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Serious bacterial infections in young children with fever without source after discharge from emergency department: A National Health Insurance database cohort study. Pediatr Neonatol 2022; 63:527-534. [PMID: 35871150 DOI: 10.1016/j.pedneo.2022.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/10/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Well-appearing febrile young children discharged from the emergency department (ED) after medical assessment are still at risk for serious bacterial infections (SBI). The incidence of SBI and the effectiveness of laboratory tests in the pneumococcal conjugate vaccine era remain unknown. METHODS We conducted a study using Taiwan's National Health Insurance claims data from 2004 to 2014. Children aged 2-24 months discharged from the ED with a diagnosis compatible with fever without source (FWS) were enrolled. RESULTS The study identified 431,884 children from the ED with FWS. 13.53% of the children had revisits, 8.62% needed hospitalization and 1.57% developed SBI. Younger children had a higher SBI rate, but a lower revisit rate. The revisit rate was 12.22% for children aged 2-6 months, 13.61% for children aged 7-12 months and 13.77% for children aged 13-24 months (p < 0.0001). The SBI rate was 4.44% for children aged 2-6 months, 1.85% for children aged 2-6 months and 0.96% for children aged 13-24 months (p < 0.0001). Children with hemogram tests, compared to those without, had a higher revisit rate (16.30% vs. 13.15%, p < 0.0001), and a higher SBI rate in the children aged 13-24 months (1.30% vs. 0.92%, p < 0.0001); furthermore, children with urinalysis had a significantly higher revisit rate (14.42% vs. 13.24%, p < 0.0001) and higher SBI rate (2.10% vs. 1.40%, p < 0.0001). CONCLUSION Children with FWS aged 2-24 months who were discharged from ED after blood test and urinalysis were still at risk for SBI, especially those aged 2-6 months.
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Simon H, Pedreira MC, Barbosa SMDM, Fernandes TF, Escobar AMDU. Clinical management of fever in children in Brazil: practical recommendations from an expert panel. EINSTEIN-SAO PAULO 2022; 20:eRW6045. [PMID: 35946741 PMCID: PMC9345508 DOI: 10.31744/einstein_journal/2022rw6045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 03/15/2021] [Indexed: 11/05/2022] Open
Abstract
The objective of this study was to answer several questions related to the assessment and treatment of fever, as well as other controversies that exist during its management in pediatric patients. First, an advisory board with medical experts was conducted to discuss the clinical journey of these patients, considering the main challenges and possible solutions. After this discussion, a non-systematic literature review was performed, between November 2019 and January 2020, to collect the most relevant evidence available in the scientific databases MEDLINE, Lilacs, and SciELO. A narrative review was carried out based on scientific evidence and on extensive experience of experts in clinical practice. The experts developed a set of recommendations and clarifications about the assessment of the severity of fever in pediatrics, the need for treatment and the choice of the most appropriate antipyretic. The most common controversies in the management of fever in pediatric patients were also addressed, such as alternating antipyretics, persistent fever, and dose equivalence. In primary management of pediatric patients, fever should be seen as a relevant symptom that requires treatment with antipyretics in potentially more complex or severe cases, when it causes discomfort to children or is associated with infectious diseases.
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Affiliation(s)
- Hany Simon
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazil Instituto da Criança, Hospital das Clínicas , Faculdade de Medicina , Universidade de São Paulo , São Paulo , SP , Brazil .
| | | | - Silvia Maria de Macedo Barbosa
- Faculdade de MedicinaUniversidade de São PauloSão PauloSPBrazil Faculdade de Medicina , Universidade de São Paulo , São Paulo , SP , Brazil .
| | | | - Ana Maria de Ulhôa Escobar
- Faculdade de MedicinaUniversidade de São PauloSão PauloSPBrazil Faculdade de Medicina , Universidade de São Paulo , São Paulo , SP , Brazil .
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Gangoiti I, Fernandez CL, Gallego M, Gomez B, Benito J, Mintegi S. Markers for invasive bacterial infections in previously healthy children. Am J Emerg Med 2021; 48:83-86. [PMID: 33862390 DOI: 10.1016/j.ajem.2021.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/06/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Iker Gangoiti
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Catarina-Livana Fernandez
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Mikel Gallego
- Microbiology Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Borja Gomez
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain.
