1
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Zalmanovich A, Temkin E, Biran D, Carmeli Y. The Yield of One vs. Two Blood Cultures in Children: Under-Detection and Over-Testing. Antibiotics (Basel) 2024; 13:113. [PMID: 38391499 PMCID: PMC10886363 DOI: 10.3390/antibiotics13020113] [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: 11/10/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
We aimed to determine whether obtaining two blood cultures (BCs) instead of one improved the detection of bloodstream infections (BSIs) in children. For this descriptive study, we used surveillance data collected in 2019-2021 from all Israeli hospitals serving children. The sample included 178,702 culturing episodes. One BC was taken in 90.1% of all episodes and 98.2% of episodes in the emergency department. A true pathogen was detected in 1687/160,964 (1.0%) of single-culture episodes and 1567/17,738 (8.9%) of two-culture episodes (p < 0.001). The yield was significantly different even when considering only the first BC in two-culture episodes: 1.0% vs. 7.5%. Among 1576 two-culture episodes that were positive for a true pathogen, the pathogen was detected only in the second culture in 252 (16.0%). We estimated that if a second culture had been taken in all episodes, an additional 343 BSIs by a true pathogen would have been detected. Among 1086 two-culture episodes with commensal bacteria, the second BC was sterile in 530 (48.8%), suggesting contamination. A commensal was isolated in 3094/4781 (64.7%) positive single-culture episodes, which could represent BSI or contamination. The yield of a single BC bottle was low, reflecting both lower sensitivity of a single bottle and the taking of single bottles in patients with a low probability of BSI.
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Affiliation(s)
- Anat Zalmanovich
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv 64239, Israel
- Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
| | - Elizabeth Temkin
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv 64239, Israel
| | - Dikla Biran
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv 64239, Israel
| | - Yehuda Carmeli
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv 64239, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
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2
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Graaf S, Keuning MW, Pajkrt D, Plötz FB. Fever without a source in children: international comparison of guidelines. World J Pediatr 2023; 19:120-128. [PMID: 36287322 PMCID: PMC9928815 DOI: 10.1007/s12519-022-00611-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/17/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fever without a source (FWS) in children poses a diagnostic challenge. To distinguish a self-limiting infection from a serious infection, multiple guidelines have been developed to aid physicians in the management of FWS. Currently, there is no comparison of existing FWS guidelines. METHODS This comparative review describes consistencies and differences in guideline definitions and diagnostic and therapeutic recommendations. A literature search was performed to include secondary care FWS guidelines of high-income countries, composed by national or regional pediatric or emergency care associations, available in English or Dutch. RESULTS Ten guidelines of five high-income countries were included, with varying age ranges of children with FWS. In children younger than one month with FWS, the majority of the guidelines recommended laboratory testing, blood and urine culturing and antibiotic treatment irrespective of the clinical condition of the patient. Recommendations for blood culture and antibiotic treatment varied for children aged 1-3 months. In children aged above three months, urine culture recommendations were inconsistent, while all guidelines consistently recommended cerebral spinal fluid testing and antibiotic treatment exclusively for children with a high risk of serious infection. CONCLUSIONS We found these guidelines broadly consistent, especially for children with FWS younger than one month. Guideline variation was seen most in the targeted age ranges and in recommendations for children aged 1-3 months and above three months of age. The findings of the current study can assist in harmonizing guideline development and future research for the management of children with FWS.
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Affiliation(s)
- Sanne Graaf
- Department of Pediatrics, Tergooi Hospital, Rijksstraatweg 1, 1261 AN, Blaricum, The Netherlands.
| | - Maya Wietske Keuning
- Department of Pediatrics, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pediatric Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Dasja Pajkrt
- Department of Pediatric Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Frans Berend Plötz
- Department of Pediatrics, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pediatric Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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3
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Bertran M, Amin-Chowdhury Z, Davies HG, Allen H, Clare T, Davison C, Sinnathamby M, Seghezzo G, Kall M, Williams H, Gent N, Ramsay ME, Ladhani SN, Oligbu G. COVID-19 deaths in children and young people in England, March 2020 to December 2021: An active prospective national surveillance study. PLoS Med 2022; 19:e1004118. [PMID: 36346784 PMCID: PMC9642873 DOI: 10.1371/journal.pmed.1004118] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Coronavirus Disease 2019 (COVID-19) deaths are rare in children and young people (CYP). The high rates of asymptomatic and mild infections complicate assessment of cause of death in CYP. We assessed the cause of death in all CYP with a positive Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) test since the start of the pandemic in England. METHODS AND FINDINGS CYP aged <20 years who died within 100 days of laboratory-confirmed SARS-CoV-2 infection between 01 March 2020 and 31 December 2021 in England were followed up in detail, using national databases, surveillance questionnaires, post-mortem reports, and clinician interviews. There were 185 deaths during the 22-month follow-up and 81 (43.8%) were due to COVID-19. Compared to non-COVID-19 deaths in CYP with a positive SARS-CoV-2 test, death due to COVID-19 was independently associated with older age (aOR 1.06 95% confidence interval (CI) 1.01 to 1.11, p = 0.02) and underlying comorbidities (aOR 2.52 95% CI 1.27 to 5.01, p = 0.008), after adjusting for age, sex, ethnicity group, and underlying conditions, with a shorter interval between SARS-CoV-2 testing and death. Half the COVID-19 deaths (41/81, 50.6%) occurred within 7 days of confirmation of SARS-CoV-2 infection and 91% (74/81) within 30 days. Of the COVID-19 deaths, 61 (75.3%) had an underlying condition, especially severe neurodisability (n = 27) and immunocompromising conditions (n = 12). Over the 22-month surveillance period, SARS-CoV-2 was responsible for 1.2% (81/6,790) of all deaths in CYP aged <20 years, with an infection fatality rate of 0.70/100,000 SARS-CoV-2 infections in this age group estimated through real-time, nowcasting modelling, and a mortality rate of 0.61/100,000. Limitations include possible under-ascertainment of deaths in CYP who were not tested for SARS-CoV-2 and lack of direct access to clinical data for hospitalised CYP. CONCLUSIONS COVID-19 deaths remain extremely rare in CYP, with most fatalities occurring within 30 days of infection and in children with specific underlying conditions.
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Affiliation(s)
- Marta Bertran
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | - Zahin Amin-Chowdhury
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | - Hannah G. Davies
- Paediatric Infectious Diseases Research Group, St George’s University of London, London, United Kingdom
| | - Hester Allen
- COVID-19 National Epidemiology Cell, UK Health Security Agency, London, United Kingdom
| | - Tom Clare
- COVID-19 National Epidemiology Cell, UK Health Security Agency, London, United Kingdom
| | - Chloe Davison
- COVID-19 National Epidemiology Cell, UK Health Security Agency, London, United Kingdom
| | - Mary Sinnathamby
- COVID-19 National Epidemiology Cell, UK Health Security Agency, London, United Kingdom
| | - Giulia Seghezzo
- COVID-19 National Epidemiology Cell, UK Health Security Agency, London, United Kingdom
| | - Meaghan Kall
- COVID-19 National Epidemiology Cell, UK Health Security Agency, London, United Kingdom
| | - Hannah Williams
- Joint Modelling Team (JMT), UK Health Security Agency, London, United Kingdom
- Emergency Preparedness, Response and Resilience, UK Health Security Agency, Porton Down, United Kingdom
| | - Nick Gent
- Joint Modelling Team (JMT), UK Health Security Agency, London, United Kingdom
- Emergency Preparedness, Response and Resilience, UK Health Security Agency, Porton Down, United Kingdom
| | - Mary E. Ramsay
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | - Shamez N. Ladhani
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
- Paediatric Infectious Diseases Research Group, St George’s University of London, London, United Kingdom
- * E-mail:
| | - Godwin Oligbu
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
- Paediatric Infectious Diseases Research Group, St George’s University of London, London, United Kingdom
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4
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Fan B, Klatt J, Moor MM, Daniels LA. Prediction of recovery from multiple organ dysfunction syndrome in pediatric sepsis patients. Bioinformatics 2022; 38:i101-i108. [PMID: 35758775 PMCID: PMC9236580 DOI: 10.1093/bioinformatics/btac229] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
MOTIVATION Sepsis is a leading cause of death and disability in children globally, accounting for ∼3 million childhood deaths per year. In pediatric sepsis patients, the multiple organ dysfunction syndrome (MODS) is considered a significant risk factor for adverse clinical outcomes characterized by high mortality and morbidity in the pediatric intensive care unit. The recent rapidly growing availability of electronic health records (EHRs) has allowed researchers to vastly develop data-driven approaches like machine learning in healthcare and achieved great successes. However, effective machine learning models which could make the accurate early prediction of the recovery in pediatric sepsis patients from MODS to a mild state and thus assist the clinicians in the decision-making process is still lacking. RESULTS This study develops a machine learning-based approach to predict the recovery from MODS to zero or single organ dysfunction by 1 week in advance in the Swiss Pediatric Sepsis Study cohort of children with blood-culture confirmed bacteremia. Our model achieves internal validation performance on the SPSS cohort with an area under the receiver operating characteristic (AUROC) of 79.1% and area under the precision-recall curve (AUPRC) of 73.6%, and it was also externally validated on another pediatric sepsis patients cohort collected in the USA, yielding an AUROC of 76.4% and AUPRC of 72.4%. These results indicate that our model has the potential to be included into the EHRs system and contribute to patient assessment and triage in pediatric sepsis patient care. AVAILABILITY AND IMPLEMENTATION Code available at https://github.com/BorgwardtLab/MODS-recovery. The data underlying this article is not publicly available for the privacy of individuals that participated in the study. SUPPLEMENTARY INFORMATION Supplementary data are available at Bioinformatics online.
