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Erdem G, Watson JR, Tomatis C, Ceyhan K, Barson W. Impact of viral testing on duration of antibiotic treatment and hospitalisation of febrile infants. Acta Paediatr 2024. [PMID: 39227731 DOI: 10.1111/apa.17413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 07/27/2024] [Accepted: 08/22/2024] [Indexed: 09/05/2024]
Abstract
AIM To assess the duration of antimicrobial treatment; hospital length of stay; and invasive bacterial infections rates in hospitalised infants following the adoption of a management guideline. METHODS Faculty agreed to a standard of 24 h of antibiotic treatment for well-appearing febrile infants with proven viral infection and no growth on bacterial cultures. The outcomes were the duration of hospitalisation and antibiotic treatment of febrile infants less than 8 weeks of age who have enterovirus, parechovirus, respiratory viruses detected. We monitored re-admissions and missed invasive infections. RESULTS Of the total 1696 infants studied, the median antibiotic treatment duration decreased from 31.5 to 24.8 h in virus-infected infants ≤21 days of age (p = 0.02) and from 26 to 19.7 h in infants 22-56 days of age (p < 0.001). The decrease was less in infants not infected with a virus. No patient had an invasive infection identified after discharge. CONCLUSION The implementation of our care standard resulted in reduction in antibiotic treatment duration without known delayed diagnosis of bacterial infections. Infants without a proven viral aetiology may need further study to inform management decisions.
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Affiliation(s)
- G Erdem
- Section of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - J R Watson
- Section of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - C Tomatis
- Section of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - K Ceyhan
- Department of Neurosurgery, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - W Barson
- Section of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University School of Medicine, Columbus, Ohio, USA
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Bushra Q, Fatima S, Hameed A, Mukhtar S. Epidemiological trends of febrile infants presenting to the Paediatric Emergency department, in a tertiary care hospital, Karachi, Pakistan: a retrospective review. BMJ Open 2024; 14:e076611. [PMID: 39181554 PMCID: PMC11344527 DOI: 10.1136/bmjopen-2023-076611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/06/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND Understanding the epidemiological patterns of febrile infants can offer valuable insights for optimising management strategies and developing quality improvement initiatives, aiming to improve healthcare delivery in high-volume, low-resource emergency departments (EDs). OBJECTIVES To characterise the epidemiology of febrile infants presenting to the paediatric ED of a tertiary care hospital. METHODS A retrospective chart review of medical records was performed for febrile infants ≤1 year old, at paediatric ED, Indus Hospital and Health Network (IHHN), Karachi, Pakistan (1 January 2020-31 December 2020). RESULTS There were a total of 2311 patients in the study, with a male-to-female ratio of 1.4:1. The mean age of presentation was 4.9±2.7 months. Cough (n=1002, 43.2%) was the most frequent presenting symptom. The most common provisional ED diagnosis in ≤1 month of age was sepsis (n=98, 51%), bronchopneumonia (n=138, 28.6%) in 1.1-3 and 3.1-6 months (n=176, 36.45%); and upper respiratory tract illness (n=206, 47.4%) in 6.1-12 months of age. Age was significantly associated with provisional ED diagnosis and outcomes (p<0.001). Of 175 ED admissions (n=47, 26.8%), patients were discharged with a hospital diagnosis of bronchopneumonia and (n=27, 15.4) of sepsis. The infant mortality rate was 3/1000 live births. CONCLUSIONS This study is the first of its kind to explore the epidemiology of febrile infants in Pakistan, highlighting the burden and severity of respiratory illnesses and sepsis. It underscores the challenges of resource-limited settings, failing to meet the need for admission of febrile infants presenting to ED, IHHN. Moreover, it has highlighted the necessity to optimise the existing triage systems to effectively allocate resources and manage high patient volumes in low-resource EDs.
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Affiliation(s)
- Quratulain Bushra
- Paediatric Emergency, Indus Hospital and Health Network, Karachi, Sindh, Pakistan
| | - Sara Fatima
- Paediatric Emergency, Indus Hospital and Health Network, Karachi, Sindh, Pakistan
| | - Ammara Hameed
- Bahria University Medical and Dental College, Karachi, Sindh, Pakistan
| | - Sama Mukhtar
- Emergency Medicine, Indus Hospital & Health Network, Karachi, Sindh, Pakistan
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Yun S, Cotton C, Faith EF, Jacobs L, Kittler N, Monir RL, Ravi M, Richmond A, Schoch J, Workman E, Zucker J, Hunt R, Lauren CT. Management of Pustules and Vesicles in Afebrile Infants ≤60 Days Evaluated by Dermatology. Pediatrics 2024; 154:e2023064364. [PMID: 38910522 DOI: 10.1542/peds.2023-064364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 06/25/2024] Open
Abstract
OBJECTIVES To assess the management and outcomes of afebrile infants who received a pediatric dermatology consultation for pustules and/or vesicles. METHODS Medical records were reviewed for all infants 60 days of age or younger who received a pediatric dermatology consult across 6 academic institutions between September 1, 2013 and August 31, 2019 to identify those infants with pustules and/or vesicles. RESULTS Of the 879 consults, 183 afebrile infants presented with pustules and/or vesicles. No cerebrospinal fluid cultures or blood cultures were positive for bacteria. No concordant positive urine cultures were identified in infants with cutaneous infection. Nine infants were diagnosed with herpes simplex virus (HSV). Five preterm infants were diagnosed with angioinvasive fungal infections. CONCLUSIONS No serious bacterial infections attributable to a skin source were identified, yet 53% of these infants received parenteral antibiotics. HSV was diagnosed in 7% of this cohort, 77.8% (7/9) of whom were term infants and 22.2% (2 of 9) of whom were preterm. Angioinvasive fungal infection was diagnosed in 3%, all of whom (100%, 5 of 5) were extremely preterm at <28 weeks gestational age. These findings suggest that in full-term afebrile infants ≤60 days, the likelihood of a life-threatening etiology of isolated pustules or vesicles is low once HSV infection is excluded. In preterm infants with pustules and/or vesicles, a high index of suspicion must be maintained, and broad infectious evaluation is recommended. HSV testing is recommended for all infants with vesicles, grouped pustules and/or punched-out erosions.