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Ericson JE, McGuire J, Michaels MG, Schwarz A, Frenck R, Deville JG, Agarwal S, Bressler AM, Gao J, Spears T, Benjamin DK, Smith PB, Bradley JS. Hospital-acquired Pneumonia and Ventilator-associated Pneumonia in Children: A Prospective Natural History and Case-Control Study. Pediatr Infect Dis J 2020; 39:658-664. [PMID: 32150005 PMCID: PMC8293907 DOI: 10.1097/inf.0000000000002642] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Clinical trials for antibiotics designed to treat hospital-acquired and ventilator-associated bacterial pneumonias (HABP/VABP) are hampered by making these diagnoses in a way that is acceptable to the United States Food and Drug Administration and consistent with standards of care. We examined laboratory and clinical features that might improve pediatric HABP/VABP trial efficiency by identifying risk factors predisposing children to HABP/VABP and describing the epidemiology of pediatric HABP/VABP. METHODS We prospectively reviewed the electronic medical records of patients <18 years of age admitted to intensive and intermediate care units (ICUs) if they received qualifying respiratory support or were started on antibiotics for a lower respiratory tract infection or undifferentiated sepsis. Subjects were followed until HABP/VABP was diagnosed or they were discharged from the ICU. Clinical, laboratory and imaging data were abstracted using structured chart review. We calculated HABP/VABP incidence and used a stepwise backward selection multivariable model to identify risk factors associated with development of HABP/VABP. RESULTS A total of 862 neonates, infants and children were evaluated for development of HABP/VABP; 10% (82/800) of those receiving respiratory support and 12% (103/862) overall developed HABP/VABP. Increasing age, shorter height/length, longer ICU length of stay, aspiration risk, blood product transfusion in the prior 7 days and frequent suctioning were associated with increased odds of HABP/VABP. The use of noninvasive ventilation and gastric acid suppression were both associated with decreased odds of HABP/VABP. CONCLUSIONS Food and Drug Administration-defined HABP/VABP occurred in 10%-12% of pediatric patients admitted to ICUs. Risk factors vary by age group.
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Affiliation(s)
| | | | | | - Adam Schwarz
- Children’s Hospital of Orange County, Orange, CA, USA
| | - Robert Frenck
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | - Jamie Gao
- Duke Clinical Research Institute, Durham, NC, USA
| | - Tracy Spears
- Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, NC, USA
- Duke University Medical Center, Durham, NC USA
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, NC, USA
- Duke University Medical Center, Durham, NC USA
| | - John S. Bradley
- University of California, San Diego School of Medicine and Rady Children’s Hospital San Diego, San Diego, CA USA
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Using Machine Learning to Predict Bacteremia in Febrile Children Presented to the Emergency Department. Diagnostics (Basel) 2020; 10:diagnostics10050307. [PMID: 32429293 PMCID: PMC7277905 DOI: 10.3390/diagnostics10050307] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 01/01/2023] Open
Abstract
Blood culture is frequently used to detect bacteremia in febrile children. However, a high rate of negative or false-positive blood culture results is common at the pediatric emergency department (PED). The aim of this study was to use machine learning to build a model that could predict bacteremia in febrile children. We conducted a retrospective case-control study of febrile children who presented to the PED from 2008 to 2015. We adopted machine learning methods and cost-sensitive learning to establish a predictive model of bacteremia. We enrolled 16,967 febrile children with blood culture tests during the eight-year study period. Only 146 febrile children had true bacteremia, and more than 99% of febrile children had a contaminant or negative blood culture result. The maximum area under the curve of logistic regression and support vector machines to predict bacteremia were 0.768 and 0.832, respectively. Using the predictive model, we can categorize febrile children by risk value into five classes. Class 5 had the highest probability of having bacteremia, while class 1 had no risk. Obtaining blood cultures in febrile children at the PED rarely identifies a causative pathogen. Prediction models can help physicians determine whether patients have bacteremia and may reduce unnecessary expenses.