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Affiliation(s)
- Bowen Fan
- Department of Biosystems Science and Engineering, ETH Zurich, Basel 4058, Switzerland
- SIB Swiss Institute of Bioinformatics, Lausanne 1015, Switzerland
| | - Juliane Klatt
- Department of Biosystems Science and Engineering, ETH Zurich, Basel 4058, Switzerland
- SIB Swiss Institute of Bioinformatics, Lausanne 1015, Switzerland
| | - Michael M Moor
- Department of Biosystems Science and Engineering, ETH Zurich, Basel 4058, Switzerland
- SIB Swiss Institute of Bioinformatics, Lausanne 1015, Switzerland
| | - Latasha A Daniels
- Division of Critical Care, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
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5
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van der Velden FJS, Gennery AR, Emonts M. Biomarkers for Diagnosing Febrile Illness in Immunocompromised Children: A Systematic Review of the Literature. Front Pediatr 2022; 10:828569. [PMID: 35372147 PMCID: PMC8965604 DOI: 10.3389/fped.2022.828569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/25/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE This study aims to assess the performance of biomarkers used for the prediction of bacterial, viral, and fungal infection in immunocompromised children upon presentation with fever. METHODS We performed a literature search using PubMed and MEDLINE and In-Process & Other Non-indexed Citations databases. Cohort and case-control studies assessing biomarkers for the prediction of bacterial, viral, or fungal infection in immunocompromised children vs. conventional microbiological investigations were eligible. Studies including adult patients were eligible if pediatric data were separately assessable. Data on definitions used for infections, fever, and neutropenia and predictive values were collected. Risk of bias was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. RESULTS Fifty-two studies involving 13,939 febrile episodes in 7,059 children were included. In total, 92.2% were in cancer patients (n = 48), and 15.7% also included hematopoietic stem cell transplantation patients (n = 8). Forty-three biomarkers were investigated, of which 6 (CRP, PCT, IL-8, IL-6, IL-10, and TNFα) were significantly associated with bacterial infection at admission, studied in multiple studies, and provided predictive data. Literature on the prediction of viral and fungal infection was too limited. Eight studies compared C-reactive protein (CRP) and procalcitonin (PCT), with PCT demonstrating superiority in 5. IL-6, IL-8, and IL-10 were compared with CRP in six, four, and one study, respectively, with mixed results on diagnostic superiority. No clear superior biomarker comparing PCT vs. IL-6, IL-8, or IL-10 was identified. DISCUSSION There is great heterogeneity in the biomarkers studied and cutoff values and definitions used, thus complicating the analysis. Literature for immunocompromised children with non-malignant disease and for non-bacterial infection is sparse. Literature on novel diagnostics was not available. We illustrated the challenges of diagnosing fever adequately in this study population and the need for improved biomarkers and clinical decision-making tools.
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Affiliation(s)
- Fabian J S van der Velden
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.,Great North Children's Hospital, Paediatric Immunology, Infectious Diseases and Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.,Great North Children's Hospital, Paediatric Immunology, Infectious Diseases and Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Marieke Emonts
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.,Great North Children's Hospital, Paediatric Immunology, Infectious Diseases and Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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6
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Allen J, Zareen Z, Doyle S, Whitla L, Afzal Z, Stack M, Franklin O, Green A, James A, Leahy TR, Quinn S, Elnazir B, Russell J, Paran S, Kiely P, Roche EF, McDonnell C, Baker L, Hensey O, Gibson L, Kelly S, McDonald D, Molloy EJ. Multi-Organ Dysfunction in Cerebral Palsy. Front Pediatr 2021; 9:668544. [PMID: 34434904 PMCID: PMC8382237 DOI: 10.3389/fped.2021.668544] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/15/2021] [Indexed: 11/20/2022] Open
Abstract
Cerebral Palsy (CP) describes a heterogenous group of non-progressive disorders of posture or movement, causing activity limitation, due to a lesion in the developing brain. CP is an umbrella term for a heterogenous condition and is, therefore, descriptive rather than a diagnosis. Each case requires detailed consideration of etiology. Our understanding of the underlying cause of CP has developed significantly, with areas such as inflammation, epigenetics and genetic susceptibility to subsequent insults providing new insights. Alongside this, there has been increasing recognition of the multi-organ dysfunction (MOD) associated with CP, in particular in children with higher levels of motor impairment. Therefore, CP should not be seen as an unchanging disorder caused by a solitary insult but rather, as a condition which evolves over time. Assessment of multi-organ function may help to prevent complications in later childhood or adulthood. It may also contribute to an improved understanding of the etiology and thus may have an implication in prevention, interventional methods and therapies. MOD in CP has not yet been quantified and a scoring system may prove useful in allowing advanced clinical planning and follow-up of children with CP. Additionally, several biomarkers hold promise in assisting with long-term monitoring. Clinicians should be aware of the multi-system complications that are associated with CP and which may present significant diagnostic challenges given that many children with CP communicate non-verbally. A step-wise, logical, multi-system approach is required to ensure that the best care is provided to these children. This review summarizes multi-organ dysfunction in children with CP whilst highlighting emerging research and gaps in our knowledge. We identify some potential organ-specific biomarkers which may prove useful in developing guidelines for follow-up and management of these children throughout their lifespan.
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Affiliation(s)
- John Allen
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | | | - Samantha Doyle
- Department of Clinical Genetics, Birmingham Women's Hospital, Birmingham, United Kingdom
| | - Laura Whitla
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Zainab Afzal
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Maria Stack
- Children's Health Ireland at Crumlin, Dublin, Ireland
- Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Orla Franklin
- Children's Health Ireland at Crumlin, Dublin, Ireland
- Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Andrew Green
- Children's Health Ireland at Crumlin, Dublin, Ireland
- Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Adam James
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Timothy Ronan Leahy
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Shoana Quinn
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Basil Elnazir
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - John Russell
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Sri Paran
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Patrick Kiely
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Edna Frances Roche
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Ciara McDonnell
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
- Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Louise Baker
- Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | | | - Louise Gibson
- Department of Paediatrics, Cork University Hospital, Cork, Ireland
| | - Stephanie Kelly
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Denise McDonald
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Eleanor J. Molloy
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
- Children's Health Ireland at Crumlin, Dublin, Ireland
- Department of Neonatology, The Coombe Women and Infants University Hospital, Dublin, Ireland
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7
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Oligbu G, Ahmed L, Ferraras-Antolin L, Ladhani S. Retrospective analysis of neonatal deaths secondary to infections in England and Wales, 2013-2015. Arch Dis Child Fetal Neonatal Ed 2021; 106:363-369. [PMID: 33239280 DOI: 10.1136/archdischild-2020-319093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/28/2020] [Accepted: 11/03/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To estimate the overall and infection-related neonatal mortality rate and the pathogens responsible using electronic death registrations. DESIGN Retrospective analysis of national electronic death registrations data. SETTING England and Wales. PATIENTS Neonates aged <28 days. MAIN OUTCOME MEASURES Overall and infection-related mortality rate per 1000 live births in term, preterm (28-36 weeks) and extremely preterm (<28 weeks) neonates; the contribution of infections and specific pathogens; comparison with mortality rates in 2003-2005. RESULTS The neonatal mortality rate during 2013-2015 (2.4/1000 live births; 5095 deaths) was 31% lower than in 2003-2005 (3.5/1000; 6700 deaths). Infection-related neonatal mortality rate in 2013-2015 (0.32/1000; n=669) was 20% lower compared with 2003-2015 (0.40/1000; n=768), respectively. Infections were responsible for 13.1% (669/5095) of neonatal deaths during 2013-2015 and 11.5% (768/6700) during 2003-2005. Of the infection-related deaths, 44.2% (296/669) were in term, 19.9% (133/669) preterm and 35.9% (240/669) extremely preterm neonates. Compared with term infants (0.15/1000 live births), infection-related mortality rate was 5.9-fold (95% CI 4.7 to 7.2) higher in preterm (0.90/1000) and 188-fold (95% CI 157 to 223) higher in extremely preterm infants (28.7/1000) during 2013-2015. A pathogen was recorded in 448 (67%) registrations: 400 (89.3%) were bacterial, 37 (8.3%) viral and 11 (2.4%) fungal. Group B streptococcus (GBS) was reported in 30.4% (49/161) of records that specified a bacterial infection and 7.3% (49/669) of infection-related deaths. CONCLUSIONS Overall and infection-related neonatal mortality rates have declined, but the contribution of infection and of specific pathogens has not changed. Further preventive measures, including antenatal GBS vaccine may be required to prevent the single most common cause of infection-related deaths in neonates.
