1
|
Florin TA, Ramilo O, Banks RK, Schnadower D, Quayle KS, Powell EC, Pickett ML, Nigrovic LE, Mistry R, Leetch AN, Hickey RW, Glissmeyer EW, Dayan PS, Cruz AT, Cohen DM, Bogie A, Balamuth F, Atabaki SM, VanBuren JM, Mahajan P, Kuppermann N. Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study. Emerg Med J 2023; 41:13-19. [PMID: 37770118 PMCID: PMC10841819 DOI: 10.1136/emermed-2023-213089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE The lack of evidence-based criteria to guide chest radiograph (CXR) use in young febrile infants results in variation in its use with resultant suboptimal quality of care. We sought to describe the features associated with radiographic pneumonias in young febrile infants. STUDY DESIGN Secondary analysis of a prospective cohort study in 18 emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network from 2016 to 2019. Febrile (≥38°C) infants aged ≤60 days who received CXRs were included. CXR reports were categorised as 'no', 'possible' or 'definite' pneumonia. We compared demographics, clinical signs and laboratory tests among infants with and without pneumonias. RESULTS Of 2612 infants, 568 (21.7%) had CXRs performed; 19 (3.3%) had definite and 34 (6%) had possible pneumonias. Patients with definite (4/19, 21.1%) or possible (11/34, 32.4%) pneumonias more frequently presented with respiratory distress compared with those without (77/515, 15.0%) pneumonias (adjusted OR 2.17; 95% CI 1.04 to 4.51). There were no differences in temperature or HR in infants with and without radiographic pneumonias. The median serum procalcitonin (PCT) level was higher in the definite (0.7 ng/mL (IQR 0.1, 1.5)) vs no pneumonia (0.1 ng/mL (IQR 0.1, 0.3)) groups, as was the median absolute neutrophil count (ANC) (definite, 5.8 K/mcL (IQR 3.9, 6.9) vs no pneumonia, 3.1 K/mcL (IQR 1.9, 5.3)). No infants with pneumonia had bacteraemia. Viral detection was frequent (no pneumonia (309/422, 73.2%), definite pneumonia (11/16, 68.8%), possible pneumonia (25/29, 86.2%)). Respiratory syncytial virus was the predominant pathogen in the pneumonia groups and rhinovirus in infants without pneumonias. CONCLUSIONS Radiographic pneumonias were uncommon in febrile infants. Viral detection was common. Pneumonia was associated with respiratory distress, but few other factors. Although ANC and PCT levels were elevated in infants with definite pneumonias, further work is necessary to evaluate the role of blood biomarkers in infant pneumonias.
Collapse
Affiliation(s)
- Todd A Florin
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Octavio Ramilo
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Russell K Banks
- Department of Pediatrics, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - David Schnadower
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kimberly S Quayle
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Elizabeth C Powell
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michelle L Pickett
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lise E Nigrovic
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rakesh Mistry
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Aaron N Leetch
- Departments of Emergency Medicine and Pediatrics, University of Arizona Medical Center-Diamond Children's, Tucson, Arizona, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Eric W Glissmeyer
- Department of Pediatrics, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Peter S Dayan
- Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Andrea T Cruz
- Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Daniel M Cohen
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Amanda Bogie
- Department of Pediatrics, The University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Fran Balamuth
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shireen M Atabaki
- Emergency Medicine, Children's National Health System, Washington, District of Columbia, USA
- Department of Pediatrics, Children's National Health System, Washington, District of Columbia, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Prashant Mahajan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, California, USA
| |
Collapse
|
2
|
Lo YHJ, Graves C, Holland JL, Rogers AJ, Money N, Hashikawa AN, Ramgopal S. Temperature threshold in the screening of bacterial infections in young infants with hypothermia. Emerg Med J 2023; 40:189-194. [PMID: 36396347 DOI: 10.1136/emermed-2022-212575] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 11/07/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Young infants with hypothermia presenting to the emergency department (ED) are at risk for serious bacterial infections (SBI), however there is no consensus temperature to prompt evaluation for SBI among these children. We sought to statistically derive a temperature threshold to guide detection of SBI in young infants with hypothermia presenting to the ED. METHODS We performed a cross-sectional study of infants ≤90 days old presenting to four academic paediatric EDs in the United States of America from January 2015 through December 2019 with a rectal temperature of ≤36.4°C. Our primary outcomes were SBI, defined as urinary tract infection (UTI), bacteraemia and/or bacterial meningitis, and invasive bacterial infections (IBI, limited to bacteraemia and/or bacterial meningitis). We constructed receiver operating characteristic (ROC) curves to evaluate an optimally derived cutpoint for minimum ED temperature and presence of SBI or IBI. RESULTS We included 3376 infants, of whom SBI were found in 62 (1.8%) and IBI in 16 (0.5%). The most common infection identified was Escherichia coli UTI. Overall, cohort minimum median temperature was 36.2°C (IQR 36.0°C-36.4°C). Patients with SBI and IBI had lower median temperatures, 35.8°C (IQR 35.8°C-36.3°C) and 35.4°C (IQR 35.7°C-36.3°C), respectively, compared with those without corresponding infections (both p<0.05). Using an outcome of SBI, the area under the ROC curve (AUROC) was 61.0% (95% CI 54.1% to 67.9%). At a cutpoint of 36.2°C, sensitivity was 59.7% and specificity was 59.2%. When using an outcome of IBI, the AUROC was 65.9% (95% CI 51.1% to 80.6%). Using a cutpoint of 36.1°C in this model resulted in a sensitivity of 68.8% and specificity of 60.1%. CONCLUSION Young infants with SBI and IBI presented with lower temperatures than infants without infections. However, there was no temperature threshold to reliably identify SBI or IBI. Further research incorporating clinical and laboratory parameters, in addition to temperature, may help to improve risk stratification for these vulnerable patients.