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Vos-Kerkhof ED, Gomez B, Milcent K, Steyerberg EW, Nijman RG, Smit FJ, Mintegi S, Moll HA, Gajdos V, Oostenbrink R. Clinical prediction models for young febrile infants at the emergency department: an international validation study. Arch Dis Child 2018; 103:1033-1041. [PMID: 29794106 DOI: 10.1136/archdischild-2017-314011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 03/28/2018] [Accepted: 04/10/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the diagnostic value of existing clinical prediction models (CPM; ie, statistically derived) in febrile young infants at risk for serious bacterial infections. METHODS A systematic literature review identified eight CPMs for predicting serious bacterial infections in febrile children. We validated these CPMs on four validation cohorts of febrile children in Spain (age <3 months), France (age <3 months) and two cohorts in the Netherlands (age 1-3 months and >3-12 months). We evaluated the performance of the CPMs by sensitivity/specificity, area under the receiver operating characteristic curve (AUC) and calibration studies. RESULTS The original cohorts in which the prediction rules were developed (derivation cohorts) ranged from 381 to 15 781 children, with a prevalence of serious bacterial infections varying from 0.8% to 27% and spanned an age range of 0-16 years. All CPMs originally performed moderately to very well (AUC 0.60-0.93). The four validation cohorts included 159-2204 febrile children, with a median age range of 1.8 (1.2-2.4) months for the three cohorts <3 months and 8.4 (6.0-9.6) months for the cohort >3-12 months of age. The prevalence of serious bacterial infections varied between 15.1% and 17.2% in the three cohorts <3 months and was 9.8% for the cohort >3-12 months of age. Although discriminative values varied greatly, best performance was observed for four CPMs including clinical signs and symptoms, urine dipstick analyses and laboratory markers with AUC ranging from 0.68 to 0.94 in the three cohorts <3 months (ranges sensitivity: 0.48-0.94 and specificity: 0.71-0.97). For the >3-12 months' cohort AUC ranges from 0.80 to 0.89 (ranges sensitivity: 0.70-0.82 and specificity: 0.78-0.90). In general, the specificities exceeded sensitivities in our cohorts, in contrast to derivation cohorts with high sensitivities, although this effect was stronger in infants <3 months than in infants >3-12 months. CONCLUSION We identified four CPMs, including clinical signs and symptoms, urine dipstick analysis and laboratory markers, which can aid clinicians in identifying serious bacterial infections. We suggest clinicians should use CPMs as an adjunctive clinical tool when assessing the risk of serious bacterial infections in febrile young infants.
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Affiliation(s)
- Evelien de Vos-Kerkhof
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Borja Gomez
- Paediatric Emergency Department, Cruces University Hospital, Bilbao, Spain.,University of the Basque Country, Bilbao, Spain
| | - Karen Milcent
- AP-HP Department of Paediatrics, Hôpitaux Universitaires Paris Sud-Antoine Béclère, Clamart, France
| | - Ewout W Steyerberg
- Department of Public Health and Clinical Decision Making, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ruud Gerard Nijman
- Department of Paediatric Accident and Emergency, St Mary's Hospital, Imperial College-NHS Healthcare Trust, Rotterdam, The Netherlands
| | - Frank J Smit
- Department of General Paediatrics, Maasstad Hospital, Rotterdam, The Netherlands
| | - Santiago Mintegi
- Paediatric Emergency Department, Cruces University Hospital, Bilbao, Spain.,University of the Basque Country, Bilbao, Spain
| | - Henriette A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Vincent Gajdos
- Université Paris-Saclay, Université Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Occult bacteremia etiology following the introduction of 13-valent pneumococcal conjugate vaccine: a multicenter study in Spain. Eur J Clin Microbiol Infect Dis 2018; 37:1449-1455. [PMID: 29736610 DOI: 10.1007/s10096-018-3270-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/30/2018] [Indexed: 10/17/2022]
Abstract
Little is known about occult bacteremia (OB) in Spain following the introduction of the 13-valent pneumococcal conjugated vaccine (PCV13). Our aim was to describe the microbiologic characteristics and management of OB among children aged 3-36 months in Spain in the era of PCV13. Data were obtained from a multicenter registry of positive blood cultures collected at 22 Spanish emergency departments (ED). Positive blood cultures performed on patients aged 3-36 months from 2011 to 2015 were retrospectively identified. Immunocompetent infants with a final diagnosis of OB were included. Non-well-appearing patients and patients with fever > 72 h were excluded. We analyzed 67 cases (median age 12.5 months [IQR 8.7-19.4]). Thirty-seven (54.4%) had received ≥ 1 dose of PCV. Overall, 47 (70.1%) were initially managed as outpatients (38.3% of them with antibiotic treatment). Phone contact was established with 43 (91.5%) of them after receiving the blood culture result and 11 (23.4%) were hospitalized with parenteral antibiotic. All patients did well. Streptococcus pneumoniae was isolated in 79.1% of the patients (42.2% of the isolated serotypes were included in the PCV13). S. pneumoniae remains the first cause of OB in patients attended in the ED, mainly with non-PCV13 serotypes. Most of the patients with OB were initially managed as outpatients with no adverse outcome.