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Affiliation(s)
- Sonora Yun
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Colleen Cotton
- Department of Dermatology, George Washington School of Medicine and Health Sciences, Washington, District of Columbia
- Division of Dermatology, Children's National Hospital, Washington, District of Columbia
| | | | - Linsey Jacobs
- Departments of Pediatrics
- Dermatology
- Palo Alto Foundation Medical Group, Palo Alto, California
| | - Nicole Kittler
- Dermatology
- University of California San Franscico, San Franscico, California
| | - Reesa L Monir
- Dermatology
- University of Florida, Gainesville, Florida
| | - Manisha Ravi
- Dermatology
- Ohio State University, Columbus, Ohio
| | - Alexandra Richmond
- Dermatology
- Medical University of South Carolina, Charleston, South Carolina
| | - Jennifer Schoch
- Departments of Pediatrics
- Dermatology
- University of Florida, Gainesville, Florida
| | - Eleanor Workman
- Dermatology
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jason Zucker
- Departments of Pediatrics
- Division of Pediatric Infectious Diseases
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- NewYork-Presbyterian Hospital, New York, New York
| | - Raegan Hunt
- Departments of Pediatrics
- Dermatology
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Christine T Lauren
- Departments of Pediatrics
- Dermatology
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- NewYork-Presbyterian Hospital, New York, New York
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Umana E, Mills C, Norman-Bruce H, Wilson K, Mitchell H, McFetridge L, Woolfall K, Lynn FA, McKeeman G, Foster S, Barrett M, Roland D, Lyttle MD, Watson C, Waterfield T. Applying clinical decision aids for the assessment and management of febrile infants presenting to emergency care in the UK and Ireland: Febrile Infant Diagnostic Assessment and Outcome (FIDO) Study protocol. BMJ Open 2023; 13:e075823. [PMID: 37730397 PMCID: PMC10514651 DOI: 10.1136/bmjopen-2023-075823] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Febrile infants 90 days and younger are at risk of invasive bacterial infections (bacteraemia and meningitis) and urinary tract infections. Together this is previously termed serious bacterial infection with an incidence of approximately 10-20%. The National Institute for Health and Care Excellence guidance advocates a cautious approach with most infants requiring septic screening, parenteral broad-spectrum antibiotics and hospital admission. Internationally, variations exist in the approach to febrile infants, with European and North American guidance advocating a tailored approach based on clinical features and biomarker testing. None of the available international clinical decision aids (CDAs) has been validated in the UK and Irish cohorts. The aim of the Febrile Infant Diagnostic Assessment and Outcome (FIDO) Study is to prospectively validate a range of CDAs in a UK and Irish population including CDAs that use procalcitonin testing. METHODS AND ANALYSIS The FIDO Study is a prospective multicentre mixed-methods cohort study conducted in UK and Irish hospitals. All infants aged 90 days and younger presenting with fever or history of fever (≥38°C) are eligible for inclusion. Infants will receive standard emergency clinical care without delay. Clinical data and blood samples will be collected, and consent will be obtained at the earliest appropriate opportunity using research without prior consent methodology. The performance and cost-effectiveness of CDAs will be assessed. An embedded qualitative study will explore clinician and caregiver views on different approaches to care and perceptions of risk. ETHICS AND DISSEMINATION This study was reviewed and approved by the Office for Research Ethics Committees Northern Ireland-Health and Social Care Research Ethics Committee B, Public Benefit and Privacy Panel for Health and Social Care Scotland, and Children's Health Ireland Research and Ethics Committee Ireland. The results of this study will be presented at academic conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT05259683.
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Affiliation(s)
- Etimbuk Umana
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Clare Mills
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Hannah Norman-Bruce
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Kathryn Wilson
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Hannah Mitchell
- Mathematical Sciences Research Centre, School of Mathematics & Physics, Queen's University Belfast, Belfast, UK
| | - Lisa McFetridge
- Mathematical Sciences Research Centre, School of Mathematics & Physics, Queen's University Belfast, Belfast, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Faculty of Health and Life Sciences, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Fiona A Lynn
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Gareth McKeeman
- Department of Clinical Biochemistry, HCS Belfast Health and Social Care Trust, Belfast, UK
| | - Steven Foster
- Emergency Department, Royal Hospital for Children, Glasgow, UK
| | - Michael Barrett
- Paediatric Emergency Medicine, Children's Health Ireland at Crumlin, Crumlin, Ireland
- Women's and Children's Health, School of Medicine, University College Dublin, Dublin, Ireland
| | - Damian Roland
- Emergency Department, Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Faculty of Health and Applied Science, University of the West of England, Bristol, UK
| | - Chris Watson
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Thomas Waterfield
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
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Cheng CY, Hsu TH, Yang YL, Huang YH. Hemoglobin and Its Z Score Reference Intervals in Febrile Children: A Cohort Study of 98,572 Febrile Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1402. [PMID: 37628401 PMCID: PMC10453815 DOI: 10.3390/children10081402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/13/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVES Febrile disease and age of children were associated with a variation in hemoglobin (Hb) level. Both CRP and Hb serve as laboratory markers that offer valuable insights into a patient's health, particularly in relation to inflammation and specific medical conditions. Although a direct correlation between CRP and Hb levels is not established, the relationship between these markers has garnered academic attention and investigation. This study aimed to determine updated reference ranges for Hb levels for age and investigated its correlation with CRP in febrile children under the age of 18. METHODS This is a cohort study of in Chang Gung Memorial Hospitals conducted from January 2010 to December 2019. Blood samples were collected from 98,572 febrile children who were or had been admitted in the pediatric emergency department. The parameters of individuals were presented as the mean ± standard deviation or 2.5th and 97.5th percentiles. We also determined the variation of Hb and Z score of Hb between CRP levels in febrile children. RESULT We observed that the Hb levels were the highest immediately after birth and subsequently underwent a rapid decline, reaching their lowest point at around 1-2 months of age, and followed by a steady increment in Hb levels throughout childhood and adolescence. In addition, there was a significant and wide variation in Hb levels during the infant period. It revealed a significant association between higher CRP levels and lower Hb levels or a more negative Z score of Hb across all age subgroups. Moreover, in patients with bacteremia, CRP levels were higher, Hb concentrations were lower, and Z scores of Hb were also lower compared to the non-bacteremia group. Furthermore, the bacteremia group exhibited a more substantial negative correlation between CRP levels and a Z score of Hb (r = -0.41, p < 0.001) compared to the non-bacteremia group (r = -0.115, p < 0.049). CONCLUSION The study findings revealed that the Hb references varied depending on the age of the children and their CRP levels. In addition, we established new reference values for Hb and its Z scores and explore their relationship with CRP. It provides valuable insights into the Hb status and its potential association with inflammation in febrile pediatric patients.