Collapse
Affiliation(s)
- Yu Hsiang Johnny Lo
- Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Christopher Graves
- Emergency Medicine, Pediatric Emergency Medicine Associates (PEMA), Atlanta, Georgia, USA
| | | | - Alexander Joseph Rogers
- Emergency Medicine and Pediatrics, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Nathan Money
- Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Andrew Nobuhide Hashikawa
- Emergency Medicine and Pediatrics, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sriram Ramgopal
- Emergency Medicine, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| |
Collapse
|
3
|
Holland JL, Ramgopal S, Money N, Graves C, Lo YH, Hashikawa A, Rogers A. Biomarkers and their association with bacterial illnesses in hypothermic infants. Am J Emerg Med 2023; 64:137-141. [PMID: 36528001 PMCID: PMC10368072 DOI: 10.1016/j.ajem.2022.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To describe the association of biomarkers with serious bacterial infection (SBI; urinary tract infection [UTI], bacteremia and/or bacterial meningitis) in hypothermic infants presenting to the emergency department (ED). METHODS We performed a cross sectional study in four academic pediatric EDs from January 2015 through December 2019, including infants ≤90 days old presenting with a rectal temperature of ≤36.4 °C. We constructed receiver operating characteristic (ROC) curves to evaluate the accuracy of blood biomarkers including white blood cell count (WBC), absolute neutrophil count (ANC) and platelets for identifying SBI, with exploratory analyses evaluating procalcitonin and band counts. RESULTS Among 850 included infants (53.5% males; median days of age 13 [IQR 5-58 days]), SBI were found in 55 (6.5%). For infants with SBI, the area under the curve (AUC; 95% confidence interval) for WBC was 0.70 (0.61-0.78) with sensitivity 0.64 (0.50-0.74) and specificity 0.77 (0.74-0.80). The AUC for ANC was 0.77 (0.70-0.84) with sensitivity 0.69 (0.55-0.81) and specificity 0.77 (0.74-0.8). For platelets, the AUC was 0.6 (0.52-0.67) with sensitivity 0.73 (0.59-0.84) and specificity 0.5 (0.46-0.53). Both the WBC and ANC were minimally accurate for identifying hypothermic infants with SBI. When looking at the accuracy of these biomarkers for identifying invasive bacterial infection (IBI; bacteremia and/or bacterial meningitis), ANC again showed minimal accuracy with an AUC of 0.70 (0.55-0.85). CONCLUSIONS Biomarkers commonly used as part of an infectious workup are generally poor at identifying SBI in hypothermic infants. Our findings from this cohort of hypothermic infants are similar to those reported from febrile infants, suggesting similarities in the bioresponse to infection between hypothermic and febrile infants. Additional research is required to improve risk stratification for hypothermic infants, and to better guide evaluation and management.
Collapse
Affiliation(s)
- Jamie L Holland
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nathan Money
- Division of Pediatric Hospital Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Christopher Graves
- Division of Pediatric Emergency Medicine, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Yu Hsiang Lo
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Andrew Hashikawa
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Alexander Rogers
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
4
|
Assessment of Infection Progression per Host Gene Expression. Crit Care Med 2022; 50:1834-1837. [PMID: 36394402 DOI: 10.1097/ccm.0000000000005677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
5
|
Graves C, Lo YH, Holland JL, Money NM, Hashikawa AN, Rogers A, Ramgopal S. Hypothermia In Young Infants. Pediatrics 2022; 150:189916. [PMID: 36345694 DOI: 10.1542/peds.2022-058213] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Christopher Graves
- Department of Pediatric Emergency Medicine, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Yu Hsiang Lo
- Department of Emergency Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | | | - Nathan M Money
- Division of Pediatric Hospital Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Andrew N Hashikawa
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Alexander Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
6
|
Tsalik EL, Henao R, Montgomery JL, Nawrocki JW, Aydin M, Lydon EC, Ko ER, Petzold E, Nicholson BP, Cairns CB, Glickman SW, Quackenbush E, Kingsmore SF, Jaehne AK, Rivers EP, Langley RJ, Fowler VG, McClain MT, Crisp RJ, Ginsburg GS, Burke TW, Hemmert AC, Woods CW. Discriminating Bacterial and Viral Infection Using a Rapid Host Gene Expression Test. Crit Care Med 2021; 49:1651-1663. [PMID: 33938716 PMCID: PMC8448917 DOI: 10.1097/ccm.0000000000005085] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Host gene expression signatures discriminate bacterial and viral infection but have not been translated to a clinical test platform. This study enrolled an independent cohort of patients to describe and validate a first-in-class host response bacterial/viral test. DESIGN Subjects were recruited from 2006 to 2016. Enrollment blood samples were collected in an RNA preservative and banked for later testing. The reference standard was an expert panel clinical adjudication, which was blinded to gene expression and procalcitonin results. SETTING Four U.S. emergency departments. PATIENTS Six-hundred twenty-three subjects with acute respiratory illness or suspected sepsis. INTERVENTIONS Forty-five-transcript signature measured on the BioFire FilmArray System (BioFire Diagnostics, Salt Lake City, UT) in ~45 minutes. MEASUREMENTS AND MAIN RESULTS Host response bacterial/viral test performance characteristics were evaluated in 623 participants (mean age 46 yr; 45% male) with bacterial infection, viral infection, coinfection, or noninfectious illness. Performance of the host response bacterial/viral test was compared with procalcitonin. The test provided independent probabilities of bacterial and viral infection in ~45 minutes. In the 213-subject training cohort, the host response bacterial/viral test had an area under the curve for bacterial infection of 0.90 (95% CI, 0.84-0.94) and 0.92 (95% CI, 0.87-0.95) for viral infection. Independent validation in 209 subjects revealed similar performance with an area under the curve of 0.85 (95% CI, 0.78-0.90) for bacterial infection and 0.91 (95% CI, 0.85-0.94) for viral infection. The test had 80.1% (95% CI, 73.7-85.4%) average weighted accuracy for bacterial infection and 86.8% (95% CI, 81.8-90.8%) for viral infection in this validation cohort. This was significantly better than 68.7% (95% CI, 62.4-75.4%) observed for procalcitonin (p < 0.001). An additional cohort of 201 subjects with indeterminate phenotypes (coinfection or microbiology-negative infections) revealed similar performance. CONCLUSIONS The host response bacterial/viral measured using the BioFire System rapidly and accurately discriminated bacterial and viral infection better than procalcitonin, which can help support more appropriate antibiotic use.