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de la Torre M, de Lucas N, Velasco R, Gómez B, Mintegi S. Etiología y evolución de las infecciones potencialmente graves en lactantes menores de 3 meses febriles. An Pediatr (Barc) 2017; 87:42-49. [DOI: 10.1016/j.anpedi.2016.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/30/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022] Open
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Aetiology and outcomes of potentially serious infections in febrile infants less than 3 months old. An Pediatr (Barc) 2017. [DOI: 10.1016/j.anpede.2016.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Laaksonen N, Rintamäki L, Korppi M. Pneumococcal vaccinations effectively prevent blood culture-negative infections that resemble occult pneumococcal bacteraemia or bacteraemic pneumococcal pneumonia at one to 36 months of age. Acta Paediatr 2016; 105:1487-1492. [PMID: 27607346 DOI: 10.1111/apa.13580] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/19/2016] [Accepted: 09/05/2016] [Indexed: 12/25/2022]
Abstract
AIM The occurrence of blood culture-positive pneumococcal bacteraemia and bacteraemic pneumonia decreased after large-scale pneumococcal vaccinations were introduced. The aim of this study was to evaluate the effect of pneumococcal vaccinations on hospitalisations due to blood culture-negative infections with fever and leucocytosis, without any other focus than pneumonic infiltration. MATERIAL This was a retrospective hospital chart review covering the prevaccination era of 2008-2009 and postvaccination era of 2012-2013. The number of study subjects with fever and blood leucocytosis of >17.5 × 10E9/L at one to 36 months of age was 202. RESULTS The incidence of hospitalisation for infections associated with fever and leucocytosis, when pneumonic infiltration was present on the chest radiograph, was 4.7/10 000/year, with a 95% confidence interval (95% CI) of 2.2-8.8 in children under 36 months in 2012-2013. When pneumonic infiltration was not present, the respective incidence was 14.6/10 000/year (95% CI: 9.6-21.1). The figure from the 2008-2009 prevaccination era was 11.3 (95% CI: 8.1-15.3) when pneumonic infiltration was present and 24.0/10 000/year (95% CI: 19.2-29.7) when pneumonic infiltration was absent. CONCLUSION This study provides evidence of the effectiveness of pneumococcal vaccinations in preventing blood culture-negative infections that resembled occult pneumococcal bacteraemia (pneumococcaemia) or bacteraemic pneumococcal pneumonia at one to 36 months of age.