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Affiliation(s)
- Godwin Oligbu
- Immunisation and Countermeasures Division, Public Health England, Colindale, London, UK.,Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Leila Ahmed
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Laura Ferraras-Antolin
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Shamez Ladhani
- Immunisation and Countermeasures Division, Public Health England, Colindale, London, UK .,Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
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8
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Vandenberk M, De Bondt K, Nuyts E, Toelen J, Verbakel JY. Shivering has little diagnostic value in diagnosing serious bacterial infection in children: a systematic review and meta-analysis. Eur J Pediatr 2021; 180:1033-1042. [PMID: 33179117 DOI: 10.1007/s00431-020-03870-7] [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: 08/15/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 11/28/2022]
Abstract
Early diagnosis of serious bacterial infections (SBI) is important for improving outcome of morbidity and mortality in children. A systematic review was conducted to examine if shivering had any value in diagnosing serious bacterial infection. We split our population (0-18 years old) into two categories depending on the presence of a known malignancy. The databases of Medline, Embase, Cinahl, and Web of Science were searched from inception until July 2019. The quality was assessed with the QUADAS-2 tool. Two by two tables were created, extracting the number of true positive (TP), true negative (TN), false positive (FP), and false negative (FN) regarding shivering and SBI, by 2 authors independently. Sensitivity, specificity, likelihood ratios, and their 95% confidence intervals were calculated using the MetaDATA Shiny app. In a population with known malignancy, we found a +LR of 3.47 (95% CI 2.58-4.36) for a serious bacterial infection when shivering was present, implying an increase of 25-30% possibility for a serious bacterial infection. In children without malignancy, diagnostic accuracy of shivering was poor.Conclusion: Shivering is of limited use to diagnose serious bacterial infection in children without malignancy. Nevertheless, in children with known malignancy, it can be useful as an alarm signal. What is Known: • In the NICE guidelines for febrile illness in children, "shivering" is considered as an intermediate risk factor ("amber" sign) for a serious illness. • A systematic literature search conducted in 2007 investigating the correlation between shivering in a febrile child and the presence of a serious bacterial infection could include only one study. What is New: • Based on the results of this systematic review, shivering has little diagnostic value in children without malignancy but can be useful as an alarm sign of serious bacterial infection in children with known malignancy. • In case of absence of shivering, serious bacterial infection cannot be ruled out.
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Affiliation(s)
| | | | - Emma Nuyts
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jaan Toelen
- Department of Pediatrics, Division of Woman and Child, UZ Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium. .,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
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9
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Ward JL, Wolfe I, Viner RM. Cause-specific child and adolescent mortality in the UK and EU15+ countries. Arch Dis Child 2020; 105:1055-1060. [PMID: 32847797 DOI: 10.1136/archdischild-2019-318097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 04/14/2020] [Accepted: 05/23/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare cause-specific UK mortality in children and young people (CYP) with EU15+ countries (European Union countries pre-2004, Australia, Canada and Norway). DESIGN Mortality estimates were coded from the WHO World Mortality Database. Causes of death were mapped using the Global Burden of Disease mortality hierarchy to 22 cause groups. We compared UK mortality by cause, age group and sex with EU15+ countries in 2015 (or latest available) using Poisson regression models. We then ranked the UK compared with the EU15+ for each cause. SETTING The UK and EU15+ countries. PARTICIPANTS CYP aged 1-19. MAIN OUTCOME MEASURE Mortality rate per 100 000 and number of deaths. RESULTS UK mortality in 2015 was significantly higher than the EU15+ for common infections (both sexes aged 1-9, boys aged 10-14 and girls aged 15-19); chronic respiratory conditions (both sexes aged 5-14); and digestive, neurological and diabetes/urological/blood/endocrine conditions (girls aged 15-19). UK mortality was significantly lower for transport injuries (boys aged 15-19). The UK had the worst to third worst mortality rank for common infections in both sexes and all age groups, and in five out of eight non-communicable disease (NCD) causes in both sexes in at least one age group. UK mortality rank for injuries in 2015 was in the top half of countries for most causes. CONCLUSIONS UK CYP mortality is higher than a group of comparable countries for common infections and multiple NCD causes. Excess UK CYP mortality may be amenable to health system strengthening.
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Affiliation(s)
- Joseph Lloyd Ward
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Ingrid Wolfe
- Department of Women and Children's Health, King's College London, London, London, UK
| | - Russell M Viner
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
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10
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Ferreras-Antolín L, Oligbu G, Okike IO, Ladhani S. Infection is associated with one in five childhood deaths in England and Wales: analysis of national death registrations data, 2013-15. Arch Dis Child 2020; 105:857-863. [PMID: 32209555 DOI: 10.1136/archdischild-2019-318001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To estimate the contribution of infections to childhood deaths in England and Wales over a 3-year period. DESIGN Retrospective analysis of national electronic death registration data. SETTING England and Wales. PATIENTS Children aged 28 days to 15 years who died during 2013-15. MAIN OUTCOME MEASURES The proportion of children who died of infection compared with total deaths over 3 years; the main pathogens responsible for infection-related deaths in different age groups; comparison with similar data from 2003 to 2005. RESULTS There were 5088 death registrations recorded in children aged 28 days to <15 years in England and Wales during the three calendar years, 2013-2015 (17.6 deaths/100 000 children annually) compared with 6897 (23.9/100 000) during 2003-05 (incidence rate ratios (IRR) 0.74, 95% CI 0.71 to 0.77). During 2013-15, there were 951 (18.7%, 951/5088) infection-related deaths compared with 1368 (19.8%, 1368/6897) during 2003-05, equivalent to an infection-related mortality rate of 3.3/100 000 compared with 4.8/100 000 during the two periods (IRR 0.69, 95% CI 0.64 to 0.75), respectively. An underlying comorbidity was recorded in 55.0% (523/951) of death registrations during 2013-15 and increased with age. Where recorded, respiratory tract infection was the most commonly reported presentation (374/876, 42.7%) during 2013-15. Central nervous system infections accounted for only 4.8% (42/876). Overall, 63.1% (378/599) of infection-related deaths were associated with a bacterial, 34.2% (205/599) with a viral and 2.5% (15/599) with a fungal infection. CONCLUSIONS Beyond the neonatal period, all-cause and infection-related childhood mortality rates have declined by 26% and 31%, respectively, over the past decade. However, infection continues to contribute to one in five childhood deaths.
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Affiliation(s)
- Laura Ferreras-Antolín
- Paediatric Infectious Diseases Research Group, St. George's University of London, London, UK.,Paediatrics, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Godwin Oligbu
- Paediatric Infectious Diseases Research Group, St. George's University of London, London, UK.,Paediatrics, Dr Gray's Hospital, Grampian, UK
| | - Ifeanyichukwu O Okike
- Paediatrics, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Shamez Ladhani
- Paediatric Infectious Diseases Research Group, St. George's University of London, London, UK .,Immunisation Department, Public Health England, London, UK
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11
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Beebeejaun K, Parikh SR, Campbell H, Gray S, Borrow R, Ramsay ME, Ladhani SN. Invasive meningococcal disease: Timing and cause of death in England, 2008-2015. J Infect 2020; 80:286-290. [PMID: 31904388 DOI: 10.1016/j.jinf.2019.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neisseria meningitidis is a major cause of bacterial meningitis and septicaemia, with death often occurring rapidly after onset of the first symptoms. Later death can also occur, but may be due to other causes, such as underlying comorbidities. The study aimed to assess the timing and cause of death in patients with invasive meningococcal disease (IMD) prior to the introduction of two new meningococcal immunisation programmes in England. METHODS Public Health England (PHE) conducts IMD surveillance in England through its national meningococcal reference unit. Laboratory-confirmed IMD cases diagnosed during 2008-2015 were linked to weekly and annual electronic death registration records as well as the Patient Demographic Service (PDS) database. RESULTS Overall, 6734 of 6808 (99%) laboratory-confirmed IMD cases matched to PDS, including 668 fatalities. Of these, 667 linked to an annual death registration record compared to 405 reports linked to weekly death registrations. In total, 429/667 (64%) of all deaths and 428/502 (85%) of IMD-related deaths occurred within one day of diagnosis. In total, 498/667 (75%) deaths had occured by 30 days after IMD diagnosis and 98% (490/498) of these were IMD-related. Serogroup B contributed to 64% (323/502) of IMD-related deaths, followed by serogroup W (84/502, 17%) and serogroup Y (70/502, 14%). Deaths occurring after 30 days were less likely to be IMD-related, mainly amongst ≥65 year-olds, with malignancy, chronic respiratory and cardiac conditions predominating. CONCLUSIONS Most IMD-related deaths occurred within a day of diagnosis and nearly all IMD-related deaths occurred within 30 days of diagnosis. The rapidity of death highlights the importance of prevention through vaccination.
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Affiliation(s)
- Kazim Beebeejaun
- Immunisation and Countermeasures Division, Public Health England, 61 Colindale Avenue, London NW9 5EQ, United Kingdom
| | - Sydel R Parikh
- Immunisation and Countermeasures Division, Public Health England, 61 Colindale Avenue, London NW9 5EQ, United Kingdom
| | - Helen Campbell
- Immunisation and Countermeasures Division, Public Health England, 61 Colindale Avenue, London NW9 5EQ, United Kingdom
| | - Steve Gray
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ray Borrow
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Mary E Ramsay
- Immunisation and Countermeasures Division, Public Health England, 61 Colindale Avenue, London NW9 5EQ, United Kingdom
| | - Shamez N Ladhani
- Immunisation and Countermeasures Division, Public Health England, 61 Colindale Avenue, London NW9 5EQ, United Kingdom; Paediatric Infectious Diseases Research Group (PIDRG), St. George's University of London, Cranmer Terrace, London SW17 0RE, United Kingdom.