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Affiliation(s)
- Chu-Yin Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Ting-Hsuan Hsu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Ya-Ling Yang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 333, Taiwan
| | - Ying-Hsien Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 333, Taiwan
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Marsh MC, Lin HM, Black J, Allen K, Weiner B, Ramilo O, Klamer B, Watson JR, Kasick R. Preterm and Term Infants Evaluated for Sepsis: Differences in Management and Clinical Outcomes. Hosp Pediatr 2023; 13:544-554. [PMID: 37222075 DOI: 10.1542/hpeds.2022-007050] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND OBJECTIVES To describe differences in practice patterns and outcomes of young preterm versus age-matched term infants evaluated for sepsis, because evaluation and management of this group are not well defined. METHODS We conducted a retrospective single-center study at an academic, freestanding children's hospital of previously healthy preterm and term infants aged 0 to 60 days, who presented for initial evaluation of fever and/or hypothermia from 2014 to 2019. We classified infants by gestational age as preterm (32-36 6/7 weeks) and term (37-42 weeks) and compared diagnostic evaluation, management, and clinical outcomes. RESULTS Out of 363 preterm infants evaluated for sepsis, 336 met inclusion criteria; within the same study period, 2331 term infants were evaluated for sepsis, of which 600 were randomly selected and 554 were included. Clinicians performed inflammatory marker testing and chest x-rays more frequently in preterm infants 31% vs 25% (P = .034) and 50% vs 32% (P < .001), respectively. Preterm infants had a higher rate of bacteremia 5.9% vs 2.5% (P = .035), were hospitalized more frequently 72% vs 63% (P = .006), and required ICU level of care more often 32% vs 5% (P < .001) than term infants. They had lower rates of viral infections 33% vs 42% (P = .015) and no significant increased return visits. Febrile preterm and term infants, and older hypothermic preterm infants had relatively higher rates of serious bacterial infections. Hypothermic preterm infants had the longest hospitalizations. CONCLUSIONS Preterm infants had increased rates of bacteremia and required higher level of care compared with age-matched term infants, likely reflecting their increased risk for sepsis and other concomitant morbidities associated with preterm birth.
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Affiliation(s)
| | | | - Joshua Black
- Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University, College of Medicine, Columbus, Ohio
| | - Karen Allen
- Nationwide Children's Hospital, Columbus, Ohio
| | - Benjamin Weiner
- The Ohio State University, College of Medicine, Columbus, Ohio
| | - Octavio Ramilo
- Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University, College of Medicine, Columbus, Ohio
| | - Brett Klamer
- Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University, College of Medicine, Columbus, Ohio
| | - Joshua R Watson
- Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University, College of Medicine, Columbus, Ohio
| | - Rena Kasick
- Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University, College of Medicine, Columbus, Ohio
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Hadhud M, Gross I, Hurvitz N, Ohana Sarna Cahan L, Ergaz Z, Weiser G, Ofek Shlomai N, Eventov Friedman S, Hashavya S. Serious Bacterial Infections in Preterm Infants: Should Their Age Be "Corrected"? J Clin Med 2023; 12:jcm12093242. [PMID: 37176683 PMCID: PMC10178985 DOI: 10.3390/jcm12093242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/24/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Adjusting the chronological age of preterm infants according to their gestational age is a widely accepted practice in the field of neurodevelopment. It has been suggested for the assessment of preterm infants with suspected infection, but has been poorly validated. Correcting for chronological age is especially critical in infants with a chronological age above 3 months, but a corrected age below 3 months due to the differences in assessment protocols. This study assessed the difference in incidence of serious bacterial infection (SBI) according to chronological and corrected age in preterm infants. A retrospective analysis of pediatric emergency department (PED) presentations was conducted for all 448 preterm infants born in between January 2010 and August 2019. Of the 448 preterm infants, 204 (46%) presented at one of 3 PEDs in Jerusalem, Israel, during their first year of life. Overall, 141 (31.4%) presented with fever and were included in the study. The infants were divided into 3 age groups: 1-corrected age >3 months; 2-chronological age >3 months, but corrected age <3 months; 3-chronological and corrected age <3 months. SBI was diagnosed in 2.6%, 16.7%, and 33.3% of the infants in groups 1, 2 and 3, respectively; (p < 0.01, p = 0.17, p < 0.001). The incidence of SBI in the control group of 300 term infants <3 months presenting to the PED due to fever was 15.3%. Preterm infants with a corrected age <3 months are at increased risk for SBI, similarly to term infants <3 months of age. Age correction should thus be considered for preterm infants presenting with fever.