Collapse
Affiliation(s)
- Ephraim L. Tsalik
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ricardo Henao
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Biostatistics and Informatics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Mert Aydin
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Emily C. Lydon
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Emily R. Ko
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Regional Hospital, Durham, NC, USA
| | - Elizabeth Petzold
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Charles B. Cairns
- University of North Carolina Medical Center, Chapel Hill, NC, USA
- Drexel University, Philadelphia, PA, USA
| | - Seth W. Glickman
- University of North Carolina Medical Center, Chapel Hill, NC, USA
| | | | | | | | | | | | - Vance G. Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Micah T. McClain
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Geoffrey S. Ginsburg
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Thomas W. Burke
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Christopher W. Woods
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | |
Collapse
|
7
|
Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, O'Leary ST, Okechukwu K, Woods CR. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics 2021; 148:peds.2021-052228. [PMID: 34281996 DOI: 10.1542/peds.2021-052228] [Citation(s) in RCA: 174] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This guideline addresses the evaluation and management of well-appearing, term infants, 8 to 60 days of age, with fever ≥38.0°C. Exclusions are noted. After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active investigators, 21 key action statements were derived. For each key action statement, the quality of evidence and benefit-harm relationship were assessed and graded to determine the strength of recommendations. When appropriate, parents' values and preferences should be incorporated as part of shared decision-making. For diagnostic testing, the committee has attempted to develop numbers needed to test, and for antimicrobial administration, the committee provided numbers needed to treat. Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
Collapse
Affiliation(s)
- Robert H Pantell
- Department of Pediatrics, School of Medicine, University of California San Francisco, San Francisco, California
| | - Kenneth B Roberts
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - William G Adams
- Boston Medical Center/Boston University School of Medicine, Deparment of Pediatrics, Boston, Massachusetts
| | - Benard P Dreyer
- Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatric, School of Medicine, University of California, Davis School of Medicine, Sacramento, California
| | - Sean T O'Leary
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | | | | | | |
Collapse
|
8
|
Abstract
Pediatric fever is a common complaint in children. The most common cause is self-limited viral infection. However, neonates and young infants are evaluated and treated differently than older, vaccinated, and clinically evaluable children. Neonates should be admitted to the hospital, young infants in the second month of life may be risk stratified, and those deemed low risk on testing may be sent home with close follow-up. Children older than 2 months may be evaluated clinically for signs of bacterial infection that require intervention. Urinary tract infections cause more than 90% of serious bacterial illness in children, and younger children have a higher incidence of infection.
Collapse
Affiliation(s)
- Emily Rose
- Department of Emergency Medicine, Los Angeles County + University of Southern California Medical Center, Keck School of Medicine of the University of Southern California, Old General Hospital, Room 1011, 1200 North State Street, Los Angeles, CA 90033, USA.
| |
Collapse
|
9
|
Ramgopal S, Horvat CM, Yanamala N, Alpern ER. Machine Learning To Predict Serious Bacterial Infections in Young Febrile Infants. Pediatrics 2020; 146:e20194096. [PMID: 32855349 PMCID: PMC7461239 DOI: 10.1542/peds.2019-4096] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Recent decision rules for the management of febrile infants support the identification of infants at higher risk of serious bacterial infections (SBIs) without the performance of routine lumbar puncture. We derive and validate a model to identify febrile infants ≤60 days of age at low risk for SBIs using supervised machine learning approaches. METHODS We conducted a secondary analysis of a multicenter prospective study performed between December 2008 and May 2013 of febrile infants. Our outcome was SBI, (culture-positive urinary tract infection, bacteremia, and/or bacterial meningitis). We developed and validated 4 supervised learning models: logistic regression, random forest, support vector machine, and a single-hidden layer neural network. RESULTS A total of 1470 patients were included (1014 >28 days old). One hundred thirty-eight (9.3%) had SBIs (122 urinary tract infections, 20 bacteremia, and 8 meningitis; 11 with concurrent SBIs). Using 4 features (urinalysis, white blood cell count, absolute neutrophil count, and procalcitonin), we demonstrated with the random forest model the highest specificity (74.9, 95% confidence interval: 71.5%-78.2%) with a sensitivity of 98.6% (95% confidence interval: 92.2%-100.0%) in the validation cohort. One patient with bacteremia was misclassified. Among 1240 patients who received a lumbar puncture, this model could have prevented 849 (68.5%) such procedures. CONCLUSIONS We derived and internally validated a supervised learning model for the risk-stratification of febrile infants. Although computationally complex, lacking parameter cutoffs, and in need of external validation, this strategy may allow for reductions in unnecessary procedures, hospitalizations, and antibiotics while maintaining excellent sensitivity.
Collapse
Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois;
| | - Christopher M Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Division of Health Informatics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Naveena Yanamala
- Institute for Software Research, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
10
|
Ramgopal S, Wilson PM. Automated Versus Manual Band Counts for the Diagnosis of Invasive Bacterial Infections in Infants Who Are Febrile. J Pediatr 2020; 221:246-250.e3. [PMID: 32145966 DOI: 10.1016/j.jpeds.2020.01.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/09/2020] [Accepted: 01/30/2020] [Indexed: 01/25/2023]
Abstract
We conducted a secondary analysis of a prospective study of infants ≤60 days of age who were febrile to assess the diagnostic accuracy of automated vs manual immature neutrophils for invasive bacterial infections. Although manual counts were superior compared with automated counts, bands had suboptimal accuracy overall and had significant variability in test characteristics based on methodology.
Collapse
Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Chicago, IL.
| | - Paria M Wilson
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH; Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
11
|
Lyons TW, Garro AC, Cruz AT, Freedman SB, Okada PJ, Mahajan P, Balamuth F, Thompson AD, Kulik DM, Uspal NG, Arms JL, Nigrovic LE. Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections. Pediatrics 2020; 145:peds.2019-3538. [PMID: 32205466 DOI: 10.1542/peds.2019-3538] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The ability of the decades-old Boston and Philadelphia criteria to accurately identify infants at low risk for serious bacterial infections has not been recently reevaluated. METHODS We assembled a multicenter cohort of infants 29 to 60 days of age who had cerebrospinal fluid (CSF) and blood cultures obtained. We report the performance of the modified Boston criteria (peripheral white blood cell count [WBC] ≥20 000 cells per mm3, CSF WBC ≥10 cells per mm3, and urinalysis with >10 WBC per high-power field or positive urine dip result) and modified Philadelphia criteria (peripheral WBC ≥15 000 cells per mm3, CSF WBC ≥8 cells per mm3, positive CSF Gram-stain result, and urinalysis with >10 WBC per high-power field or positive urine dip result) for the identification of invasive bacterial infections (IBIs). We defined IBI as bacterial meningitis (growth of pathogenic bacteria from CSF culture) or bacteremia (growth from blood culture). RESULTS We applied the modified Boston criteria to 8344 infants and the modified Philadelphia criteria to 8131 infants. The modified Boston criteria identified 133 of the 212 infants with IBI (sensitivity 62.7% [95% confidence interval (CI) 55.9% to 69.3%] and specificity 59.2% [95% CI 58.1% to 60.2%]), and the modified Philadelphia criteria identified 157 of the 219 infants with IBI (sensitivity 71.7% [95% CI 65.2% to 77.6%] and specificity 46.1% [95% CI 45.0% to 47.2%]). The modified Boston and Philadelphia criteria misclassified 17 of 53 (32.1%) and 13 of 56 (23.3%) infants with bacterial meningitis, respectively. CONCLUSIONS The modified Boston and Philadelphia criteria misclassified a substantial number of infants 29 to 60 days old with IBI, including those with bacterial meningitis.