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Affiliation(s)
- Neea Laaksonen
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Lilja Rintamäki
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Matti Korppi
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
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Westra SJ, Karmazyn BK, Alazraki AL, Dempsey ME, Dillman JR, Garber M, Moore SG, Raske ME, Rice HE, Rigsby CK, Safdar N, Simoneaux SF, Strouse PJ, Trout AT, Wootton-Gorges SL, Coley BD. ACR Appropriateness Criteria Fever Without Source or Unknown Origin—Child. J Am Coll Radiol 2016; 13:922-30. [DOI: 10.1016/j.jacr.2016.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 04/27/2016] [Indexed: 11/16/2022]
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Mace SE, Gemme SR, Valente JH, Eskin B, Bakes K, Brecher D, Brown MD, Brown MD, Brecher D, Byyny R, Diercks DB, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Ingalsbe GS, Kaji A, Kwok H, Lo BM, Mace SE, Nazarian DJ, Proehl JA, Promes SB, Shah K, Shih RD, Silvers SM, Smith MD, Thiessen ME, Tomaszewski CA, Valente JH, Wall SP, Wolf SJ, Cantrill SV, O’Connor RE, Whitson RR, Mitchell MA. Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever. Ann Emerg Med 2016; 67:625-639.e13. [DOI: 10.1016/j.annemergmed.2016.01.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Hernández-Bou S, Trenchs Sainz de la Maza V, Esquivel Ojeda J, Gené Giralt A, Luaces Cubells C. Predictive factors of contamination in a blood culture with bacterial growth in an Emergency Department. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.anpede.2015.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Hernández-Bou S, Trenchs Sainz de la Maza V, Esquivel Ojeda J, Gené Giralt A, Luaces Cubells C. Factores predictores de contaminación ante un hemocultivo con crecimiento bacteriano en Urgencias. An Pediatr (Barc) 2015; 82:426-32. [DOI: 10.1016/j.anpedi.2014.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/03/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022] Open
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Hernandez-Bou S, Trenchs V, Batlle A, Gene A, Luaces C. Occult bacteraemia is uncommon in febrile infants who appear well, and close clinical follow-up is more appropriate than blood tests. Acta Paediatr 2015; 104:e76-81. [PMID: 25378087 DOI: 10.1111/apa.12852] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 10/23/2014] [Accepted: 11/03/2014] [Indexed: 12/01/2022]
Abstract
AIM The rate of paediatric occult bacteraemia after the introduction of the 13-valent pneumococcal conjugated vaccine is relatively unknown. We determined the rate, and identified isolated pathogens, in children aged three to 36 months who presented to a paediatric emergency department with fever, but otherwise appeared well. We also analysed the yield of laboratory parameters traditionally considered risk factors for occult bacteraemia. METHODS Children aged three to 36 months who were febrile, but otherwise appeared well, were included if they had blood tests in the paediatric emergency department between April 2010 and September 2012. RESULTS Of the 591 patients, only six (1.0%) had a true bacterial pathogen and three of those were Streptococcus pneumoniae (0.5%). None of the children with pneumococcal bacteraemia had been immunised. The contaminant rate was 2.7%, and an elevated band count was the best predictor of occult bacteraemia, with positive and negative likelihood ratios of 10 and 0.4, respectively. The yield of the other laboratory parameters was very limited. CONCLUSION In the era of the 13-valent pneumococcal conjugated vaccine, occult bacteraemia is an uncommon event in febrile children aged three to 36 who otherwise appear well and close follow-up should replace blood analysis in such cases.