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12
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Leigh S, Grant A, Murray N, Faragher B, Desai H, Dolan S, Cabdi N, Murray JB, Rejaei Y, Stewart S, Edwardson K, Dean J, Mehta B, Yeung S, Coenen F, Niessen LW, Carrol ED. The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department. BMC Med 2019; 17:48. [PMID: 30836976 PMCID: PMC6402102 DOI: 10.1186/s12916-019-1275-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/30/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Paediatric fever is a common cause of emergency department (ED) attendance. A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes. METHODS We studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children's Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing. RESULTS Infants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39-£2993.37] per child, (p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0-5.1-fold] higher resource use than consultants (p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5-13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate 'red flag', treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations. CONCLUSION The economic impact of diagnostic uncertainty when managing paediatric febrile illness is significant, and the precautionary use of antibiotics is strongly associated with increased costs. The use of ED resources is highest among infants (aged less than 3 months) and those infants managed by lesser experienced doctors, independent of clinical severity. Diagnostic advances which could increase confidence to withhold antibiotics may yield considerable efficiency gains in these groups, where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest.
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Affiliation(s)
- Simon Leigh
- Institute of Infection and Global Health, University of Liverpool, 8 West Derby St, Liverpool, L69 7BE UK
- Infectious Diseases Department, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Alison Grant
- Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Nicola Murray
- The Royal Liverpool University Hospital, Prescot St, Liverpool, L7 8XP UK
| | - Brian Faragher
- Medical Statistics Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Henal Desai
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE UK
| | - Samantha Dolan
- Royal Bolton Hospital, Minerva Road, Farnworth, BL4 0JR UK
| | - Naeema Cabdi
- School of Medicine, University of Liverpool, Cedar House, Liverpool, L69 3GE UK
| | - James B. Murray
- Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, B15 2TH UK
| | - Yasmin Rejaei
- Pinderfields District General Hospital, Aberford Road, Wakefield, WF1 4DG UK
| | - Stephanie Stewart
- Wirral University Teaching Hospital, Arrowe Park Road, Wirral, CH49 5PE UK
| | - Karl Edwardson
- Information Department, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Jason Dean
- Finance Department, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Bimal Mehta
- Emergency Department, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Shunmay Yeung
- Department of Clinical Research, MARCH Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Frans Coenen
- Department of Computer Science, University of Liverpool, Ashton Building, Ashton Street, Liverpool, L693BX UK
| | - Louis W. Niessen
- Department of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine and University of Liverpool, Liverpool, UK
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA USA
| | - Enitan D. Carrol
- Institute of Infection and Global Health, University of Liverpool, 8 West Derby St, Liverpool, L69 7BE UK
- Infectious Diseases Department, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
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13
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Boyd G, Heaton PA, Wilkinson R, Paul SP. Nursing management of childhood chickenpox infection. Emerg Nurse 2017; 25:32-41. [PMID: 29219259 DOI: 10.7748/en.2017.e1720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 11/09/2022]
Abstract
Chickenpox is an extremely contagious infectious disease caused by varicella zoster virus (VZV). It is a common childhood illness characterised by an itchy vesicular rash and fever, which usually resolves spontaneously without medical intervention. Serious, and rarely fatal, complications can occur, including pneumonia, central nervous system infection, overwhelming secondary bacterial infections, especially with Group A streptococcus, and necrotising fasciitis. Therefore it is crucial that emergency department (ED) nurses can recognise the signs and symptoms that indicate deterioration. This article reviews best practice management of children with chickenpox, gives up-to-date guidance on the safe use of antipyretics, the avoidance of ibuprofen and discusses immunisation against VZV. It also includes implications for nursing practice and a case study that illustrates some of the challenges that ED nurses may encounter.
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Affiliation(s)
- Grace Boyd
- Medical School, University of Bristol, England
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14
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Irwin AD, Grant A, Williams R, Kolamunnage-Dona R, Drew RJ, Paulus S, Jeffers G, Williams K, Breen R, Preston J, Appelbe D, Chesters C, Newland P, Marzouk O, McNamara PS, Diggle PJ, Carrol ED. Predicting Risk of Serious Bacterial Infections in Febrile Children in the Emergency Department. Pediatrics 2017; 140:peds.2016-2853. [PMID: 28679639 DOI: 10.1542/peds.2016-2853] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Improving the diagnosis of serious bacterial infections (SBIs) in the children's emergency department is a clinical priority. Early recognition reduces morbidity and mortality, and supporting clinicians in ruling out SBIs may limit unnecessary admissions and antibiotic use. METHODS A prospective, diagnostic accuracy study of clinical and biomarker variables in the diagnosis of SBIs (pneumonia or other SBI) in febrile children <16 years old. A diagnostic model was derived by using multinomial logistic regression and internally validated. External validation of a published model was undertaken, followed by model updating and extension by the inclusion of procalcitonin and resistin. RESULTS There were 1101 children studied, of whom 264 had an SBI. A diagnostic model discriminated well between pneumonia and no SBI (concordance statistic 0.84, 95% confidence interval 0.78-0.90) and between other SBIs and no SBI (0.77, 95% confidence interval 0.71-0.83) on internal validation. A published model discriminated well on external validation. Model updating yielded good calibration with good performance at both high-risk (positive likelihood ratios: 6.46 and 5.13 for pneumonia and other SBI, respectively) and low-risk (negative likelihood ratios: 0.16 and 0.13, respectively) thresholds. Extending the model with procalcitonin and resistin yielded improvements in discrimination. CONCLUSIONS Diagnostic models discriminated well between pneumonia, other SBIs, and no SBI in febrile children in the emergency department. Improvements in the classification of nonevents have the potential to reduce unnecessary hospital admissions and improve antibiotic prescribing. The benefits of this improved risk prediction should be further evaluated in robust impact studies.
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Affiliation(s)
| | | | | | | | - Richard J Drew
- Department of Microbiology, Rotunda Hospital, Dublin, Ireland.,Department of Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland; and
| | | | | | | | - Rachel Breen
- Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | | | - Duncan Appelbe
- Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | - Christine Chesters
- Biochemistry, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Paul Newland
- Biochemistry, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | | | | | - Peter J Diggle
- Institute of Infection and Global Health.,Centre for Health Informatics, Computing, and Statistics, Lancaster University, Lancaster, United Kingdom
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15
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Epidemiology of blood culture-proven bacterial sepsis in children in Switzerland: a population-based cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:124-133. [PMID: 30169202 DOI: 10.1016/s2352-4642(17)30010-x] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/03/2017] [Accepted: 06/06/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Sepsis is a leading cause of childhood mortality worldwide. We assessed population-based incidence and outcomes of blood culture-proven bacterial sepsis in children in Switzerland. METHODS We did a multicentre, prospective, cohort study at ten paediatric hospitals in Switzerland. We included neonates and children younger than 17 years with blood culture-proven bacterial sepsis. Children were eligible if they met criteria for systemic inflammatory response syndrome-according to 2005 paediatric consensus definition- at the time of blood culture sampling. Incidence was calculated by dividing the number of annual sepsis episodes in the study for the years 2012-15 by the end-of-year resident paediatric population in Switzerland. The primary outcome was in-hospital mortality in the first 30 days after sepsis onset. FINDINGS Between Sept 1, 2011, and Dec 31, 2015, we enrolled 1096 children to our study. Of 1181 episodes of blood culture-proven bacterial sepsis, 382 (32%) occurred in 379 previously healthy children, 402 (34%) in 391 neonates, and 397 (34%) in 341 children with comorbidities. Incidence was 25·1 cases per 100 000 (95% CI 23·8-26·4) in children and 146·0 cases per 100 000 (133·2-159·6) in neonates. Central line-associated bloodstream infections and primary bloodstream infections accounted for 569 (48%) of 1181 episodes, and organ dysfunction was present in 455 (39%) of 1181 episodes. Escherichia coli (242 of 1181 [20%]), Staphylococcus aureus (177 of 1181 [15%]), coagulase-negative staphylococci (135 of 1181 [11%]), and Streptococcus pneumoniae (118 of 1181 [10%]) were the most prevalent pathogens in our study, accounting for 57% of episodes. The overall case-fatality ratio was 7% (82 of 1181 episodes; 95% CI 5·6-8·6), and it was higher in neonates (11%, 45 of 402 episodes; 8·4-14·8; adjusted odds ratio [OR] 4·41, 95% CI 1·75-11·1) and children with comorbidities (7%, 27 of 397 episodes; 4·6-9·9; OR 4·97, 1·84-13·4) compared with previously healthy children (3%, ten of 382 episodes; 1·3-4·9). The case-fatality ratio was 1% (five of 726 episodes [95% CI 0·3-1·7]) for children without organ dysfunction, which increased to 17% (77 of 455 episodes [13·7-20·8]) when organ dysfunction was present (adjusted OR 4·84, 95% CI 1·40-16·7). INTERPRETATION The burden of blood culture-proven bacterial sepsis on child health remains considerable. We recorded key differences in predominant organisms, severity, and outcome between neonates, previously healthy children, and children with comorbidities. Although for most episodes of blood culture-proven bacterial sepsis, no organ dysfunction was seen, presence of organ dysfunction was strongly associated with mortality. FUNDING Swiss National Science Foundation, Swiss Society of Intensive Care, Bangerter Foundation, Vinetum and Borer Foundation, and Foundation for the Health of Children and Adolescents.