Collapse
Affiliation(s)
- Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts;
| | - Aris C Garro
- Departments of Pediatrics and Emergency Medicine, Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Andrea T Cruz
- Sections of Pediatric Emergency Medicine and Pediatric Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital and Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pamela J Okada
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Fran Balamuth
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy D Thompson
- Departments of Pediatrics and Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Dina M Kulik
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Neil G Uspal
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Joseph L Arms
- Department of Pediatrics, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | |
Collapse
|
12
|
Fieber ohne Fokus beim jungen Säugling. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00767-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
13
|
Rogers AJ, Kuppermann N, Anders J, Roosevelt G, Hoyle JD, Ruddy RM, Bennett JE, Borgialli DA, Dayan PS, Powell EC, Casper TC, Ramilo O, Mahajan P. Practice Variation in the Evaluation and Disposition of Febrile Infants ≤60 Days of Age. J Emerg Med 2019; 56:583-591. [PMID: 31014970 PMCID: PMC6589384 DOI: 10.1016/j.jemermed.2019.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/08/2019] [Accepted: 03/04/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Febrile infants commonly present to emergency departments for evaluation. OBJECTIVE We describe the variation in diagnostic testing and hospitalization of febrile infants ≤60 days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network. METHODS We enrolled a convenience sample of non-critically ill-appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60 days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0-28 days of age) and older (29-60 days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age group using chi-square tests and by site using analysis of variance. RESULTS Four thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0-28 days of age. Rates of lumbar puncture and hospitalization were high (>90%) among infants ≤28 days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29-60 days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%. CONCLUSIONS The evaluation and disposition of febrile infants ≤60 days of age is highly variable, particularly among infants who are 29-60 days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization.
Collapse
Affiliation(s)
| | - Nathan Kuppermann
- University of California, Davis School of Medicine, Sacramento, California;
| | | | | | | | | | | | | | - Peter S. Dayan
- New York Presbyterian-Morgan Stanley Children’s Hospital, New York, New York;
| | | | | | | | | | | |
Collapse
|
14
|
Cooper A, Davies F, Edwards M, Anderson P, Carson-Stevens A, Cooke MW, Donaldson L, Dale J, Evans BA, Hibbert PD, Hughes TC, Porter A, Rainer T, Siriwardena A, Snooks H, Edwards A. The impact of general practitioners working in or alongside emergency departments: a rapid realist review. BMJ Open 2019; 9:e024501. [PMID: 30975667 PMCID: PMC6500276 DOI: 10.1136/bmjopen-2018-024501] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 12/14/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%-43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak. DESIGN Rapid realist literature review. SETTING Emergency departments. INCLUSION CRITERIA Articles describing general practitioners working in or alongside emergency departments. AIM To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system. RESULTS Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes. CONCLUSIONS Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research. PROSPERO REGISTRATION NUMBER CRD42017069741.
Collapse
Affiliation(s)
- Alison Cooper
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Freya Davies
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Centre for Health Economics, Swansea University, Swansea, UK
| | | | | | - Liam Donaldson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Peter D Hibbert
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Thomas C Hughes
- Emergency Department, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Alison Porter
- College of Medicine, Swansea University, Swansea, UK
| | - Tim Rainer
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - Helen Snooks
- College of Medicine, Swansea University, Swansea, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| |
Collapse
|
15
|
Kuppermann N, Dayan PS, Levine DA, Vitale M, Tzimenatos L, Tunik MG, Saunders M, Ruddy RM, Roosevelt G, Rogers AJ, Powell EC, Nigrovic LE, Muenzer J, Linakis JG, Grisanti K, Jaffe DM, Hoyle JD, Greenberg R, Gattu R, Cruz AT, Crain EF, Cohen DM, Brayer A, Borgialli D, Bonsu B, Browne L, Blumberg S, Bennett JE, Atabaki SM, Anders J, Alpern ER, Miller B, Casper TC, Dean JM, Ramilo O, Mahajan P. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr 2019; 173:342-351. [PMID: 30776077 PMCID: PMC6450281 DOI: 10.1001/jamapediatrics.2018.5501] [Citation(s) in RCA: 206] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. OBJECTIVE To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. DESIGN, SETTING, AND PARTICIPANTS Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018. EXPOSURES Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. MAIN OUTCOMES AND MEASURES Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. RESULTS We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109 per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. CONCLUSIONS AND RELEVANCE We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.
