reassuring. There was wide range of opinion on how reassuring the use of an electronic device was thought to be. CONCLUSIONS This study confirms that physicians are reassured by specific behaviours in ill children, and provides a framework which may be used to help guide the assessment of the unwell child. Validation of individual features could lead to improved specificity of diagnostic aids for diagnosing sepsis.
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Affiliation(s)
- Edward Snelson
- Emergency Department, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK.,Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Shammi Ramlakhan
- Emergency Department, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK.,Faculty of Medical Sciences, The University of the West Indies, Saint Augustine, Trinidad and Tobago
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Pantell RH, Roberts KB, Greenhow TL, Pantell MS. Advances in the Diagnosis and Management of Febrile Infants: Challenging Tradition. Adv Pediatr 2018; 65:173-208. [PMID: 30053923 DOI: 10.1016/j.yapd.2018.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Robert H Pantell
- Kapi'olani Medical Center for Women and Children, 1319 Punahou Street, Honolulu, HI 96824, USA.
| | | | - Tara L Greenhow
- Kaiser Permanente, Northern California, 2200 O'Farrell St, San Francisco, CA 94115, USA
| | - Matthew S Pantell
- University of California San Francisco, Suite 465, 3333 California Street, San Francisco, CA 94118, USA
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Multiplex Cytokine Profiling Identifies Interleukin-27 as a Novel Biomarker For Neonatal Early Onset Sepsis. Shock 2018; 47:140-147. [PMID: 27648693 DOI: 10.1097/shk.0000000000000753] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early onset sepsis (EOS) remains a major cause of mortality and morbidity in neonates, and traditional clinical markers effective for adults are less effective in these patients. This study aimed to assess the value of individual plasma biomarkers as well as biomarker combinations for predicting EOS in neonates. METHODS This prospective study included 151 neonates with suspected EOS. Plasma levels of interleukin (IL)-27, IL-6, IL-8, tumor necrosis factor (TNF)-α, heat shock protein (HSP) 70, macrophage inflammatory protein (MIP)-1α, MIP-1β, granzyme B, and matrix metalloproteinase (MMP)-8 were measured through multiplex cytokine profiling and assessed along with C-reactive protein (CRP) and procalcitonin (PCT). Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive ability of biomarkers individually and in combination. Logistic regression model was constructed to identify independent predictors of EOS. RESULTS The proven sepsis and probable sepsis groups were combined to form the infected group (n = 68), and the possible sepsis and low-risk sepsis groups were combined to form the uninfected group (n = 83). The ROC area under the curve was 0.747 for IL-27 (P <0.01). In addition, IL-6, TNF-α, HSP 70, MMP-8, PCT, and CRP were significantly predictive of EOS, whereas IL-8, granzyme B, MIP-1α, and MIP-1β were not. Both IL-27 and PCT were identified as independent predictors of EOS in the multivariate model, and the combined use of these markers showed significantly increased predictive ability for EOS. CONCLUSION Our results indicate that elevated IL-27 strongly correlates with EOS and may provide additional diagnostic value along with PCT.
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Herreros ML, Tagarro A, García-Pose A, Sánchez A, Cañete A, Gili P. Performing a urine dipstick test with a clean-catch urine sample is an accurate screening method for urinary tract infections in young infants. Acta Paediatr 2018; 107:145-150. [PMID: 28940750 DOI: 10.1111/apa.14090] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/20/2017] [Accepted: 09/20/2017] [Indexed: 12/15/2022]
Abstract
AIM This study evaluated using urine dipstick tests with the clean-catch method to screen for urinary tract infection (UTI) in febrile infants under 90 days of age. METHODS We carried out a comparative diagnostic accuracy study of infants under 90 days old, who were studied for unexplained fever without any source, in the emergency room of a hospital in Madrid from January 2011 to January 2013. We obtained matched samples of urine using two different methods: a clean-catch, standardised stimulation technique and catheterisation collection. The results of the leucocyte esterase test and nitrite test were compared with their urine cultures. RESULTS We obtained 60 pairs of matched samples. A combined analysis of leukocyte esterase and, or, nitrites yielded a sensitivity of 86% and a specificity of 80% for the diagnosis of UTIs in clean-catch samples. The sensitivity of leukocyte esterase and, or, nitrites in samples obtained by catheterisation were not statistically different to the clean-catch samples (p = 0.592). CONCLUSION Performing urine dipstick tests using urine samples obtained by the clean-catch method was an accurate screening test for diagnosing UTIs in febrile infants of less than 90 days old. This provided a good alternative to bladder catheterisation when screening for UTIs.