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16
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Asgari S, McLaren PJ, Peake J, Wong M, Wong R, Bartha I, Francis JR, Abarca K, Gelderman KA, Agyeman P, Aebi C, Berger C, Fellay J, Schlapbach LJ. Exome Sequencing Reveals Primary Immunodeficiencies in Children with Community-Acquired Pseudomonas aeruginosa Sepsis. Front Immunol 2016; 7:357. [PMID: 27703454 PMCID: PMC5028722 DOI: 10.3389/fimmu.2016.00357] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/01/2016] [Indexed: 01/10/2023] Open
Abstract
One out of three pediatric sepsis deaths in high income countries occur in previously healthy children. Primary immunodeficiencies (PIDs) have been postulated to underlie fulminant sepsis, but this concept remains to be confirmed in clinical practice. Pseudomonas aeruginosa (P. aeruginosa) is a common bacterium mostly associated with health care-related infections in immunocompromised individuals. However, in rare cases, it can cause sepsis in previously healthy children. We used exome sequencing and bioinformatic analysis to systematically search for genetic factors underpinning severe P. aeruginosa infection in the pediatric population. We collected blood samples from 11 previously healthy children, with no family history of immunodeficiency, who presented with severe sepsis due to community-acquired P. aeruginosa bacteremia. Genomic DNA was extracted from blood or tissue samples obtained intravitam or postmortem. We obtained high-coverage exome sequencing data and searched for rare loss-of-function variants. After rigorous filtrations, 12 potentially causal variants were identified. Two out of eight (25%) fatal cases were found to carry novel pathogenic variants in PID genes, including BTK and DNMT3B. This study demonstrates that exome sequencing allows to identify rare, deleterious human genetic variants responsible for fulminant sepsis in apparently healthy children. Diagnosing PIDs in such patients is of high relevance to survivors and affected families. We propose that unusually severe and fatal sepsis cases in previously healthy children should be considered for exome/genome sequencing to search for underlying PIDs.
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Affiliation(s)
- Samira Asgari
- Global Health Institute, School of Life Sciences, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland; Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Paul J McLaren
- National HIV and Retrovirology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada; Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
| | - Jane Peake
- Lady Cilento Children's Hospital , Brisbane, QLD , Australia
| | - Melanie Wong
- Children's Hospital Westmead , Sydney, NSW , Australia
| | - Richard Wong
- Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital , Brisbane, QLD , Australia
| | - Istvan Bartha
- Global Health Institute, School of Life Sciences, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland; Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Joshua R Francis
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Royal Darwin Hospital, Darwin, NT, Australia
| | - Katia Abarca
- Departamento de Enfermedades Infecciosas e Inmunología Pediátrica, Escuela de Medicina, Pontificia Universidad Católica de Chile , Santiago , Chile
| | | | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Christoph Aebi
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | | | - Jacques Fellay
- Global Health Institute, School of Life Sciences, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland; Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Luregn J Schlapbach
- Lady Cilento Children's Hospital, Brisbane, QLD, Australia; Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Paediatric Critical Care Research Group (PCCRG), Mater Research, University of Queensland, Brisbane, QLD, Australia
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Abstract
In 2015, the UK became the first country in the world to have a comprehensive routine meningococcal vaccine programme targeting all of the main capsular groups of N. meningitidis. 1 An infant vaccine programme against meningococcal capsular group B Neisseria meningitidis (MenB) was launched from 1st September with an aim to reduce endemic MenB disease in early childhood. On 1st August 2015, an adolescent programme against groups A, C, W and Y meningococci (MenACWY) was rolled out to halt a growing outbreak of capsular group W disease (MenW) caused by a hypervirulent clone of N. meningitidis, in addition to maintaining control against MenC disease provided by the current adolescent programme. 2.
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Affiliation(s)
| | - Mary Ramsay
- Immunisation Department, Public Health England, London, UK
| | - Ray Borrow
- Vaccine Evaluation Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Andrew Riordan
- Department of Infectious Diseases and Immunology, Alder Hey Children's Hospital, Liverpool, UK
| | | | - Andrew J Pollard
- Department of Paediatrics, University of Oxford, Children's Hospital, Oxford, UK
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18
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Antibiotic Resistance Prevalence in Routine Bloodstream Isolates from Children's Hospitals Varies Substantially from Adult Surveillance Data in Europe. Pediatr Infect Dis J 2015; 34:734-41. [PMID: 25607829 DOI: 10.1097/inf.0000000000000652] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surveillance of antimicrobial resistance (AMR) is central for defining appropriate strategies to deal with changing AMR levels. It is unclear whether childhood AMR patterns differ from those detected in isolates from adult patients. METHODS Resistance percentages of nonduplicate Staphylococcus aureus, Streptococcus pneumoniae, Enterococcus faecalis, Enterococcus faecium, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa bloodstream isolates from children less than 18 years of age reported to the Antibiotic Resistance and Prescribing in European Children (ARPEC) project were compared with all-age resistance percentages reported by the European Antimicrobial Resistance Surveillance Network (EARS-Net) for the same pathogen-antibiotic class combinations, period and countries. In addition, resistance percentages were compared between ARPEC isolates from children less than 1 year of age and children greater than or equal to1 year of age. RESULTS Resistance percentages for many important pathogen-antibiotic class combinations were different for ARPEC isolates compared with EARS-Net. E. coli and K. pneumoniae fluoroquinolone resistance percentages were substantially lower in ARPEC (13.4% and 17.9%) than in EARS-Net (23.0% and 30.7%), whereas the reverse was true for all pathogen-antibiotic class combinations in P. aeruginosa (for example, 27.3% aminoglycoside resistance in ARPEC, 19.3% in EARS-Net, 32.8% carbapenem resistance in ARPEC and 20.5% in EARS-Net), and for S. pneumoniae and macrolide resistance. For many Gram-negative pathogen-antibiotic class combinations, isolates from children greater than or equal to 1 year of age showed higher resistance percentages than isolates from children less than 1 year of age. CONCLUSIONS Age-stratified presentation of resistance percentage estimates by surveillance programs will allow identification of important variations in resistance patterns between different patient groups for targeted intervention.
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19
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Wells R, Le Doare K, Sharland M, Heath P, Ladhani SN. Targeted empiric antibiotic therapy for children with non-oncological comorbidities and community-onset invasive bacterial infections. J Infect 2015; 71:294-301. [PMID: 25964234 DOI: 10.1016/j.jinf.2015.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 04/27/2015] [Accepted: 05/02/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To describe the aetiology, risk factors, treatment and outcome of children with community-onset invasive bacterial infections (IBI) and determine the appropriateness of the nationally recommended empiric antibiotic therapy in children with non-oncological comorbidities. METHOD The CABIN network prospectively collected clinical information for all positive blood and cerebrospinal fluid cultures in children aged 1 month to 15 years in southwest London over three years. RESULTS During 2009-11, 119 healthy children each had a single IBI episode and 61 children with non-oncological comorbidities had 83 IBI episodes. The pathogens causing IBI in children with comorbidities and no central venous catheter (CVC) were similar to those causing IBI in healthy children. However, those with a CVC had multiple IBI episodes, often with pathogens usually associated with nosocomial infection. In particular, gastro-intestinal commensals were frequently responsible for IBI in TPN-dependent children with gastro-intestinal disease (16/43 episodes) and those with liver disease (8/43). Nationally recommended antibiotics were commenced empirically in 93%, with additional or alternate antibiotics more likely to be prescribed in children with comorbidities or those requiring intensive care. Fifteen children died (11 healthy, 4 with comorbidity), including 12 who died before arrival or in the Emergency Department. CONCLUSION Increasing care of children with comorbidities in the community has resulted in a significant proportion of community-onset IBI occurring in this group. Children with a CVC in situ - particularly those with gastro-intestinal and liver disease - were infected with a wider range of potentially more virulent pathogens. They might benefit from more broad-spectrum antimicrobial cover.
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Affiliation(s)
- Rosy Wells
- Paediatric Infectious Diseases Research Group, St. George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Kirsty Le Doare
- Paediatric Infectious Diseases Research Group, St. George's Hospital, Blackshaw Road, London, SW17 0QT, UK; Centre for International Child Health, Imperial College, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St. George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Paul Heath
- Paediatric Infectious Diseases Research Group, St. George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Shamez N Ladhani
- Paediatric Infectious Diseases Research Group, St. George's Hospital, Blackshaw Road, London, SW17 0QT, UK; Immunisation Department, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.