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Affiliation(s)
- Susanna Hernandez-Bou
- Emergency Department; Hospital Sant Joan de Déu Barcelona; Esplugues de LIobregat Spain
| | - Victoria Trenchs
- Emergency Department; Hospital Sant Joan de Déu Barcelona; Esplugues de LIobregat Spain
| | - Astrid Batlle
- Emergency Department; Hospital Sant Joan de Déu Barcelona; Esplugues de LIobregat Spain
| | - Amadeu Gene
- Microbiology Department; Hospital Sant Joan de Déu Barcelona; Esplugues de LIobregat Spain
| | - Carles Luaces
- Emergency Department; Hospital Sant Joan de Déu Barcelona; Esplugues de LIobregat Spain
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Bacteremia in previously healthy children in emergency departments: clinical and microbiological characteristics and outcome. Eur J Clin Microbiol Infect Dis 2014; 34:453-60. [PMID: 25252630 DOI: 10.1007/s10096-014-2247-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 09/10/2014] [Indexed: 10/24/2022]
Abstract
A blood culture (BC) is frequently requested in both patients with a suspected occult bacteremia/invasive infection as well as those with certain focal infections. Few data are available on the characteristics of patients in whom a bacteremia is identified in the Pediatric Emergency Department (PED). A prospective multicenter registry was established by the Spanish Pediatric Emergency Society. Epidemiological data, complementary test results, clinical management, and final outcome were recorded. Data from the first three years of the registry were analyzed. A true bacterial pathogen grew in 932 of 65,169 BCs collected [1.43 %; 95 % confidence interval (CI) 1.34-1.51 %], with 711 of them collected in patients without previously known bacteremia risk factors. Among them, 335 (47.1 %) were younger than 1 year old and 467 (65.7 %) had a normal Pediatric Assessment Triangle (PAT) on admission. Overall, the most frequently isolated bacterial species was Streptococcus pneumoniae (27.3 %; 47.6 % among patients with an altered PAT). The main pathogens were Escherichia coli (40.3 %) and S. agalactiae (35.7 %) among patients younger than 3 months, S. pneumoniae among patients 3-60 months old (40.0 %), and S. aureus (31.9 %) among patients over 60 months of age. Neisseria meningitidis was the leading cause of sepsis in patients older than 3 months. Eight patients died; none of them had a pneumococcal bacteremia and all had abnormal PAT findings on admission. S. pneumoniae is the main cause of bacteremia in patients without bacteremia risk factors who attended Spanish PEDs. Age and general appearance influence the frequency of each bacterial species. General appearance also influences the associated mortality.
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Occult bloodstream infections in adults: a “benign” entity. Am J Emerg Med 2014; 32:966-71. [DOI: 10.1016/j.ajem.2014.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 05/04/2014] [Accepted: 05/05/2014] [Indexed: 11/22/2022] Open
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Abstract
Fever is one of the most common reasons for a visit to the primary care provider or the emergency department. Traditionally, clinicians have used various risk-stratification strategies to identify serious bacterial infections (SBI) without an obvious source in febrile children, because missed bacterial infections in such children can result in meningitis, sepsis, and death; therefore, early and accurate identification of SBIs is critical. Infants aged less than 60 to 90 days are at greatest risk of SBI. The epidemiology of SBI continues to evolve, especially after the successful introduction of conjugate vaccines against Streptococcus pneumoniae and Haemophilus influenzae.
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Affiliation(s)
- Rajan Arora
- Division of Emergency Medicine, Carman and Ann Adam Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Boulevard, Detroit, MI 48201, USA
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Abstract
Fever is the most common reason that children and infants are brought to emergency departments. Emergency physicians face the challenge of quickly distinguishing benign from life-threatening conditions. The management of fever in children is guided by the patient's age, immunization status, and immune status as well as the results of a careful physical examination and appropriate laboratory tests and radiographic views. In this article, the evaluation and treatment of children with fevers of known and unknown origin are described. Causes of common and dangerous conditions that include fever in their manifestation are also discussed.
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Affiliation(s)
- Robyn Wing
- Department of Pediatrics, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
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Karppa H, Vuento R, Toropainen M, Kaijalainen T, Siira L, Korppi M. Pneumococcemia in children--a retrospective study before universal pneumococcal vaccinations. Acta Paediatr 2013; 102:514-9. [PMID: 23398588 DOI: 10.1111/apa.12194] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 01/18/2013] [Accepted: 02/05/2013] [Indexed: 01/09/2023]
Abstract
AIM To evaluate the incidence and characteristics of blood culture-positive occult pneumococcemia compared with blood culture-positive pneumococcal pneumonia in children. METHODS In years 2001-2010, 105 children with positive blood cultures for Streptococcus pneumoniae were identified from hospital electronic files. The patient cards were retrospectively charted for clinical and laboratory data, and 38 patients had and 67 had not pneumonia. RESULTS The annual incidence of pneumococcemia was, on average, 29.0/10 000 at 0-12 months, 5.3/10 000 at 13-24 months and 1.9/10 000 at 2-4 years of ages, with no increasing or decreasing trend. The incidence of bacteraemic pneumococcal pneumonia increased (p = 0.022) during the study period. The duration of fever before hospitalization (<24 h 73.9% vs. 25.0%, p = 0.022) and the duration of intravenous antibiotics, usually G-penicillin (median 72 vs. 96 h, p = 0.021) was shorter in pneumococcemia patients. On admission, blood leucocyte count was higher in pneumococcemia (mean 26.6 vs. 21.9 × 10E9/L, p = 0.012), but serum CRP was higher in pneumonia (median 160 vs. 67.4 mg/L, p < 0.001). The serotypes 6B and 14 caused 53.2% of pneumococcemia cases. CONCLUSION The incidence of pneumococcemia was highest in 1-2-year-old children, and typical for pneumococcemia was rapid onset of fever, high blood leucocyte count and a modestly elevated CRP on admission.