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Affiliation(s)
- María Luisa Herreros
- Department of Pediatrics; Infanta Sofía University Hospital; San Sebastián de los Reyes, Madrid Spain
- Faculty of Health Sciences; European University; Madrid Spain
| | - Alfredo Tagarro
- Department of Pediatrics; Infanta Sofía University Hospital; San Sebastián de los Reyes, Madrid Spain
- Faculty of Health Sciences; European University; Madrid Spain
| | - Araceli García-Pose
- Department of Pediatrics; Infanta Sofía University Hospital; San Sebastián de los Reyes, Madrid Spain
| | - Aida Sánchez
- Department of Microbiology; Infanta Sofía University Hospital; San Sebastián de los Reyes, Madrid Spain
| | - Alfonso Cañete
- Department of Pediatrics; Infanta Sofía University Hospital; San Sebastián de los Reyes, Madrid Spain
- Faculty of Health Sciences; European University; Madrid Spain
| | - Pablo Gili
- Faculty of Health Sciences; European University; Madrid Spain
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Li W, Luo S, Zhu Y, Wen Y, Shu M, Wan C. C-reactive protein concentrations can help to determine which febrile infants under three months should receive blood cultures during influenza seasons. Acta Paediatr 2017; 106:2017-2024. [PMID: 28799220 DOI: 10.1111/apa.14022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/03/2017] [Accepted: 08/08/2017] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Weiran Li
- Department of Paediatrics; West China Second Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University); Ministry of Education; Chengdu China
| | - Shuanghong Luo
- Department of Paediatrics; West China Second Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University); Ministry of Education; Chengdu China
| | - Yu Zhu
- Department of Paediatrics; West China Second Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University); Ministry of Education; Chengdu China
| | - Yang Wen
- Department of Paediatrics; West China Second Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University); Ministry of Education; Chengdu China
| | - Min Shu
- Department of Paediatrics; West China Second Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University); Ministry of Education; Chengdu China
| | - Chaomin Wan
- Department of Paediatrics; West China Second Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University); Ministry of Education; Chengdu China
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de la Torre M, de Lucas N, Velasco R, Gómez B, Mintegi S. Etiología y evolución de las infecciones potencialmente graves en lactantes menores de 3 meses febriles. An Pediatr (Barc) 2017; 87:42-49. [DOI: 10.1016/j.anpedi.2016.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/30/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022] Open
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Aetiology and outcomes of potentially serious infections in febrile infants less than 3 months old. An Pediatr (Barc) 2017. [DOI: 10.1016/j.anpede.2016.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Mintegi S, Gomez B, Martinez-Virumbrales L, Morientes O, Benito J. Outpatient management of selected young febrile infants without antibiotics. Arch Dis Child 2017; 102:244-249. [PMID: 27470162 DOI: 10.1136/archdischild-2016-310600] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To analyse the outpatient management of selected febrile infants younger than 90 days without systematic lumbar puncture and antibiotics. METHODS A prospective registry-based cohort study including all the infants ≤90 days with fever without a source (FWS) who were evaluated in a paediatric emergency department (ED) over a 7-year period (September 2007-August 2014). We analysed the outcome of those infants with low-risk criteria for serious bacterial infection (SBI) managed as outpatients without antibiotics and without undergoing a lumbar puncture. Low-risk criteria: Well appearing, older than 21 days of age, no leucocyturia, absolute neutrophil count ≤10 000, serum C reactive protein ≤20 mg/L, procalcitonin <0.5 ng/mL and no clinical deterioration during the stay in the ED (always <24 hours). RESULTS 1472 infants with FWS attended the ED. Of these, 676 were classified to be at low risk for SBI without performing a lumbar puncture. After staying <24 hours in the short-stay unit of the ED, 586 (86.6%) were managed as outpatients without antibiotics. Two patients were diagnosed with SBI: one occult bacteraemia and one bacterial gastroenteritis. Both were afebrile when evaluated again and did well. No patient returned to the ED due to clinical deterioration. Fifty-one infants (8.7%) returned to the ED mainly due to persistence of fever or irritability. None was diagnosed with definite SBI or non-bacterial meningitis. CONCLUSIONS Outpatient management without antibiotics and systematic lumbar puncture is appropriate for selected febrile infants younger than 3 months of age with close follow-up.