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20
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Irwin AD, Drew RJ, Marshall P, Nguyen K, Hoyle E, Macfarlane KA, Wong HF, Mekonnen E, Hicks M, Steele T, Gerrard C, Hardiman F, McNamara PS, Diggle PJ, Carrol ED. Etiology of childhood bacteremia and timely antibiotics administration in the emergency department. Pediatrics 2015; 135:635-42. [PMID: 25755240 DOI: 10.1542/peds.2014-2061] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Bacteremia is now an uncommon presentation to the children's emergency department (ED) but is associated with significant morbidity and mortality. Its evolving etiology may affect the ability of clinicians to initiate timely, appropriate antimicrobial therapy. METHODS A retrospective time series analysis of bacteremia was conducted in the Alder Hey Children's Hospital ED between 2001 and 2011. Data on significant comorbidities, time to empirical therapy, and antibiotic susceptibility were recorded. RESULTS A total of 575 clinical episodes were identified, and Streptococcus pneumoniae (n = 109), Neisseria meningitidis (n = 96), and Staphylococcus aureus (n = 89) were commonly isolated. The rate of bacteremia was 1.42 per 1000 ED attendances (95% confidence interval: 1.31-1.53). There was an annual reduction of 10.6% (6.6%-14.5%) in vaccine-preventable infections, and an annual increase of 6.7% (1.2%-12.5%) in Gram-negative infections. The pneumococcal conjugate vaccine was associated with a 49% (32%-74%) reduction in pneumococcal bacteremia. The rate of health care-associated bacteremia increased from 0.17 to 0.43 per 1000 ED attendances (P = .002). Susceptibility to empirical antibiotics was reduced (96.3%-82.6%; P < .001). Health care-associated bacteremia was associated with an increased length of stay of 3.9 days (95% confidence interval: 2.3-5.8). Median time to antibiotics was 184 minutes (interquartile range: 63-331) and 57 (interquartile range: 27-97) minutes longer in Gram-negative bacteremia than in vaccine-preventable bacteremia. CONCLUSIONS Changes in the etiology of pediatric bacteremia have implications for prompt, appropriate empirical treatment. Increasingly, pediatric bacteremia in the ED is health care associated, which increases length of inpatient stay. Prompt, effective antimicrobial administration requires new tools to improve recognition, in addition to continued etiological surveillance.
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Affiliation(s)
- Adam D Irwin
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom;
| | | | - Philippa Marshall
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Kha Nguyen
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Emily Hoyle
- Pediatrics, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom; and
| | - Kate A Macfarlane
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Hoying F Wong
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Ellen Mekonnen
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Matthew Hicks
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Tom Steele
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | | | - Paul S McNamara
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | - Enitan D Carrol
- Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
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Global assessment of antimicrobial susceptibility among Gram-negative organisms collected from pediatric patients between 2004 and 2012: results from the Tigecycline Evaluation and Surveillance Trial. J Clin Microbiol 2015; 53:1286-93. [PMID: 25653413 DOI: 10.1128/jcm.03184-14] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The Tigecycline Evaluation and Surveillance Trial (TEST) was designed to monitor susceptibility to commonly used antimicrobial agents among important pathogens. We report here on susceptibility among Gram-negative pathogens collected globally from pediatric patients between 2004 and 2012. Antimicrobial susceptibility was determined using guidelines published by the Clinical and Laboratory Standards Institute (CLSI). Most Enterobacteriaceae showed high rates of susceptibility (>95%) to amikacin, tigecycline, and the carbapenems (imipenem and meropenem); 90.8% of Acinetobacter baumannii isolates were susceptible to minocycline, and susceptibility rates were highest in North America, Europe, and Asia/Pacific Rim. Amikacin was the most active agent against Pseudomonas aeruginosa (90.4% susceptibility), with susceptibility rates being highest in North America. Extended-spectrum β-lactamases (ESBLs) were reported for 11.0% of Escherichia coli isolates and 24.2% of Klebsiella pneumoniae isolates globally, with rates reaching as high as 25.7% in the Middle East and >43% in Africa and Latin America, respectively. Statistically significant (P<0.01) differences in susceptibility rates were noted between pediatric age groups (1 to 5 years, 6 to 12 years, or 13 to 17 years of age), globally and in some regions, for all pathogens except Haemophilus influenzae. Significant (P<0.01) differences were reported for all pathogens globally and in most regions, considerably more frequently, when pediatric and adult susceptibility results were compared. Amikacin, tigecycline, and the carbapenems were active in vitro against most Gram-negative pathogens collected from pediatric patients; A. baumannii and P. aeruginosa were susceptible to fewer antimicrobial agents. Susceptibility rates among isolates from pediatric patients were frequently different from those among isolates collected from adults.
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Schlapbach LJ, Straney L, Alexander J, MacLaren G, Festa M, Schibler A, Slater A. Mortality related to invasive infections, sepsis, and septic shock in critically ill children in Australia and New Zealand, 2002-13: a multicentre retrospective cohort study. THE LANCET. INFECTIOUS DISEASES 2014; 15:46-54. [PMID: 25471555 DOI: 10.1016/s1473-3099(14)71003-5] [Citation(s) in RCA: 218] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Severe infections kill more than 4·5 million children every year. Population-based data for severe infections in children requiring admission to intensive care units (ICUs) are scarce. We assessed changes in incidence and mortality of severe infections in critically ill children in Australia and New Zealand. METHODS We did a retrospective multicentre cohort study of children requiring intensive care in Australia and New Zealand between 2002 and 2013, with data from the Australian and New Zealand Paediatric Intensive Care Registry. We included children younger than 16 years with invasive infection, sepsis, or septic shock. We assessed incidence and mortality in the ICU for 2002-07 versus 2008-13. FINDINGS During the study period, 97 127 children were admitted to ICUs, 11 574 (11·9%) had severe infections, including 6688 (6·9%) with invasive infections, 2847 (2·9%) with sepsis, and 2039 (2·1%) with septic shock. Age-standardised incidence increased each year by an average of 0·56 cases per 100 000 children (95% CI 0·41-0·71) for invasive infections, 0·09 cases per 100 000 children (0·00-0·17) for sepsis, and 0·08 cases per 100 000 children (0·04-0·12) for septic shock. 260 (3·9%) of 6688 patients with invasive infection died, 159 (5·6%) of 2847 with sepsis died, and 346 (17·0%) of 2039 with septic shock died, compared with 2893 (3·0%) of all paediatric ICU admissions. Children admitted with invasive infections, sepsis, and septic shock accounted for 765 (26·4%) of 2893 paediatric deaths in ICUs. Comparing 2008-13 with 2002-07, risk-adjusted mortality decreased significantly for invasive infections (odds ratio 0·72, 95% CI 0·56-0·94; p=0·016), and for sepsis (0·66, 0·47-0·93; p=0·016), but not significantly for septic shock (0·79, 0·61-1·01; p=0·065). INTERPRETATION Severe infections remain a major cause of mortality in paediatric ICUs, representing a major public health problem. Future studies should focus on patients with the highest risk of poor outcome, and assess the effectiveness of present sepsis interventions in children. FUNDING National Medical Health and Research Council, Australian Resuscitation Outcomes Consortium, Centre of Research Excellence (1029983).
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Affiliation(s)
- Luregn J Schlapbach
- Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, QLD, Australia; Paediatric Intensive Care Unit, Mater Children's Hospital, Brisbane, QLD, Australia; Children's Critical Care Services, Gold Coast University Hospital, Southport, QLD, Australia.
| | - Lahn Straney
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Janet Alexander
- Australian and New Zealand Paediatric Intensive Care Registry, CORE, Royal Children's Hospital Brisbane, Herston, QLD, Australia
| | - Graeme MacLaren
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, VIC, Australia; Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - Marino Festa
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, NSW, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, QLD, Australia; Paediatric Intensive Care Unit, Mater Children's Hospital, Brisbane, QLD, Australia
| | - Anthony Slater
- Paediatric Intensive Care Unit, Royal Children's Hospital Brisbane, Herston, QLD, Australia
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Abstract
In the past century, child mortality has fallen to very low rates in all developed countries. However, rates between and within countries vary widely, and factors can be identified that could be modified to reduce the risk of future deaths. An understanding of the nature and patterns of child death and of the factors contributing to child deaths is essential to drive preventive initiatives. We discuss the epidemiology of child deaths in England and Wales. We use available data, particularly that of death registration and other available datasets, and published literature to emphasise issues relevant to reduction of child deaths in developed countries. We examine the different patterns of mortality at different ages in five broad categories of death: perinatal causes, congenital abnormalities, acquired natural causes, external causes, and unexplained deaths. For each category, we explore what is known about the main causes of death and some of the contributory factors. We then explain how this knowledge might be used to help to drive prevention initiatives.
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Affiliation(s)
- Peter Sidebotham
- Division of Mental Health and Well Being, University of Warwick, Coventry, UK.
| | - James Fraser
- Bristol Royal Hospital for Children, Bristol, UK
| | - Peter Fleming
- School of Social and Community Medicine, St Michaels Hospital, Bristol, UK
| | | | - Richard Hain
- Welsh Paediatric Palliative Medicine Network, Bangor University, Bangor, UK; University of Glamorgan Children's Hospital, Cardiff, UK
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Le Doare K, Nichols AL, Payne H, Wells R, Navidnia S, Appleby G, Calton E, Sharland M, Ladhani SN. Very low rates of culture-confirmed invasive bacterial infections in a prospective 3-year population-based surveillance in Southwest London. Arch Dis Child 2014; 99:526-31. [PMID: 24554055 DOI: 10.1136/archdischild-2013-305565] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To estimate the incidence, clinical characteristics and risk factors for culture-confirmed invasive bacterial infections in England. DESIGN Prospective, observational, study of all children with positive blood and/or cerebrospinal fluid (CSF) culture over a 3-year period (2009-2011). SETTING All five hospitals within a geographically defined region in southwest London providing care for around 600 000 paediatric residents. PATIENTS Children aged 1 month to 15 years MAIN OUTCOME MEASURES Rates of community-acquired and hospital-acquired invasive bacterial infections in healthy children and those with co-morbidities; pathogens by age group, risk group and clinical presentation. RESULTS During 2009-2011, 44 118 children had 46 039 admissions, equivalent to 26 admissions per 1000 children. Blood/CSF cultures were obtained during 44.7% of admissions, 7.4% were positive but only 504 were clinically significant, equivalent to 32.9% of positive blood/CSF cultures, 2.4% of all blood/CSF cultures and 1.1% of hospital admissions. The population incidence of culture-confirmed invasive bacterial infection was 28/100 000. One-third of infections were hospital acquired and, of the community-acquired infections, two-thirds occurred in children with pre-existing co-morbidities. In previously healthy children, therefore, the incidence of community-acquired invasive bacterial infection was only 6.4/100 000. CONCLUSIONS Although infection was suspected in almost half the children admitted to hospital, a significant pathogen was cultured from blood or CSF in only 2.4%, mainly among children with pre-existing co-morbidities, who may require a more broad-spectrum empiric antibiotic regime compared to previously healthy children. Invasive bacterial infection in previously healthy children is now very rare. Improved strategies to manage low-risk febrile children are required.