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Affiliation(s)
- Mohamad Hadhud
- Department of Pediatrics, Hadassa-Hebrew University Medical Center, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Itai Gross
- Department of Pediatric Emergency Medicine, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
- Department of Pediatrics, Hadassah Medical Center, Ein Kerem, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel
| | - Noa Hurvitz
- Department of Pediatrics, Hadassa-Hebrew University Medical Center, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Lea Ohana Sarna Cahan
- Department of Pediatric Emergency Medicine, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Zivanit Ergaz
- Department of Neonatology, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Giora Weiser
- Department of Pediatric Emergency Medicine and Shaare Zedek Medical Center, Jerusalem 91120, Israel
| | - Noa Ofek Shlomai
- Department of Neonatology, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Smadar Eventov Friedman
- Department of Neonatology, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
| | - Saar Hashavya
- Department of Pediatric Emergency Medicine, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel
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8
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Yang Y, Wang YM, Lin CHR, Cheng CY, Tsai CM, Huang YH, Chen TY, Chiu IM. Explainable deep learning model to predict invasive bacterial infection in febrile young infants: A retrospective study. Int J Med Inform 2023; 172:105007. [PMID: 36731394 DOI: 10.1016/j.ijmedinf.2023.105007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/09/2022] [Accepted: 01/24/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Machine learning models have demonstrated superior performance in predicting invasive bacterial infection (IBI) in febrile infants compared to commonly used risk stratification criteria in recent studies. However, the black-box nature of these models can make them difficult to apply in clinical practice. In this study, we developed and validated an explainable deep learning model that can predict IBI in febrile infants ≤ 60 days of age visiting the emergency department. METHODS We conducted a retrospective study of febrile infants aged ≤ 60 days who presented to the pediatric emergency department of a medical center in Taiwan between January 1, 2011 and December 31, 2019. Patients with uncertain test results and complex chronic health conditions were excluded. IBI was defined as the growth of a pathogen in the blood or cerebrospinal fluid. We used a deep neural network to develop a predictive model for IBI and compared its performance to the IBI score and step-by-step approach. The SHapley Additive Explanations (SHAP) technique was used to explain the model's predictions at different levels. RESULTS Our study included 1847 patients, 53 (2.7%) of whom had IBI. The deep learning model performed similarly to the IBI score and step-by-step approach in terms of sensitivity and negative predictive value, but provided better specificity (54%), positive predictive value (5%), and area under the receiver-operating characteristic curve (0.87). SHapley Additive exPlanations identified five influential predictive variables (absolute neutrophil count, body temperature, heart rate, age, and C-reactive protein). CONCLUSION We have developed an explainable deep learning model that can predict IBI in febrile infants aged 0-60 days. The model not only performs better than previous scoring systems, but also provides insight into how it arrives at its predictions through individual features and cases.
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Affiliation(s)
- Ying Yang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yi-Min Wang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chun-Hung Richard Lin
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chi-Yung Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chi-Ming Tsai
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Ying-Hsien Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tien-Yu Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan.
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Performance Evaluation of Host Biomarker Combinations for the Diagnosis of Serious Bacterial Infection in Young Febrile Children: A Double-Blind, Multicentre, Observational Study. J Clin Med 2022; 11:jcm11216563. [DOI: 10.3390/jcm11216563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 10/30/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022] Open
Abstract
The diagnosis of serious bacterial infection (SBI) in young febrile children remains challenging. This prospective, multicentre, observational study aimed to identify new protein marker combinations that can differentiate a bacterial infection from a viral infection in 983 children, aged 7 days–36 months, presenting with a suspected SBI at three French paediatric emergency departments. The blood levels of seven protein markers (CRP, PCT, IL-6, NGAL, MxA, TRAIL, IP-10) were measured at enrolment. The patients received the standard of care, blinded to the biomarker results. An independent adjudication committee assigned a bacterial vs. viral infection diagnosis based on clinical data, blinded to the biomarker results. Computational modelling was applied to the blood levels of the biomarkers using independent training and validation cohorts. Model performances (area under the curve (AUC), positive and negative likelihood ratios (LR+ and LR–)) were calculated and compared to those of the routine biomarkers CRP and PCT. The targeted performance for added value over CRP or PCT was LR+ ≥ 5.67 and LR− ≤ 0.5. Out of 652 analysed patients, several marker combinations outperformed CRP and PCT, although none achieved the targeted performance criteria in the 7 days–36 months population. The models seemed to perform better in younger (7–91 day-old) patients, with the CRP/MxA/TRAIL combination performing best (AUC 0.895, LR+ 10.46, LR− 0.16). Although computational modelling using combinations of bacterial- and viral-induced host-protein markers is promising, further optimisation is necessary to improve SBI diagnosis in young febrile children.
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Yaeger JP, Jones J, Ertefaie A, Caserta MT, Fiscella KA. Derivation of a clinical-based model to detect invasive bacterial infections in febrile infants. J Hosp Med 2022; 17:893-900. [PMID: 36036211 PMCID: PMC9633417 DOI: 10.1002/jhm.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/28/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Febrile infants are at risk for invasive bacterial infections (IBIs) (i.e., bacteremia and bacterial meningitis), which, when undiagnosed, may have devastating consequences. Current IBI predictive models rely on serum biomarkers, which may not provide timely results and may be difficult to obtain in low-resource settings. OBJECTIVE The aim of this study was to derive a clinical-based IBI predictive model for febrile infants. DESIGNS, SETTING, AND PARTICIPANTS This is a cross-sectional study of infants brought to two pediatric emergency departments from January 2011 to December 2018. Inclusion criteria were age 0-90 days, temperature ≥38°C, and documented gestational age, fever duration, and illness duration. MAIN OUTCOME AND MEASURES To detect IBIs, we used regression and ensemble machine learning models and evidence-based predictors (i.e., sex, age, chronic medical condition, gestational age, appearance, maximum temperature, fever duration, illness duration, cough status, and urinary tract inflammation). We up-weighted infants with IBIs 8-fold and used 10-fold cross-validation to avoid overfitting. We calculated the area under the receiver operating characteristic curve (AUC), prioritizing a high sensitivity to identify the optimal cut-point to estimate sensitivity and specificity. RESULTS Of 2311 febrile infants, 39 had an IBI (1.7%); the median age was 54 days (interquartile range: 35-71). The AUC was 0.819 (95% confidence interval: 0.762, 0.868). The predictive model achieved a sensitivity of 0.974 (0.800, 1.00) and a specificity of 0.530 (0.484, 0.575). Findings suggest that a clinical-based model can detect IBIs in febrile infants, performing similarly to serum biomarker-based models. This model may improve health equity by enabling clinicians to estimate IBI risk in any setting. Future studies should prospectively validate findings across multiple sites and investigate performance by age.