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Affiliation(s)
- Henna Karppa
- Paediatric Research Centre; Tampere University and University Hospital; Tampere; Finland
| | - Risto Vuento
- Fimlab Laboratories; Pirkanmaa Hospital District; Tampere; Finland
| | - Maija Toropainen
- National Institute for Health and Welfare; Helsinki and Oulu; Finland
| | - Tarja Kaijalainen
- National Institute for Health and Welfare; Helsinki and Oulu; Finland
| | - Lotta Siira
- National Institute for Health and Welfare; Helsinki and Oulu; Finland
| | - Matti Korppi
- Paediatric Research Centre; Tampere University and University Hospital; Tampere; Finland
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Kossiva L, Soldatou A, Gourgiotis DI, Stamati L, Tsentidis C. Serum hepcidin: indication of its role as an "acute phase" marker in febrile children. Ital J Pediatr 2013; 39:25. [PMID: 23618075 PMCID: PMC3660274 DOI: 10.1186/1824-7288-39-25] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 03/26/2013] [Indexed: 11/26/2022] Open
Abstract
Background Hepcidin is classified as a type II acute phase protein; its production is a component of the innate immune response to infections. Objective To evaluate the alterations of serum hepcidin in children during and following an acute febrile infection. Materials and methods 22 children with fever of acute onset (< 6 hours) admitted to the 2nd Department of Pediatrics-University of Athens. Based on clinical and laboratory findings our sample formed two groups: the viral infection group (13 children) and the bacterial infection group (9 children). Hepcidin, ferritin and serum iron measurements were performed in all subjects. Results Serum hepcidin values did not differ notably between children with viral and bacterial infection, but a significant reduction of hepcidin was noted in both groups post-infection. Conclusion Our study provides clinical pediatric data on the role of hepcidin in the face of an acute infection. In our sample of children, hepcidin was found to rise during the acute infection and fall post-infection.
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Affiliation(s)
- Lydia Kossiva
- Second Department of Pediatrics P&A Kyriakou Children's Hospital, Medical School, Athens University, Athens, Greece.
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22
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Nijman RG, Vergouwe Y, Thompson M, van Veen M, van Meurs AHJ, van der Lei J, Steyerberg EW, Moll HA, Oostenbrink R. Clinical prediction model to aid emergency doctors managing febrile children at risk of serious bacterial infections: diagnostic study. BMJ 2013; 346:f1706. [PMID: 23550046 PMCID: PMC3614186 DOI: 10.1136/bmj.f1706] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To derive, cross validate, and externally validate a clinical prediction model that assesses the risks of different serious bacterial infections in children with fever at the emergency department. DESIGN Prospective observational diagnostic study. SETTING Three paediatric emergency care units: two in the Netherlands and one in the United Kingdom. PARTICIPANTS Children with fever, aged 1 month to 15 years, at three paediatric emergency care units: Rotterdam (n=1750) and the Hague (n=967), the Netherlands, and Coventry (n=487), United Kingdom. A prediction model was constructed using multivariable polytomous logistic regression analysis and included the predefined predictor variables age, duration of fever, tachycardia, temperature, tachypnoea, ill appearance, chest wall retractions, prolonged capillary refill time (>3 seconds), oxygen saturation <94%, and C reactive protein. MAIN OUTCOME MEASURES Pneumonia, other serious bacterial infections (SBIs, including septicaemia/meningitis, urinary tract infections, and others), and no SBIs. RESULTS Oxygen saturation <94% and presence of tachypnoea were important predictors of pneumonia. A raised C reactive protein level predicted the presence of both pneumonia and other SBIs, whereas chest wall retractions and oxygen saturation <94% were useful to rule out the presence of other SBIs. Discriminative ability (C statistic) to predict pneumonia was 0.81 (95% confidence interval 0.73 to 0.88); for other SBIs this was even better: 0.86 (0.79 to 0.92). Risk thresholds of 10% or more were useful to identify children with serious bacterial infections; risk thresholds less than 2.5% were useful to rule out the presence of serious bacterial infections. External validation showed good discrimination for the prediction of pneumonia (0.81, 0.69 to 0.93); discriminative ability for the prediction of other SBIs was lower (0.69, 0.53 to 0.86). CONCLUSION A validated prediction model, including clinical signs, symptoms, and C reactive protein level, was useful for estimating the likelihood of pneumonia and other SBIs in children with fever, such as septicaemia/meningitis and urinary tract infections.