Collapse
Affiliation(s)
- Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Peter S. Dayan
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Deborah A. Levine
- Department of Pediatrics, Bellevue Hospital, New York University Langone Medical Center, New York, New York
| | - Melissa Vitale
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Michael G. Tunik
- Department of Pediatrics, Bellevue Hospital, New York University Langone Medical Center, New York, New York
| | - Mary Saunders
- Department of Pediatrics, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee,Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora
| | - Richard M. Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Genie Roosevelt
- Department of Pediatrics, The Colorado Children’s Hospital, University of Colorado, Denver
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan School of Medicine, Ann Arbor
| | - Elizabeth C. Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jared Muenzer
- Division of Emergency Medicine, Department of Pediatrics, St Louis Children’s Hospital, Washington University, St Louis, Missouri,Division of Emergency Medicine, Phoenix Children’s Hospital, Phoenix, Arizona
| | - James G. Linakis
- Department of Emergency Medicine and Pediatrics, Hasbro Children’s Hospital, Providence, Rhode Island,Brown University School of Medicine, Providence, Rhode Island
| | - Kathleen Grisanti
- Department of Pediatrics, Women and Children’s Hospital of Buffalo, State University of New York at Buffalo School of Medicine
| | - David M. Jaffe
- Division of Emergency Medicine, Department of Pediatrics, St Louis Children’s Hospital, Washington University, St Louis, Missouri
| | - John D. Hoyle
- Department of Emergency Medicine, Helen DeVos Children’s Hospital of Spectrum Health, Grand Rapids, Michigan,Departments of Emergency Medicine and Pediatrics, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo
| | - Richard Greenberg
- Division of Emergency Medicine, Department of Pediatrics, Primary Children’s Medical Center, University of Utah, Salt Lake City
| | - Rajender Gattu
- Division of Emergency Medicine, Department of Pediatrics, University of Maryland Medical Center, Baltimore
| | - Andrea T. Cruz
- Sections of Emergency Medicine and Infectious Diseases, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston
| | - Ellen F. Crain
- Department of Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Daniel M. Cohen
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio,The Ohio State University School of Medicine, Columbus
| | - Anne Brayer
- Departments of Emergency Medicine and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Dominic Borgialli
- Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan,University of Michigan School of Medicine, Ann Arbor
| | - Bema Bonsu
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio,The Ohio State University School of Medicine, Columbus
| | - Lorin Browne
- Departments of Pediatrics and Emergency Medicine, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Stephen Blumberg
- Department of Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Jonathan E. Bennett
- Division of Emergency Medicine, Alfred I. duPont Hospital for Children, Nemours Children’s Health System, Thomas Jefferson School of Medicine, Wilmington, Delaware
| | - Shireen M. Atabaki
- Division of Emergency Medicine, Department of Pediatrics, Children’s National Medical Center, The George Washington School of Medicine and Health Sciences, Washington, DC
| | - Jennifer Anders
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Benjamin Miller
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - T. Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - J. Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Octavio Ramilo
- The Ohio State University School of Medicine, Columbus,Division of Pediatric Infectious Diseases and Center for Vaccines and Immunity, Nationwide Children’s Hospital, Columbus, Ohio
| | - Prashant Mahajan
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, Michigan,Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor
| | | |
Collapse
|
16
|
Mahajan P, Browne LR, Levine DA, Cohen DM, Gattu R, Linakis JG, Anders J, Borgialli D, Vitale M, Dayan PS, Casper TC, Ramilo O, Kuppermann N. Risk of Bacterial Coinfections in Febrile Infants 60 Days Old and Younger with Documented Viral Infections. J Pediatr 2018; 203:86-91.e2. [PMID: 30195552 PMCID: PMC7094460 DOI: 10.1016/j.jpeds.2018.07.073] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/17/2018] [Accepted: 07/20/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections. STUDY DESIGN Planned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants. RESULTS Of the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The rate of bacterial meningitis tended to be lower in the virus-positive group (0.4%) than in the viral-negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6), was significantly associated with SBI in multivariable analysis. CONCLUSIONS Febrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis.
Collapse
Affiliation(s)
- Prashant Mahajan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI.
| | - Lorin R. Browne
- Department of Pediatrics and Emergency Medicine, Children's Hospital of Wisconsin, Medical College of Wisconsin, Wauwatosa, WI
| | - Deborah A. Levine
- Department of Emergency Medicine and Pediatrics, Bellevue Hospital New York University Langone Medical Center, Bellevue Hospital Center, New York, NY
| | - Daniel M. Cohen
- Section of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Rajender Gattu
- Division of Emergency Medicine, Department of Pediatrics, University of Maryland Medical Center, Baltimore, MD
| | - James G. Linakis
- Department of Emergency Medicine and Pediatrics, Hasbro Children's Hospital and Brown University, Providence, RI
| | - Jennifer Anders
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Dominic Borgialli
- Department of Emergency Medicine, Hurley Medical Center and University of Michigan, Flint, MI
| | - Melissa Vitale
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Peter S. Dayan
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, NY
| | | | - Octavio Ramilo
- Division of Pediatric Infectious Diseases and Center for Vaccines and Immunity, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine and UC Davis Health, Davis, CA
| | - Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN)PowellElizabeth C.MD, MPH14LevineDeborah A.MD15TunikMichael G.MD15NigrovicLise E.MD, MPH16RooseveltGenieMD17MahajanPrashantMD, MPH, MBA18AlpernElizabeth R.MD, MSCE19VitaleMelissaMD20BrowneLorinDO21SaundersMaryMD21AtabakiShireen M.MD, MPH22RuddyRichard M.MD23LinakisJames G.MD, PhD24HoyleJohn D.Jr.MD25BorgialliDominicDO, MPH26BlumbergStephenMD27CrainEllen F.MD, PhD27AndersJenniferMD28BonsuBemaMD29CohenDaniel M.MD29BennettJonathan E.MD30DayanPeter S.MD, MSc31GreenbergRichardMD32JaffeDavid M.MD33MuenzerJaredMD33CruzAndrea T.MD, MPH34MaciasCharlesMD34KuppermannNathanMD, MPH35TzimenatosLeahMD35GattuRajenderMD36RogersAlexander J.MD37BrayerAnneMD38LillisKathleenMD39Ann & Robert H. Lurie Children's HospitalBellevue Hospital CenterBoston Children's HospitalChildren's Hospital of ColoradoChildren's Hospital of MichiganChildren's Hospital of PhiladelphiaChildren's Hospital of PittsburghChildren's Hospital of WisconsinChildren's National Medical CenterCincinnati Children's Hospital Medical CenterHasbro Children's HospitalHelen DeVos Children's HospitalHurley Medical CenterJacobi Medical CenterJohns Hopkins Children's CenterNationwide Children's HospitalNemours/Alfred I. DuPont Hospital for ChildrenNew York Presbyterian-Morgan Stanley Children's HospitalPrimary Children's Medical CenterSt. Louis Children's HospitalTexas Children's HospitalUniversity of California Davis HealthUniversity of MarylandUniversity of MichiganUniversity of RochesterWomen and Children's Hospital of Buffalo
| |
Collapse
|
17
|
Powell EC, Mahajan PV, Roosevelt G, Hoyle JD, Gattu R, Cruz AT, Rogers AJ, Atabaki SM, Jaffe DM, Casper TC, Ramilo O, Kuppermann N. Epidemiology of Bacteremia in Febrile Infants Aged 60 Days and Younger. Ann Emerg Med 2018; 71:211-216. [PMID: 28988964 PMCID: PMC5815881 DOI: 10.1016/j.annemergmed.2017.07.488] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/12/2017] [Accepted: 07/25/2017] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN). METHODS We conducted a planned secondary analysis of a prospective observational study of febrile infants 60 days of age and younger presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood cultures obtained. We excluded infants with significant comorbidities or critically ill appearance. The primary outcome was prevalence of bacteremia. RESULTS Of 7,335 screened infants, 4,778 (65.1%) had blood cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95% confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed by week of age for infants 28 days of age and younger (0 to 7 days: 4/156, 2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28 days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95% CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%). Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger (1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%; 95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to 53.5%) had urinary tract infections (E coli 83%); 11 (13.1%; 95% CI 7.5% to 21.9%) had bacterial meningitis. CONCLUSION The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens.