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Affiliation(s)
- Jeffrey P Yaeger
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremiah Jones
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York, USA
| | - Ashkan Ertefaie
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York, USA
| | - Mary T Caserta
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Boston Febrile Infant Algorithm 2.0: Improving Care of the Febrile Infant 1-2 Months of Age. Pediatr Qual Saf 2022; 7:e616. [PMID: 36337736 PMCID: PMC9622664 DOI: 10.1097/pq9.0000000000000616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/05/2022] [Indexed: 02/05/2023] Open
Abstract
UNLABELLED Significant variation exists in the management of febrile infants, particularly those between 1 and 2 months of age. An established algorithm for well-appearing febrile infants 1-2 months of age guided clinical care for three decades in our emergency department. With mounting evidence for procalcitonin (PCT) to detect invasive bacterial infection (IBI), we revised our algorithm intending to decrease lumbar punctures (LPs) and antibiotic administration without increasing hospitalizations, revisits, or missed IBI. METHODS The algorithm's risk stratification was revised based on the expert review of evidence regarding test performance of PCT for IBI in febrile infants. With the revision, routine LP and empiric antibiotics were not recommended for low-risk infants. We used quality improvement strategies to disseminate the revised algorithm and reinforce uptake. The primary outcomes were the proportion of infants undergoing lumbar punctures or receiving antibiotics. Admission rates, 72-hour revisits requiring admission, and missed IBI were monitored as balancing measures. RESULTS We studied 616 infants including 326 (52.9%), after the implementation of the revised algorithm. LP was performed in 66.2% prerevision and 31.9% postrevision (34.3% absolute reduction, P < 0.001). Antibiotic administration decreased by 26.2% (pre 62.4% to post 36.2%, P < 0.001) and hospitalization rates decreased by 8.1% (P = 0.03). There have been no missed IBIs. Adherence to the pathway led to a sustained reduction in LPs and antibiotic administration for 24 months. CONCLUSION A revised pathway with the addition of PCT resulted in a safe, sustained reduction in LPs and reduced antibiotic administration in febrile infants 1-2 months of age.
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12
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Liu X, Huang S, Ma L, Ye H, Lin J, Cai X, Shang Q, Zheng C, Xu R, Zhang D. Recent advances in wearable medical diagnostic sensors and new therapeutic dosage forms for fever in children. J Pharm Biomed Anal 2022; 220:115006. [PMID: 36007307 DOI: 10.1016/j.jpba.2022.115006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/05/2022] [Accepted: 08/13/2022] [Indexed: 11/17/2022]
Abstract
Fever in children is one of the most common symptoms of pediatric diseases and the most common complaint in pediatric clinics, especially in the emergency department. Diseases such as pneumonia, sepsis, and meningitis are leading causes of death in children, and the early manifestations of these diseases are accompanied by fever symptoms. Accurate diagnosis and real-time monitoring of the status of febrile children, rapid and effective identification of the cause, and treatment can have a positive impact on relieving their symptoms and improving their quality of life. In recent years, wearable diagnostic sensors have attracted special attention for their high flexibility, real-time monitoring, and sensitivity. Temperature sensors and heart rate sensors have provided new advances in detecting children's body temperature and heart rate. Furthermore, some novel formulations have also received wide attention for addressing bottlenecks in medication administration for febrile children, such as difficulty in swallowing and inaccurate dosing. In this context, the present review provides recent advances of novel wearable medical sensor devices for diagnosing fever. Moreover, the application progress of innovative dosage forms of classical antipyretic drugs for children is presented. Finally, challenges and prospects of wearable sensor-based diagnostics and novel agent-based treatment of fever in children are discussed in brief.
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Affiliation(s)
- Xuemei Liu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Shengjie Huang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Lele Ma
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Hui Ye
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Junzhi Lin
- TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, PR China
| | - Xinfu Cai
- Sichuan Guangda Pharmaceutical Co. Ltd., Pengzhou 611930, PR China; National Engineering Research Center for Modernization of Traditional Chinese Medicine, Pengzhou 611930, PR China
| | - Qiang Shang
- Sichuan Guangda Pharmaceutical Co. Ltd., Pengzhou 611930, PR China; National Engineering Research Center for Modernization of Traditional Chinese Medicine, Pengzhou 611930, PR China
| | - Chuan Zheng
- TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, PR China.
| | - Runchun Xu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China.
| | - Dingkun Zhang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China.
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13
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Improving the Evidence-based Care of Febrile Neonates: A Quality Improvement Initiative. Pediatr Qual Saf 2022; 7:e583. [PMID: 35928020 PMCID: PMC9345640 DOI: 10.1097/pq9.0000000000000583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/02/2022] [Indexed: 11/26/2022] Open
Abstract
Our emergency department updated our care algorithm to provide evidence-based, standardized care to 0- to 60-day-old febrile neonates. Specifically, we wanted to increase the proportion of visits for which algorithm-adherent care was provided from 90% to 95% for infants 0–28 days, and from 67% to 95% for infants 29–60 days, by June 30, 2020.