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Affiliation(s)
- Kirsty Le Doare
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK Wellcome Trust/Imperial Centre for Global Health Research, Imperial College, London, UK
| | - Anna-Louise Nichols
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Helen Payne
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Rosy Wells
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Sonia Navidnia
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Gayle Appleby
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Elizabeth Calton
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Shamez N Ladhani
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK Immunisation Department, Public Health England, London, UK
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Murray J, Bottle A, Sharland M, Modi N, Aylin P, Majeed A, Saxena S. Risk factors for hospital admission with RSV bronchiolitis in England: a population-based birth cohort study. PLoS One 2014; 9:e89186. [PMID: 24586581 PMCID: PMC3935842 DOI: 10.1371/journal.pone.0089186] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/16/2014] [Indexed: 11/30/2022] Open
Abstract
Objective To examine the timing and duration of RSV bronchiolitis hospital admission among term and preterm infants in England and to identify risk factors for bronchiolitis admission. Design A population-based birth cohort with follow-up to age 1 year, using the Hospital Episode Statistics database. Setting 71 hospitals across England. Participants We identified 296618 individual birth records from 2007/08 and linked to subsequent hospital admission records during the first year of life. Results In our cohort there were 7189 hospital admissions with a diagnosis of bronchiolitis, 24.2 admissions per 1000 infants under 1 year (95%CI 23.7–24.8), of which 15% (1050/7189) were born preterm (47.3 bronchiolitis admissions per 1000 preterm infants (95% CI 44.4–50.2)). The peak age group for bronchiolitis admissions was infants aged 1 month and the median was age 120 days (IQR = 61–209 days). The median length of stay was 1 day (IQR = 0–3). The relative risk (RR) of a bronchiolitis admission was higher among infants with known risk factors for severe RSV infection, including those born preterm (RR = 1.9, 95% CI 1.8–2.0) compared with infants born at term. Other conditions also significantly increased risk of bronchiolitis admission, including Down's syndrome (RR = 2.5, 95% CI 1.7–3.7) and cerebral palsy (RR = 2.4, 95% CI 1.5–4.0). Conclusions Most (85%) of the infants who are admitted to hospital with bronchiolitis in England are born at term, with no known predisposing risk factors for severe RSV infection, although risk of admission is higher in known risk groups. The early age of bronchiolitis admissions has important implications for the potential impact and timing of future active and passive immunisations. More research is needed to explain why babies born with Down's syndrome and cerebral palsy are also at higher risk of hospital admission with RSV bronchiolitis.
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Affiliation(s)
- Joanna Murray
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
- * E-mail:
| | - Alex Bottle
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Mike Sharland
- Paediatric Infectious Diseases Unit, St. George's Hospital NHS Trust, London, United Kingdom
| | - Neena Modi
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Paul Aylin
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Sonia Saxena
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
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Williams EJ, Embleton ND, Bythell M, Ward Platt MP, Berrington JE. The changing profile of infant mortality from bacterial, viral and fungal infection over two decades. Acta Paediatr 2013; 102:999-1004. [PMID: 23826761 DOI: 10.1111/apa.12341] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 06/12/2013] [Accepted: 07/01/2013] [Indexed: 11/28/2022]
Abstract
AIM Infection is an important cause of neonatal and infant mortality. We evaluated changes in infant deaths from infections from 1988 to 2008 in the North of England. METHODS We interrogated a population-based survey and reviewed infant deaths from infection. Proportional contribution to deaths, pathogens identified and risk factors were analysed. RESULTS Thirteen percentage of 4366 infant deaths from a population of 704 536 livebirths were infectious. The absolute numbers of infant deaths from infection fell over time but the proportion of deaths from infection increased (12.1%, 13.6% and 14.9%). Significantly preterm infants were increasingly represented in successive epochs (14%, 24% and 38%). Infant mortality rate (IMR) from meningococcus and Group B Streptococcus (GBS) fell in the latest epoch, but there was a corresponding increase from Escherichia coli and candida. DISCUSSION This large study shows that infections have become proportionately more important causes of death especially in very preterm infants. Recent significant reductions in death from meningococcus and GBS are likely to represent successful achievements of vaccination and antibiotic prophylactic policies. Increases in IMR from E. coli may relate to GBS prophylaxis and increases in candida to the increase from preterm populations. Further efforts to understand these changing patterns and develop additional prevention and treatment strategies and vaccines remain an urgent priority.
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Affiliation(s)
- Eleri J Williams
- Newcastle Neonatal Service; Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle-upon-Tyne; UK
| | - Nicholas D Embleton
- Newcastle Neonatal Service; Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle-upon-Tyne; UK
| | - Mary Bythell
- Regional Maternity Survey Office; Newcastle-upon-Tyne; UK
| | | | - Janet E Berrington
- Newcastle Neonatal Service; Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle-upon-Tyne; UK
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Henderson KL, Müller-Pebody B, Johnson AP, Wade A, Sharland M, Gilbert R. Community-acquired, healthcare-associated and hospital-acquired bloodstream infection definitions in children: a systematic review demonstrating inconsistent criteria. J Hosp Infect 2013; 85:94-105. [PMID: 24011498 DOI: 10.1016/j.jhin.2013.07.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 07/04/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Historically, bacterial infections were categorized as either community-acquired (CA) or hospital-acquired (HA). However, the CA/HA dichotomy no longer adequately reflects patterns of emerging healthcare-associated (HCA) infections in complex patients managed between hospital and the community. Studies trying to define this evolving epidemiology often excluded children. AIM To identify what criteria have been used to distinguish between CA, HCA and HA bloodstream infections (BSIs) in children, and the proportional distribution of CA, HCA and HA among total BSIs and by organism. METHODS We systematically reviewed published literature from PubMed, UK Department of Health and US Centers for Disease Control and Prevention websites. FINDINGS Results from 23 studies and the websites highlighted the use of inconsistent criteria. There were 13 and 15 criteria variations for CA and HA BSI respectively, although a 48h cut-off for cultures sampled post admission was most commonly reported. Five studies used variable clinical criteria to define HCA. The mean proportion of paediatric CA BSI in nine studies was 50%. Only four BSI organisms from five studies were predominantly CA (Streptococcus pneumoniae, Salmonella spp.) or HA (coagulase-negative staphylococci, Enterococcus spp.), whereas Pseudomonas spp., Klebsiella spp. and Enterobacter spp. did not clearly fit into either category. CONCLUSIONS Our study reveals inconsistent use of criteria, and a lack of evidence upon which to base them, to distinguish between CA, HCA and HA BSI in children. Criteria for CA, HCA and HA BSI need to be developed using population-based studies that consider patients' clinical characteristics, recent healthcare exposure as well as isolated organism species.
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Affiliation(s)
- K L Henderson
- Department of Healthcare-Associated Infections and Antimicrobial Resistance, Public Health England, London, UK; Centre for Paediatric Epidemiology and Biostatistics, UCL Institute of Child Health, London, UK.
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Williams EJ, Embleton ND, Clark JE, Bythell M, Ward Platt MP, Berrington JE. Viral infections: contributions to late fetal death, stillbirth, and infant death. J Pediatr 2013; 163:424-8. [PMID: 23507026 DOI: 10.1016/j.jpeds.2013.02.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 12/14/2012] [Accepted: 02/04/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the role of viral infections in causing fetal and infant death. STUDY DESIGN We assessed a well-validated population database of fetal (≥20 weeks gestation) and infant death for infective deaths and deaths from viruses over a 21-year period (1988-2008). We analyzed by specific viral cause, timing (late fetal loss [20-23 weeks], stillbirth [≥24 weeks], neonatal death [0-27 days], and post-neonatal infant death [28-364 days]) and across time. RESULTS Of the 989 total infective deaths, 108 were attributable to viral causes (6.5% of late fetal losses, 14.5% of stillbirths, 6.5% of neonatal deaths, and 19.4% of postneonatal infant deaths). Global loss (combined fetal and infant losses per 100,000 registerable births) was 139.6 (95% CI, 130.9-148.3) for any infective cause and 15.2 (95% CI, 12.3-18.1) for viral infections. More than one-third (37%) of viral-attributed deaths were before live birth, from parvovirus (63%) or cytomegalovirus (33%). Parvovirus accounted for 26% (28 of 108) of all viral deaths. Cytomegalovirus was associated with a global loss rate of 3.1 (95% CI, 1.8-4.4) and an infant mortality rate of 1.3 (95% CI, 0.4-2.1) per 100,000 live births; 91% of cases were congenital infections. Herpes simplex virus caused death only after live births (infant mortality rate, 1.4; 95% CI, 0.5-2.3). No changes in rates were seen over time. CONCLUSION We have identified a substantial contribution of viral infections to global fetal and infant losses. More than one-third of these losses occurred before live births. Considering our methodology, our estimates represent the minimum contribution of viral illness. Strategies to reduce this burden are needed.