Collapse
Affiliation(s)
- Elizabeth C Powell
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
| | - Prashant V Mahajan
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI
| | - Genie Roosevelt
- Department of Emergency Medicine, University of Colorado, Denver, CO
| | - John D Hoyle
- Departments of Emergency Medicine and Pediatrics, Western Michigan University, Kalamazoo, MI
| | - Rajender Gattu
- Department of Pediatrics, University of Maryland, Baltimore, MD
| | - Andrea T Cruz
- Sections of Emergency Medicine and Infectious Diseases, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI
| | - Shireen M Atabaki
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, The George Washington School of Medicine and Health Sciences, Washington, DC
| | - David M Jaffe
- Department of Education, American Academy of Pediatrics, Elk Grove Village, IL
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Octavio Ramilo
- Division of Pediatric Infectious Diseases and Center for Vaccines and Immunity, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, CA
| |
Collapse
|
18
|
Abstract
Infants aged 90 days or younger with fever are frequently evaluated in the pediatric emergency department. Physical examination findings and individual laboratory investigations are not reliable to differentiate benign viral infections from serious bacterial infections in febrile infants. Clinical prediction models were developed more than 25 years ago and have high sensitivity but relatively low specificity to identify bacterial infections in febrile infants. Newer laboratory investigations such as C-reactive protein and procalcitonin have favorable test characteristics compared with traditional laboratory studies such as a white blood cell count. These novel biomarkers have not gained widespread acceptance because of lack of robust prospectively collected data, varying thresholds to define positivity, and differing inclusion criteria across studies. However, C-reactive protein and procalcitonin, when combined with other patient characteristics in the step-by-step approach, have a high sensitivity for detection of serious bacterial infection. The RNA biosignatures are a novel biomarker under investigation for detection of bacterial infection in febrile infants.
Collapse
|
19
|
Kimberlin DW, Poole CL. Assessing the Febrile Child for Serious Infection: A Step Closer to Meaningful Rapid Results. Pediatrics 2017; 140:peds.2017-1210. [PMID: 28904071 DOI: 10.1542/peds.2017-1210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- David W Kimberlin
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Claudette L Poole
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
20
|
Nigrovic LE, Mahajan PV, Blumberg SM, Browne LR, Linakis JG, Ruddy RM, Bennett JE, Rogers AJ, Tzimenatos L, Powell EC, Alpern ER, Casper TC, Ramilo O, Kuppermann N. The Yale Observation Scale Score and the Risk of Serious Bacterial Infections in Febrile Infants. Pediatrics 2017; 140:peds.2017-0695. [PMID: 28759413 PMCID: PMC5495524 DOI: 10.1542/peds.2017-0695] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess the performance of the Yale Observation Scale (YOS) score and unstructured clinician suspicion to identify febrile infants ≤60 days of age with and without serious bacterial infections (SBIs). METHODS We performed a planned secondary analysis of a prospective cohort of non-critically ill, febrile, full-term infants ≤60 days of age presenting to 1 of 26 participating emergency departments in the Pediatric Emergency Care Applied Research Network. We defined SBIs as urinary tract infections, bacteremia, or bacterial meningitis, with the latter 2 considered invasive bacterial infections. Emergency department clinicians applied the YOS (range: 6-30; normal score: ≤10) and estimated the risk of SBI using unstructured clinician suspicion (<1%, 1%-5%, 6%-10%, 11%-50%, or >50%). RESULTS Of the 4591 eligible infants, 444 (9.7%) had SBIs and 97 (2.1%) had invasive bacterial infections. Of the 4058 infants with YOS scores of ≤10, 388 (9.6%) had SBIs (sensitivity: 51/439 [11.6%]; 95% confidence interval [CI]: 8.8%-15.0%; negative predictive value: 3670/4058 [90.4%]; 95% CI: 89.5%-91.3%) and 72 (1.8%) had invasive bacterial infections (sensitivity 23/95 [24.2%], 95% CI: 16.0%-34.1%; negative predictive value: 3983/4055 [98.2%], 95% CI: 97.8%-98.6%). Of the infants with clinician suspicion of <1%, 106 had SBIs (6.4%) and 16 (1.0%) had invasive bacterial infections. CONCLUSIONS In this large prospective cohort of febrile infants ≤60 days of age, neither the YOS score nor unstructured clinician suspicion reliably identified those with invasive bacterial infections. More accurate clinical and laboratory predictors are needed to risk stratify febrile infants.
Collapse
Affiliation(s)
- Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Prashant V. Mahajan
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, Michigan;,Departments of Emergency Medicine, and,Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Stephen M. Blumberg
- Department of Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Lorin R. Browne
- Departments of Pediatrics, and,Emergency Medicine, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James G. Linakis
- Departments of Emergency Medicine, and,Pediatrics, Hasbro Children’s Hospital and Brown University, Providence, Rhode Island
| | - Richard M. Ruddy
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan E. Bennett
- Division of Pediatric Emergency Medicine, Alfred I. duPont Hospital for Children, Nemours Children’s Health System, Wilmington, Delaware
| | - Alexander J. Rogers
- Departments of Emergency Medicine, and,Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | - Elizabeth C. Powell
- Division of Emergency Medicine, Department of Pediatrics, Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Lurie Children’s Hospital of Chicago, Chicago, Illinois;,Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - T. Charles Casper
- Pediatric Emergency Care Applied Research Network Data Coordinating Center, Salt Lake City, Utah; and
| | | | - Nathan Kuppermann
- Departments of Emergency Medicine, and,Pediatrics, School of Medicine, University of California, Davis, Sacramento, California
| | | |
Collapse
|
21
|
Ramilo O, Mejias A. Host transcriptomics for diagnosis of infectious diseases: one step closer to clinical application. Eur Respir J 2017; 49:49/6/1700993. [PMID: 28619965 DOI: 10.1183/13993003.00993-2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Octavio Ramilo
- Dept of Pediatrics, Division of Infectious Diseases and Center for Vaccines and Immunity, The Research Institute at Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Asuncion Mejias
- Dept of Pediatrics, Division of Infectious Diseases and Center for Vaccines and Immunity, The Research Institute at Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| |
Collapse
|
22
|
Greenhow TL, Hung YY, Pantell RH. Management and Outcomes of Previously Healthy, Full-Term, Febrile Infants Ages 7 to 90 Days. Pediatrics 2016; 138:peds.2016-0270. [PMID: 27940667 DOI: 10.1542/peds.2016-0270] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There is considerable variation in the approach to infants presenting to the emergency department and outpatient clinics with fever without a source. We set out to describe the current clinical practice regarding culture acquisition on febrile young infants and review the outcomes of infants with and without cultures obtained. METHODS This study analyzed Kaiser Permanente Northern California's electronic medical record to identify all febrile, full term, previously healthy infants born between July 1, 2010, and June 30, 2013, presenting for care between 7 and 90 days of age. RESULTS During this 3-year study, 96 156 full-term infants were born at Kaiser Permanente Northern California. A total of 1380 infants presented for care with a fever with an incidence rate of 14.4 (95% confidence interval: 13.6-15.1) per 1000 full term births. Fifty-nine percent of infants 7 to 28 days old had a full evaluation compared with 25% of infants 29 to 60 days old and 5% of infants 61 to 90 days old. Older infants with lower febrile temperatures presenting to an office setting were less likely to have a culture. In the 30 days after fevers, 1% of infants returned with a urinary tract infection. No infants returned with bacteremia or meningitis. CONCLUSIONS Fever in a medical setting occurred in 1.4% of infants in this large cohort. Forty-one percent of febrile infants did not have any cultures including 24% less than 28 days. One percent returned in the following month with a urinary tract infection. There was no delayed identification of bacteremia or meningitis.