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14
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A Clinical Prediction Rule for Bacterial Musculoskeletal Infections in Children with Monoarthritis in Lyme Endemic Regions. Ann Emerg Med 2022; 80:225-234. [DOI: 10.1016/j.annemergmed.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022]
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15
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Waterfield T, Lyttle MD, Munday C, Foster S, McNulty M, Platt R, Barrett M, Rogers E, Durnin S, Jameel N, Maney JA, McGinn C, McFetridge L, Mitchell H, Puthucode D, Roland D. Validating clinical practice guidelines for the management of febrile infants presenting to the emergency department in the UK and Ireland. Arch Dis Child 2022; 107:329-334. [PMID: 34531196 DOI: 10.1136/archdischild-2021-322586] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/03/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To report the performance of clinical practice guidelines (CPG) in the diagnosis of serious/invasive bacterial infections (SBI/IBI) in infants presenting with a fever to emergency care in the UK and Ireland. Two CPGs were from the National Institutes for Health and Care Excellence (NICE guidelines NG51 and NG143) and one was from the British Society for Antimicrobial Chemotherapy (BSAC). DESIGN Retrospective multicentre cohort study. PATIENTS Febrile infants aged 90 days or less attending between the 31 August 2018 to 1 September 2019. MAIN OUTCOME MEASURES The sensitivity, specificity and predictive values of CPGs in identifying SBI and IBI. SETTING Six paediatric Emergency Departments in the UK/Ireland. RESULTS 555 participants were included in the analysis. The median age was 53 days (IQR 32 to 70), 447 (81%) underwent blood testing and 421 (76%) received parenteral antibiotics. There were five participants with bacterial meningitis (1%), seven with bacteraemia (1%) and 66 (12%) with urinary tract infections. The NICE NG51 CPG was the most sensitive: 1.00 (95% CI 0.95 to 1.00). This was significantly more sensitive than NICE NG143: 0.91 (95% CI 0.82 to 0.96, p=0.0233) and BSAC: 0.82 (95% 0.72 to 0.90, p=0.0005). NICE NG51 was the least specific 0.0 (95% CI 0.0 to 0.01), and this was significantly lower than the NICE NG143: 0.09 (95% CI 0.07 to 0.12, p<0.0001) and BSAC: 0.14 (95% CI 0.1 to 0.17, p<0.0001). CONCLUSION None of the studied CPGs demonstrated ideal performance characteristics. CPGs should be improved to guide initial clinical decision making. TRIAL REGISTRATION NUMBER NCT04196192.
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Affiliation(s)
- Thomas Waterfield
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Charlotte Munday
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Steven Foster
- Emergency Department, Royal Hospital for Children, Glasgow, UK
| | - Marc McNulty
- Emergency Department, Royal Hospital for Children, Glasgow, UK
| | - Rebecca Platt
- Emergency Department, Barts Health NHS Trust, London, UK
| | - Michael Barrett
- Emergency Department, Children's Health Ireland at Crumlin, Crumlin, Ireland.,Women's and Children's Health, School of Medicine, University College Dublin, Dublin, Ireland
| | - Emma Rogers
- Emergency Department, Children's Health Ireland at Crumlin, Crumlin, Ireland
| | - Sheena Durnin
- Emergency Department, Children's Health Ireland at Tallaght, Dublin, Ireland.,Discipline of Paediatrics, Trinity College, University of Dublin, Dublin, Ireland
| | - Nida Jameel
- Emergency Department, Children's Health Ireland at Tallaght, Dublin, Ireland
| | - Julie-Ann Maney
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Claire McGinn
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Lisa McFetridge
- Mathematical Sciences Research Centre, Queen's University Belfast, Belfast, UK
| | - Hannah Mitchell
- Mathematical Sciences Research Centre, Queen's University Belfast, Belfast, UK
| | - Deepika Puthucode
- Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Damian Roland
- Department of Health Sciences, University of Leicester, Leicester, UK.,Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK
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16
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Yaeger JP, Jones J, Ertefaie A, Caserta MT, van Wijngaarden E, Fiscella K. Refinement and Validation of a Clinical-Based Approach to Evaluate Young Febrile Infants. Hosp Pediatr 2022; 12:399-407. [PMID: 35347337 DOI: 10.1542/hpeds.2021-006214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE For febrile infants, predictive models to detect bacterial infections are available, but clinical adoption remains limited by implementation barriers. There is a need for predictive models using widely available predictors. Thus, we previously derived 2 novel predictive models (machine learning and regression) by using demographic and clinical factors, plus urine studies. The objective of this study is to refine and externally validate the predictive models. METHODS This is a cross-sectional study of infants initially evaluated at one pediatric emergency department from January 2011 to December 2018. Inclusion criteria were age 0 to 90 days, temperature ≥38°C, documented gestational age, and insurance type. To reduce potential biases, we derived models again by using derivation data without insurance status and tested the ability of the refined models to detect bacterial infections (ie, urinary tract infection, bacteremia, and meningitis) in the separate validation sample, calculating areas-under-the-receiver operating characteristic curve, sensitivities, and specificities. RESULTS Of 1419 febrile infants (median age 53 days, interquartile range = 32-69), 99 (7%) had a bacterial infection. Areas-under-the-receiver operating characteristic curve of machine learning and regression models were 0.92 (95% confidence interval [CI] 0.89-0.94) and 0.90 (0.86-0.93) compared with 0.95 (0.91-0.98) and 0.96 (0.94-0.98) in the derivation study. Sensitivities and specificities of machine learning and regression models were 98.0% (94.7%-100%) and 54.2% (51.5%-56.9%) and 96.0% (91.5%-99.1%) and 50.0% (47.4%-52.7%). CONCLUSIONS Compared with the derivation study, the machine learning and regression models performed similarly. Findings suggest a clinical-based model can estimate bacterial infection risk. Future studies should prospectively test the models and investigate strategies to optimize clinical adoption.