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Affiliation(s)
- Santiago Mintegi
- Paediatric Emergency Department, Cruces University Hospital. University of the Basque Country, Bilbao, Spain
| | - Borja Gomez
- Paediatric Emergency Department, Cruces University Hospital. University of the Basque Country, Bilbao, Spain
| | - Lidia Martinez-Virumbrales
- Paediatric Emergency Department, Cruces University Hospital. University of the Basque Country, Bilbao, Spain
| | - Oihane Morientes
- Paediatric Emergency Department, Cruces University Hospital. University of the Basque Country, Bilbao, Spain
| | - Javier Benito
- Paediatric Emergency Department, Cruces University Hospital. University of the Basque Country, Bilbao, Spain
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Díaz Álvarez M, Acosta Batista B, Pérez Córdova R, Hernández Robledo E. [Urinary tract infection caused by Enterobacteriaceae and its relationship with vesicoureteral reflux]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2017; 74:34-40. [PMID: 29364812 DOI: 10.1016/j.bmhimx.2016.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/23/2016] [Accepted: 10/19/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND The first urinary tract infection can be a marker of a urinary tract anomaly, mainly vesicoureteral reflux. The aim of this work was to determine the association between isolated enterobacteria with the presence and grade of vesicoureteral reflux in neonatal patients with their first urinary tract infection. METHODS A retrospective, observational and analytic study of newborns, who were admitted to the Neonatal Department, University Pediatric Hospital "Juan Manuel Márquez," in Havana, Cuba, from 1992 to 2013 was conducted. The causal microorganism of urinary tract infection was from the Enterobacteriaceae family. They were evaluated by radio imaging. The association between the presence and grade of vesicoureteral reflux with the causal microorganism of the urinary tract infection was analyzed. RESULTS Newborn infants with urinary tract infection (450) were studied. Bacterial isolations in the urine cultures corresponded to E. coli in 316 cases (70.2%). The prevalence of vesicoureteral reflux was 18.2%. The presence of bacteria corresponding to the Enterobacteriaceae family (other than E. coli) had significant risk association with vesicoureteral reflux (OR: 2.02; p < 0.01) and vesicoureteral reflux classification (for higher grades, p < 0.01). CONCLUSIONS E. coli is the most frequent causal microorganism in neonatal urinary tract infection. However, an association between the isolation of a microorganism of the Enterobacteriaceae family different to E. coli with the presence of vesicoureteral reflux and mainly with higher grades of vesicoureteral reflux exists.
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Affiliation(s)
- Manuel Díaz Álvarez
- Servicio de Neonatología, Hospital Pediátrico Universitario "Juan M. Márquez", La Habana, Cuba.
| | - Bárbara Acosta Batista
- Servicio de Neonatología, Hospital Pediátrico Universitario "Juan M. Márquez", La Habana, Cuba
| | - Rodolfo Pérez Córdova
- Servicio de Neonatología, Hospital Pediátrico Universitario "Juan M. Márquez", La Habana, Cuba
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Hammoud MS, Al-Taiar A, Al-Abdi SY, Bozaid H, Khan A, AlMuhairi LM, Rehman MU. Culture-proven early-onset neonatal sepsis in Arab states in the Gulf region: two-year prospective study. Int J Infect Dis 2016; 55:11-15. [PMID: 27979783 DOI: 10.1016/j.ijid.2016.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 12/03/2016] [Accepted: 12/05/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the incidence and the pattern of causative organisms of culture-proven early-onset sepsis (EOS) in Arab states in the Gulf region. METHODS Five neonatal care units participated in this 2-year prospective study in Kuwait, the United Arab Emirates, and Saudi Arabia. Data were collected prospectively using a standardized data collection form. EOS was defined as the growth of a single potentially pathogenic organism from blood or cerebrospinal fluid in infants within 72h of birth, with clinical and laboratory findings consistent with infection. RESULTS Out of 67 474 live births, 102 cases of EOS occurred. The overall incidence of EOS was 1.5 (95% confidence interval 1.2-1.8) per 1000 live-births, ranging from 2.64 per 1000 live-births in Kuwait to 0.40 per 1000 live-births in King Abdulaziz Hospital in Saudi Arabia. The most common causative organism of EOS was group B Streptococcus (GBS; 60.0%), followed by Escherichia coli (13%). The incidence of invasive GBS disease was 0.90 per 1000 live-births overall and ranged from 1.4 per 1000 live-births in Kuwait to 0.6 per 1000 live-births in Dubai Hospital. CONCLUSIONS The incidence of EOS and the patterns of the causative organisms in the Arab states in the Gulf region are similar to those in developed countries before the era of intrapartum antibiotic prophylaxis. Efforts should be made to improve intrapartum antibiotic prophylaxis in the Arab state setting, which could avert large numbers of GBS infections.