Collapse
Affiliation(s)
- Tara L Greenhow
- Kaiser Permanente Northern California, San Francisco, California;
| | - Yun-Yi Hung
- Kaiser Permanente Division of Research, Oakland, California; and
| | - Robert H Pantell
- University of California San Francisco, San Francisco, California
| |
Collapse
|
23
|
Abstract
This article is the last in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated on program completion. This article focuses on the many career paths as educators, researchers, advocates, innovators, consultants, administrators, and leaders available to pediatric emergency medicine physicians, in both clinical and nonclinical realms, and how fellows and junior faculty can enrich and prolong their careers through diversification.
Collapse
|
24
|
Mahajan P, Kuppermann N, Mejias A, Suarez N, Chaussabel D, Casper TC, Smith B, Alpern ER, Anders J, Atabaki SM, Bennett JE, Blumberg S, Bonsu B, Borgialli D, Brayer A, Browne L, Cohen DM, Crain EF, Cruz AT, Dayan PS, Gattu R, Greenberg R, Hoyle JD, Jaffe DM, Levine DA, Lillis K, Linakis JG, Muenzer J, Nigrovic LE, Powell EC, Rogers AJ, Roosevelt G, Ruddy RM, Saunders M, Tunik MG, Tzimenatos L, Vitale M, Dean JM, Ramilo O. Association of RNA Biosignatures With Bacterial Infections in Febrile Infants Aged 60 Days or Younger. JAMA 2016; 316:846-57. [PMID: 27552618 PMCID: PMC5122927 DOI: 10.1001/jama.2016.9207] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Young febrile infants are at substantial risk of serious bacterial infections; however, the current culture-based diagnosis has limitations. Analysis of host expression patterns ("RNA biosignatures") in response to infections may provide an alternative diagnostic approach. OBJECTIVE To assess whether RNA biosignatures can distinguish febrile infants aged 60 days or younger with and without serious bacterial infections. DESIGN, SETTING, AND PARTICIPANTS Prospective observational study involving a convenience sample of febrile infants 60 days or younger evaluated for fever (temperature >38° C) in 22 emergency departments from December 2008 to December 2010 who underwent laboratory evaluations including blood cultures. A random sample of infants with and without bacterial infections was selected for RNA biosignature analysis. Afebrile healthy infants served as controls. Blood samples were collected for cultures and RNA biosignatures. Bioinformatics tools were applied to define RNA biosignatures to classify febrile infants by infection type. EXPOSURE RNA biosignatures compared with cultures for discriminating febrile infants with and without bacterial infections and infants with bacteremia from those without bacterial infections. MAIN OUTCOMES AND MEASURES Bacterial infection confirmed by culture. Performance of RNA biosignatures was compared with routine laboratory screening tests and Yale Observation Scale (YOS) scores. RESULTS Of 1883 febrile infants (median age, 37 days; 55.7% boys), RNA biosignatures were measured in 279 randomly selected infants (89 with bacterial infections-including 32 with bacteremia and 15 with urinary tract infections-and 190 without bacterial infections), and 19 afebrile healthy infants. Sixty-six classifier genes were identified that distinguished infants with and without bacterial infections in the test set with 87% (95% CI, 73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier genes distinguished infants with bacteremia from those without bacterial infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures over the YOS score was 0.37 (95% CI, 0.30-0.43). CONCLUSIONS AND RELEVANCE In this preliminary study, RNA biosignatures were defined to distinguish febrile infants aged 60 days or younger with vs without bacterial infections. Further research with larger populations is needed to refine and validate the estimates of test accuracy and to assess the clinical utility of RNA biosignatures in practice.