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Affiliation(s)
- Jeffrey P Yaeger
- Departments of Pediatrics, and.,Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | | | | | | | | | - Kevin Fiscella
- Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
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17
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Hollaway W, Borland ML. Return visits to the paediatric emergency department. Emerg Med Australas 2022; 34:584-589. [PMID: 35322579 DOI: 10.1111/1742-6723.13961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine the rate of unplanned return visits (uRVs) within 48 h to a paediatric ED over a 12-month period and describe the factors associated with these uRV. METHODS Retrospective review of electronic data regarding the initial and follow-up visit at a tertiary paediatric hospital ED in Western Australia. The primary outcome was the number of patients who presented for uRV within 48 h of their initial ED visit. RESULTS Between August 2018 and July 2019, 2322 patients returned to the ED for a uRV comprising 3.4% of 68 352 ED presentations with more than 53% returning with infectious causes. Triage category 3 patients were most likely to represent (OR 1.11, P = 0.029) with 3-month to 1-year old (OR 1.37, P < 0.00001) and 1-5-year old (OR 1.32, P < 0.00001) the commonest age groups. There was seasonal variation in uRVs demonstrating a greater number in the winter months. The percentage of uRVs to overall ED presentations was greater in the summer months (3.8-4.1%). There was a significant increase in uRVs occurring up to 2 weeks after the changeovers in middle-grade ED doctors only. CONCLUSIONS The present study has demonstrated associations between uRV and initial-visit triage category 3, age between 3 months and 5 years, and presentations because of infectious illness. Middle-grade doctor changeover was also associated with an increase in uRVs.
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Affiliation(s)
- William Hollaway
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Health and Medical Sciences (Pediatrics and Emergency Medicine), The University of Western Australia, Perth, Western Australia, Australia
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18
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Buonsenso D, Sodero G, Valentini P. Transcript host-RNA signatures to discriminate bacterial and viral infections in febrile children. Pediatr Res 2022; 91:454-463. [PMID: 34912024 DOI: 10.1038/s41390-021-01890-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 11/08/2021] [Accepted: 11/30/2021] [Indexed: 12/29/2022]
Abstract
Traditional laboratory markers, such as white blood cell count, C-reactive protein, and procalcitonin, failed to discriminate viral and bacterial infections in children. The lack of an accurate diagnostic test has a negative impact on child's care, limiting the ability of early diagnosis and appropriate management of children. This, on the one hand, may lead to delayed recognition of sepsis and severe bacterial infections, which still represent the leading causes of child morbidity and mortality. On the other hand, this may lead to overuse of empiric antibiotic therapies, particularly for specific subgroups of patients, such as infants younger than 90 days of life or neutropenic patients. This approach has an adverse effect on costs, antibiotic resistance, and pediatric microbiota. Transcript host-RNA signatures are a new tool used to differentiate viral from bacterial infections by analyzing the transcriptional biosignatures of RNA in host leukocytes. In this systematic review, we evaluate the efficacy and the possible application of this new diagnostic method in febrile children, along with challenges in its implementation. Our review support the growing evidence that the application of these new tools can improve the characterization of the spectrum of bacterial and viral infections and optimize the use of antibiotics in children. IMPACT: Transcript host RNA signatures may allow to better characterize the spectrum of viral, bacterial, and inflammatory illnesses in febrile children and can be used with traditional diagnostic methods to determine if and when to start antibiotic therapy. This is the first review on the use of transcript RNA signatures in febrile children to distinguish viral from bacterial infections. Our review identified a wide variability of target populations and gold standards used to define sepsis and SBIs, limiting the generalization of our findings.
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Affiliation(s)
- Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy. .,Global Health Research Institute, Istituto di Igiene, Università Cattolica del Sacro Cuore, 00168, Rome, Italy. .,Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168, Rome, Italy. .,Danilo Buonsenso, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Giorgio Sodero
- Istituto di Pediatria, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Piero Valentini
- Global Health Research Institute, Istituto di Igiene, Università Cattolica del Sacro Cuore, 00168, Rome, Italy.,Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168, Rome, Italy.,Istituto di Pediatria, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
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19
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Nash KA, Kimia A, Fleegler EW, Guedj R. Equitable and Timely Care of Febrile Neonates: A Cross-Sectional Study. Pediatr Emerg Care 2021; 37:e1351-e1357. [PMID: 32011559 DOI: 10.1097/pec.0000000000002034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In pediatric emergency departments (EDs), racial/ethnic minorities are less likely to receive needed and timely care; however, clinical protocols have the potential to mitigate disparities. Neonatal fever management is protocolized in many EDs, but the timeliness to antibiotic administration is likely variable. We investigated the timeliness of antibiotic administration for febrile neonates and whether timeliness was associated with patients' race/ethnicity. METHODS Retrospective cross-sectional study of febrile neonates evaluated in one pediatric ED that uses an evidence-based guideline for the management of neonatal fever between March 2010 and December 2015. Primary outcome was time from ED arrival to antibiotic administration. Analysis of variance tests compared mean time with antibiotic administration across race/ethnicity. Multivariable linear regression investigated racial/ethnic differences in time to antibiotic administration after adjusting for patient demographics, timing of visit, the number of physicians involved, and ED census. RESULTS We evaluated 317 febrile neonates. Of the 269 patients with racial/ethnic data (84.9%), 54% were white non-Hispanic, 13% were black non-Hispanic, and 23% were Hispanic. The mean time to antibiotic administration was 204 minutes (range = 51-601 minutes). There was no significant association between patient race/ethnicity and time to first antibiotic administration. Emergency department census was significantly associated with timeliness. CONCLUSIONS There was a 10-hour range in the time to antibiotic administration for febrile neonates; however, variability in timeliness did not differ by race or ethnicity. This study demonstrates the need to further examine the role of protocols in mitigating disparities as well as factors that influence timeliness in antibiotic administration to febrile neonates.