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Affiliation(s)
- Eleri J Williams
- Newcastle Neonatal Service, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals National Health Service Foundation Trust, Newcastle-Upon-Tyne, United Kingdom
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Gkentzi D, Collins S, Slack MPE, Ladhani SN. Childhood Haemophilus influenzae related deaths in England and Wales. J Public Health (Oxf) 2013. [DOI: 10.1007/s10389-013-0576-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
BACKGROUND There are few population-based studies on the epidemiology of neonatal and pediatric invasive Candida infections, despite their significant clinical impact on patients. This study aimed to describe the epidemiology of pediatric candidemia in England and Wales during a 10-year period as a means of quantifying the changing burden of infection and identifying emerging trends. METHODS National Health Service hospital microbiology laboratories in England and Wales routinely report clinically significant invasive infections electronically to the Health Protection Agency. Records of all positive blood cultures for Candida species in children aged <15 years between 2000 and 2009 inclusive were extracted for analysis. RESULTS During 2000 to 2009, 1473 childhood candidemia cases were reported in England and Wales (annual incidence, 1.52/100,000 person-years), with the highest rate in <1 year olds (n = 706; 11.0/100,000), followed by 1-4 year olds (n = 440; 1.77/100,000), 5-9 year olds (n = 168; 0.53/100,000) and 10-14 year olds (n = 159; 0.47/100,000). Incidence increased from 1.04 per 100,000 in 2000 to 2.09 per 100,000 in 2007 (P < 0.001) before falling to 1.53 per 100,000 in 2009 (P < 0.001). Candida species was reported in 89.6% (1320/1473) cases, with Candida albicans and Candida parapsilosis accounting for most infections in all age groups. There were no significant differences in species distribution by season or year of study and the proportion of non-albicans cases did not increase with time. CONCLUSIONS Pediatric candidemia rates are beginning to fall in England and Wales. C. albicans continues to account for most Candida bloodstream infections in all age groups with no evidence of increases in non-albicans species.
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Blackburn RM, Henderson KL, Minaji M, Muller-Pebody B, Johnson AP, Sharland M. Exploring the Epidemiology of Hospital-Acquired Bloodstream Infections in Children in England (January 2009-March 2010) by Linkage of National Hospital Admissions and Microbiological Databases. J Pediatric Infect Dis Soc 2012; 1:284-92. [PMID: 26619421 DOI: 10.1093/jpids/pis084] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 08/05/2012] [Indexed: 11/14/2022]
Abstract
BACKGROUND Hospital-acquired bloodstream infection (HA-BSI) requires immediate effective antibiotic treatment. However, there are no published national data for England that describe the pathogen profile and antibiotic resistance rates of HA-BSI in children. METHODS Probabilistic matching methods were used to link national data on microbiologically confirmed BSI to hospital in-patient admissions data for the period of January 2009-March 2010. HA-BSI was defined as a positive blood culture drawn from a child aged 1 month-18 years 2 or more days after admission (and before discharge). RESULTS A total of 8718 episodes of BSI was reported during the study period. Linkage allowed 82% of records to be matched, of which 23% (1734) were HA-BSI, giving a rate of 4.74 per 1000 admissions. The median age of infection was 1 year, and 54% of infections were in males. Methicillin resistance was seen in 83% and 17% of coagulase-negative staphylococci and Staphylococcus aureus, respectively. Penicillin resistance was rare in pyogenic streptococci but more common in viridans streptococci (39%). Among Gram-positive organisms, only 3% were vancomycin-resistant. The overall proportion of Gram-negative bacteria resistant to recommended empirical antibiotics (meropenem or piperacillin/tazobactam) was 5% and 16%, respectively, but <4% of isolates were resistant when either of these drugs were combined with gentamicin. CONCLUSIONS This study provides the first national estimates of the proportion of pediatric BSI that is hospital-acquired and describes the antimicrobial resistance of organisms causing infection. Pediatric HA-BSI remains unacceptably high; interventions must focus on identifying effective means of preventing HA-BSI, fostering antibiotic stewardship, and improving surveillance.
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Affiliation(s)
- Ruth M Blackburn
- Healthcare Associated Infection and Antimicrobial Resistance, Health Protection Agency
| | - Katherine L Henderson
- Healthcare Associated Infection and Antimicrobial Resistance, Health Protection Agency
| | - Mehdi Minaji
- Healthcare Associated Infection and Antimicrobial Resistance, Health Protection Agency
| | - Berit Muller-Pebody
- Healthcare Associated Infection and Antimicrobial Resistance, Health Protection Agency
| | - Alan P Johnson
- Healthcare Associated Infection and Antimicrobial Resistance, Health Protection Agency
| | - Mike Sharland
- Paediatric Infectious Diseases Research Unit, St George's Hospital, London, United Kingdom
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JUNG YJ, KIM JH, PARK YJ, KAHNG J, LEE H, LEE KY, KIM MY, HAN K, LEE W. Evaluation of cell population data on the UniCel DxH 800 Coulter Cellular Analysis system as a screening for viral infection in children. Int J Lab Hematol 2012; 34:283-9. [DOI: 10.1111/j.1751-553x.2011.01392.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Lambert SB, Ware RS, Cook AL, Maguire FA, Whiley DM, Bialasiewicz S, Mackay IM, Wang D, Sloots TP, Nissen MD, Grimwood K. Observational Research in Childhood Infectious Diseases (ORChID): a dynamic birth cohort study. BMJ Open 2012; 2:bmjopen-2012-002134. [PMID: 23117571 PMCID: PMC3547315 DOI: 10.1136/bmjopen-2012-002134] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Even in developed economies infectious diseases remain the most common cause of illness in early childhood. Our current understanding of the epidemiology of these infections is limited by reliance on data from decades ago performed using low-sensitivity laboratory methods, and recent studies reporting severe, hospital-managed disease. METHODS AND ANALYSIS The Observational Research in Childhood Infectious Diseases (ORChID) study is an ongoing study enrolling a dynamic birth cohort to document the community-based epidemiology of viral respiratory and gastrointestinal infections in early childhood. Women are recruited antenatally, and their healthy newborn is followed for the first 2 years of life. Parents keep a daily symptom diary for the study child, collect a weekly anterior nose swab and dirty nappy swab and complete a burden diary when a child meets pre-defined illness criteria. Specimens will be tested for a wide range of viruses by real-time PCR assays. Primary analyses involves calculating incidence rates for acute respiratory illness (ARI) and acute gastroenteritis (AGE) for the cohort by age and seasonality. Control material from children when they are without symptoms will allow us to determine what proportion of ARIs and AGE can be attributed to specific pathogens. Secondary analyses will assess the incidence and shedding duration of specific respiratory and gastrointestinal pathogens. ETHICS AND DISSEMINATION This study is approved by The Human Research Ethics Committees of the Children's Health Queensland Hospital and Health Service, the Royal Brisbane and Women's Hospital and The University of Queensland. TRIAL REGISTRATION clinicaltrials.gov NCT01304914.
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Affiliation(s)
- Stephen Bernard Lambert
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, The University of Queensland and the Royal Children's Hospital, Brisbane, Queensland, Australia
- Queensland Health Immunisation Program, Communicable Diseases Branch, Queensland Health, Brisbane, Queensland, Australia
| | - Robert S Ware
- School of Population Health and the Queensland Children's Medical Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Anne L Cook
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, The University of Queensland and the Royal Children's Hospital, Brisbane, Queensland, Australia
| | - Frances A Maguire
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, The University of Queensland and the Royal Children's Hospital, Brisbane, Queensland, Australia
| | - David M Whiley
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, The University of Queensland and the Royal Children's Hospital, Brisbane, Queensland, Australia
| | - Seweryn Bialasiewicz
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, The University of Queensland and the Royal Children's Hospital, Brisbane, Queensland, Australia
| | - Ian M Mackay
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, The University of Queensland and the Royal Children's Hospital, Brisbane, Queensland, Australia
| | - David Wang
- Departments of Molecular Microbiology and Pathology & Immunology, Washington University, School of Medicine, St. Louis, Missouri, USA
| | - Theo P Sloots
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, The University of Queensland and the Royal Children's Hospital, Brisbane, Queensland, Australia
- Microbiology Division, Pathology Queensland Central Laboratory, Queensland Health, Brisbane, Queensland, Australia
| | - Michael D Nissen
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, The University of Queensland and the Royal Children's Hospital, Brisbane, Queensland, Australia
- Microbiology Division, Pathology Queensland Central Laboratory, Queensland Health, Brisbane, Queensland, Australia
| | - Keith Grimwood
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, The University of Queensland and the Royal Children's Hospital, Brisbane, Queensland, Australia
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Abstract
This study used anonymized death certificate data to determine the contribution of specific infections to neonatal deaths in England and Wales between 2003 and 2005. Infection was recorded in 11% of deaths, with two-thirds occurring in premature neonates. Group B Streptococcus was indicated in 32% of death certificates that specified a bacterial infection and in 11% of all infection-related deaths.
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