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Affiliation(s)
- Ruud G Nijman
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, 3015 GJ Rotterdam, Netherlands
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Fu CM, Tseng WP, Chiang WC, Lai MS, Chie WC, Chou HC, Hsueh PR, Huei-Ming Ma M, Fang CC, Chen SC, Chen WJ, Chen SY. Occult Staphylococcus aureus Bacteremia in Adult Emergency Department Patients: Rare but Important. Clin Infect Dis 2012; 54:1536-44. [DOI: 10.1093/cid/cis214] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Bressan S, Berlese P, Mion T, Masiero S, Cavallaro A, Da Dalt L. Bacteremia in feverish children presenting to the emergency department: a retrospective study and literature review. Acta Paediatr 2012; 101:271-7. [PMID: 21950707 DOI: 10.1111/j.1651-2227.2011.02478.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To evaluate the incidence of bacteremia, and the isolated pathogens, in well-appearing children with fever without source (FWS) presenting to the pediatric emergency department (PED), after pneumococcal conjucate vaccine - 7 valent (PCV-7) widespread introduction in the Veneto region of north-eastern Italy, and to review the main literature contributions on the subject. METHODS Blood cultures performed at the PED of Padova from 1 June 2006 to 31 January 2009 in febrile children aged 1-36 months were retrospectively retrieved. Medical records of previously healthy well-appearing children with FWS were identified and reviewed. RESULTS The study finally included 392 patients. Bacteremia rate was 0.34% (95% CI 0-1) in the age group 3-36 months and 2% (95% CI 0-4.7) in infants 1-3 months. No Streptococcus pneumoniae was isolated. The literature review identified 10 relevant studies carried out in the USA and Spain showing an overall bacteremia rate <1% for feverish children aged 3-36 months, with values <0.5% in settings with high PCV-7 coverage. CONCLUSION Overall bacteremia rate is currently <0.5% in well-appearing children aged 3-36 months with FWS attending the PED in areas with PCV-7 widespread vaccination and is sufficiently low to preclude laboratory testing in favour of close follow-up. Further research is needed to evaluate a more conservative approach in infants 2-3 months of age.
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Abstract
Asplenia may refer to the spleen's surgical removal, functional impairment, or congenital absence. It is a risk factor for the development of severe bacterial infection. Functional asplenia is likely the most common presentation of this entity and has many etiologies. Those that are previously undiagnosed may present completely well until an episode of overt sepsis develops. The true incidence of mortality secondary to functional asplenia remains elusive. As lifetime mortality remains exceedingly high in the asplenic population regardless of etiology, markers of hyposplenism are important to detect. The present report describes an infant with trisomy 21 and previously undiagnosed functional asplenia who ultimately experienced overwhelming pneumococcal sepsis with features of Waterhouse-Friderichsen syndrome and died within 12 hours of initial presentation. It is a poignant reminder of what features to be cognizant of on peripheral blood smear in a previously well child, who may be at risk for a devastating consequence.
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