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Affiliation(s)
- Majeda S Hammoud
- Department of Pediatrics, Faculty of Medicine, Kuwait University, PO Box 24923, Safat, Kuwait City 13110, Kuwait.
| | - Abdullah Al-Taiar
- Department of Community Medicine and Behavioural Sciences, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | | | - Hussain Bozaid
- Maternity and Children's Hospital, Al-Ahsa, Saudi Arabia
| | - Anwar Khan
- Dubai Hospital, Dubai, United Arab Emirates
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Laaksonen N, Rintamäki L, Korppi M. Pneumococcal vaccinations effectively prevent blood culture-negative infections that resemble occult pneumococcal bacteraemia or bacteraemic pneumococcal pneumonia at one to 36 months of age. Acta Paediatr 2016; 105:1487-1492. [PMID: 27607346 DOI: 10.1111/apa.13580] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/19/2016] [Accepted: 09/05/2016] [Indexed: 12/25/2022]
Abstract
AIM The occurrence of blood culture-positive pneumococcal bacteraemia and bacteraemic pneumonia decreased after large-scale pneumococcal vaccinations were introduced. The aim of this study was to evaluate the effect of pneumococcal vaccinations on hospitalisations due to blood culture-negative infections with fever and leucocytosis, without any other focus than pneumonic infiltration. MATERIAL This was a retrospective hospital chart review covering the prevaccination era of 2008-2009 and postvaccination era of 2012-2013. The number of study subjects with fever and blood leucocytosis of >17.5 × 10E9/L at one to 36 months of age was 202. RESULTS The incidence of hospitalisation for infections associated with fever and leucocytosis, when pneumonic infiltration was present on the chest radiograph, was 4.7/10 000/year, with a 95% confidence interval (95% CI) of 2.2-8.8 in children under 36 months in 2012-2013. When pneumonic infiltration was not present, the respective incidence was 14.6/10 000/year (95% CI: 9.6-21.1). The figure from the 2008-2009 prevaccination era was 11.3 (95% CI: 8.1-15.3) when pneumonic infiltration was present and 24.0/10 000/year (95% CI: 19.2-29.7) when pneumonic infiltration was absent. CONCLUSION This study provides evidence of the effectiveness of pneumococcal vaccinations in preventing blood culture-negative infections that resembled occult pneumococcal bacteraemia (pneumococcaemia) or bacteraemic pneumococcal pneumonia at one to 36 months of age.
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Affiliation(s)
- Neea Laaksonen
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Lilja Rintamäki
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Matti Korppi
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
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Velasco R, Gómez B, Hernández-Bou S, Olaciregui I, de la Torre M, González A, Rivas A, Durán I, Rubio A. Validation of a predictive model for identifying febrile young infants with altered urinalysis at low risk of invasive bacterial infection. Eur J Clin Microbiol Infect Dis 2016; 36:281-284. [DOI: 10.1007/s10096-016-2798-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
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Lack of Accuracy of Biomarkers and Physical Examination to Detect Bacterial Infection in Febrile Infants. Pediatr Emerg Care 2016; 32:664-668. [PMID: 25822238 DOI: 10.1097/pec.0000000000000401] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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