Collapse
Affiliation(s)
- Prashant Mahajan
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento
| | - Asuncion Mejias
- Division of Pediatric Infectious Diseases and Center for Vaccines and Immunity, Nationwide Children's Hospital and The Ohio State University, Columbus
| | - Nicolas Suarez
- Division of Pediatric Infectious Diseases and Center for Vaccines and Immunity, Nationwide Children's Hospital and The Ohio State University, Columbus
| | - Damien Chaussabel
- Benaroya Research Institute, Virginia Mason and Sidra Medical and Research Center, Seattle, Washington, and Doha, Qatar
| | | | - Bennett Smith
- Division of Pediatric Infectious Diseases and Center for Vaccines and Immunity, Nationwide Children's Hospital and The Ohio State University, Columbus
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania7Now at Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer Anders
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Shireen M Atabaki
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Jonathan E Bennett
- Division of Pediatric Emergency Medicine, Alfred I. DuPont Hospital for Children, Nemours Children's Health System, Wilmington, Delaware
| | - Stephen Blumberg
- Department of Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Bema Bonsu
- Section of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Dominic Borgialli
- Department of Emergency Medicine, Hurley Medical Center and University of Michigan, Flint
| | - Anne Brayer
- Departments of Emergency Medicine and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Lorin Browne
- Departments of Pediatrics and Emergency Medicine, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Daniel M Cohen
- Section of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus
| | - Ellen F Crain
- Division of Pediatric Emergency Medicine, Alfred I. DuPont Hospital for Children, Nemours Children's Health System, Wilmington, Delaware
| | - Andrea T Cruz
- Sections of Emergency Medicine and Infectious Diseases, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Peter S Dayan
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, New York
| | - Rajender Gattu
- Division of Emergency Medicine, Department of Pediatrics, University of Maryland Medical Center, Baltimore
| | - Richard Greenberg
- Department of Pediatrics, Primary Children's Medical Center, University of Utah, Salt Lake City
| | - John D Hoyle
- Department of Emergency Medicine, Helen DeVos Children's Hospital of Spectrum Health, Grand Rapids, Michigan22Now with the Departments of Emergency Medicine and Pediatrics, Western Michigan University Homer Stryker, MD, School of Medicine, Kalamazoo
| | - David M Jaffe
- Department of Pediatrics, St Louis Children's Hospital, Washington University, St Louis, Missouri24Now with the Division of Pediatric Emergency Medicine, University of California San Francisco School of Medicine
| | - Deborah A Levine
- Department of Pediatrics, Bellevue Hospital New York University Langone Center, New York
| | - Kathleen Lillis
- Department of Pediatrics, Women and Children's Hospital of Buffalo, State University of New York at Buffalo
| | - James G Linakis
- Department of Emergency Medicine and Pediatrics, Hasbro Children's Hospital and Brown University, Providence, Rhode Island
| | - Jared Muenzer
- Department of Pediatrics, Bellevue Hospital New York University Langone Center, New York28Now with the Department of Emergency Medicine, Phoenix Children's Hospital, Phoenix, Arizona
| | - Lise E Nigrovic
- Department of Pediatrics, Boston Children's Hospital, Harvard University, Boston, Massachusetts
| | - Elizabeth C Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor
| | - Genie Roosevelt
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Denver, Aurora
| | - Richard M Ruddy
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mary Saunders
- Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee35Now with Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora
| | - Michael G Tunik
- Department of Pediatrics, Bellevue Hospital, New York University Langone Medical Center, New York
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Melissa Vitale
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Octavio Ramilo
- Division of Pediatric Infectious Diseases and Center for Vaccines and Immunity, Nationwide Children's Hospital and The Ohio State University, Columbus
| | | |
Collapse
|
25
|
Iroh Tam PY, Obaro SK, Storch G. Challenges in the Etiology and Diagnosis of Acute Febrile Illness in Children in Low- and Middle-Income Countries. J Pediatric Infect Dis Soc 2016; 5:190-205. [PMID: 27059657 PMCID: PMC7107506 DOI: 10.1093/jpids/piw016] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 03/04/2016] [Indexed: 01/01/2023]
Abstract
Acute febrile illness is a common cause of hospital admission, and its associated infectious causes contribute to substantial morbidity and death among children worldwide, especially in low- and middle-income countries. Declining transmission of malaria in many regions, combined with the increasing use of rapid diagnostic tests for malaria, has led to the increasing recognition of leptospirosis, rickettsioses, respiratory viruses, and arboviruses as etiologic agents of fevers. However, clinical discrimination between these etiologies can be difficult. Overtreatment with antimalarial drugs is common, even in the setting of a negative test result, as is overtreatment with empiric antibacterial drugs. Viral etiologies remain underrecognized and poorly investigated. More-sensitive diagnostics have led to additional dilemmas in discriminating whether a positive test result reflects a causative pathogen. Here, we review and summarize the current epidemiology and focus particularly on children and the challenges for future research.
Collapse
Affiliation(s)
- Pui-Ying Iroh Tam
- Department of Pediatrics
,
University of Minnesota Medical School
,
Minneapolis,Corresponding Author:
Pui-Ying Iroh Tam, MD, 3-210 MTRF, 2001 6th St. SE, Minneapolis, MN 55455. E-mail:
| | - Stephen K. Obaro
- Department of Pediatrics, University of Nebraska Medical Center, Omaha
| | - Gregory Storch
- Department of Pediatrics
,
Washington University School of Medicine
,
St Louis, Missouri
| |
Collapse
|
26
|
Detecting specific infections in children through host responses: a paradigm shift. Curr Opin Infect Dis 2015; 27:228-35. [PMID: 24739346 DOI: 10.1097/qco.0000000000000065] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW There is a need for improved diagnosis and for optimal classification of patients with infectious diseases. An alternative approach to the pathogen-detection strategy is based on a comprehensive analysis of the host response to the infection. This review focuses on the value of transcriptome analyses of blood leukocytes for the diagnosis and management of patients with infectious diseases. RECENT FINDINGS Initial studies showed that RNA from blood leukocytes of children with acute viral and bacterial infections carried pathogen-specific transcriptional signatures. Subsequently, transcriptional signatures for several other infections have been described and validated in humans with malaria, dengue, salmonella, melioidosis, respiratory syncytial virus, influenza, tuberculosis, and HIV. In addition, transcriptome analyses represent an invaluable tool to understand disease pathogenesis and to objectively classify patients according to the clinical severity. SUMMARY Microarray studies have been shown to be highly reproducible using different platforms, and in different patient populations, confirming the value of blood transcriptome analyses to study pathogen-specific host immune responses in the clinical setting. Combining the detection of the pathogen with a comprehensive assessment of the host immune response will provide a new understanding of the correlations between specific causative agents, the host response, and the clinical manifestations of the disease.
Collapse
|
27
|
Tsalik EL, McClain M, Zaas AK. Moving toward prime time: host signatures for diagnosis of respiratory infections. J Infect Dis 2015; 212:173-5. [PMID: 25637349 DOI: 10.1093/infdis/jiv032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/13/2015] [Indexed: 01/12/2023] Open
Affiliation(s)
- Ephraim L Tsalik
- Institute for Genome Sciences and Precision Medicine, Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Micah McClain
- Institute for Genome Sciences and Precision Medicine, Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Aimee K Zaas
- Institute for Genome Sciences and Precision Medicine, Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
28
|
Tzimenatos L, Kim E, Kuppermann N. The Pediatric Emergency Care Applied Research Network: a history of multicenter collaboration in the United States. Clin Exp Emerg Med 2014; 1:78-86. [PMID: 27752557 PMCID: PMC5052835 DOI: 10.15441/ceem.14.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 11/20/2014] [Accepted: 11/21/2014] [Indexed: 11/25/2022] Open
Abstract
In this article, we review the history and progress of a large multicenter research network pertaining to emergency medical services for children. We describe the history, organization, infrastructure, and research agenda of the Pediatric Emergency Care Applied Research Network (PECARN), and highlight some of the important accomplishments since its inception. We also describe the network’s strategy to grow its research portfolio, train new investigators, and study how to translate new evidence into practice. This strategy ensures not only the sustainability of the network in the future, but the growth of research in emergency medical services for children in general.
Collapse
Affiliation(s)
- Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Emily Kim
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, USA; Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA, USA
| |
Collapse
|