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Affiliation(s)
- Katherine A Nash
- From the Yale National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT
| | - Amir Kimia
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School
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20
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Chen YT, Chang YJ, Liu BY, Lee EP, Wu HP. Severe bacterial infection in young infants with pyrexia admitted to the emergency department. Medicine (Baltimore) 2021; 100:e26596. [PMID: 34232210 PMCID: PMC8270585 DOI: 10.1097/md.0000000000026596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/18/2021] [Indexed: 01/04/2023] Open
Abstract
The objectives of this study were to understand the clinical presentations of febrile young infants with severe bacterial infection (SBI), and to investigate the pathogen variations throughout the vaccine era and after antenatal group B Streptococcus (GBS) screening.All infants < 90 days old with a body temperature of ≥38.0°C and admitted to the emergency department were retrospectively enrolled in our study. SBI was defined as a positive culture of urine, blood, or cerebrospinal fluid. All clinical variables were analyzed and compared between the SBI group and the non-SBI group, to identify the relevant risk factors for SBI in infants with pyrexia.A total of 498 infants were studied, 279 of whom (56%) had SBI. The body temperature at triage was higher in the SBI group, and the difference was highly obvious in the neonatal group. White blood cell count and C-reactive protein levels were both significantly higher in the SBI group (P < .05), whereas neutrophil percentage and band percentage demonstrated no significant differences. Escherichia coli was the most common pathogen and plasmid-mediated extended-spectrum lactamases were detected in up to 9.1%. GBS was detected in 16 cases of bacteremia (6 cases with concurrent meningitis).The body temperature at triage may provide a clue for differentiating sick babies, especially in the neonatal group. Complete serum analysis is required for infection survey, especially white blood cell and C-reactive protein. Escherichia coli is the most common pathogen, and clinician should raise awareness of drug resistance in some patients. The prevalence of GBS infection in the young infant group remains high after routine antenatal GBS screening.
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Affiliation(s)
- Yin-Ting Chen
- Division of Neonatology, Department of Pediatrics, Children Hospital, China Medical University, Taichung, Taiwan
- Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Yu-Jun Chang
- Laboratory of Epidemiology and Biostastics, Big Data Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Bang-Yan Liu
- Division of Neonatology, Department of Pediatrics, Children Hospital, China Medical University, Taichung, Taiwan
| | - En-Pei Lee
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Han-Ping Wu
- Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
- Department of Pediatric Emergency Medicine, Children Hospital, China Medical University, Taichung, Taiwan
- Department of Medical Research, Children's Hospital, China Medical University, Taichung, Taiwan
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21
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Yaeger JP, Jones J, Ertefaie A, Caserta MT, van Wijngaarden E, Fiscella K. Using Clinical History Factors to Identify Bacterial Infections in Young Febrile Infants. J Pediatr 2021; 232:192-199.e2. [PMID: 33421424 DOI: 10.1016/j.jpeds.2020.12.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To develop a novel predictive model using primarily clinical history factors and compare performance to the widely used Rochester Low Risk (RLR) model. STUDY DESIGN In this cross-sectional study, we identified infants brought to one pediatric emergency department from January 2014 to December 2016. We included infants age 0-90 days, with temperature ≥38°C, and documented gestational age and illness duration. The primary outcome was bacterial infection. We used 10 predictors to develop regression and ensemble machine learning models, which we trained and tested using 10-fold cross-validation. We compared areas under the curve (AUCs), sensitivities, and specificities of the RLR, regression, and ensemble models. RESULTS Of 877 infants, 67 had a bacterial infection (7.6%). The AUCs of the RLR, regression, and ensemble models were 0.776 (95% CI 0.746, 0.807), 0.945 (0.913, 0.977), and 0.956 (0.935, 0.975), respectively. Using a bacterial infection risk threshold of .01, the sensitivity and specificity of the regression model was 94.6% (87.4%, 100%) and 74.5% (62.4%, 85.4%), compared with 95.5% (87.5%, 99.1%) and 59.6% (56.2%, 63.0%) using the RLR model. CONCLUSIONS Compared with the RLR model, sensitivities of the novel predictive models were similar whereas AUCs and specificities were significantly greater. If externally validated, these models, by producing an individualized bacterial infection risk estimate, may offer a targeted approach to young febrile infants that is noninvasive and inexpensive.
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Affiliation(s)
- Jeffrey P Yaeger
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY.
| | - Jeremiah Jones
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | - Ashkan Ertefaie
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | - Mary T Caserta
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Edwin van Wijngaarden
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - Kevin Fiscella
- Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Declines in the Number of Lumbar Punctures Performed at United States Children's Hospitals, 2009-2019. J Pediatr 2021; 231:87-93.e1. [PMID: 33080276 DOI: 10.1016/j.jpeds.2020.10.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/22/2020] [Accepted: 10/15/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate trends in lumbar puncture (LP) performance among US children's hospitals to assess how these trends may impact pediatric resident trainee exposure to LP. STUDY DESIGN We quantified LPs for emergency department (ED) and inpatient encounters at 29 US children's hospitals from 2009 to 2019. LP was defined by either a LP procedure code or cerebrospinal fluid culture billing code. Temporal trends and hospital variation in LP were assessed using logistic regression analysis. RESULTS A total of 215 030 LPs were performed during the study period (0.8% of all encounters). Twenty six thousand and five hundred twenty three and 16 696 LPs were performed in the 2009 and 2018 academic years, respectively (overall 37.1% reduction, per-year OR, 0.935; 95% CI, 0.922-0.948; P < .001), and the rate of LP decreased from 10.9 per 1000 hospital encounters to 6.0 per 1000 hospital encounters over the same period. CONCLUSIONS LP rates have declined across US children's hospitals over the past decade, potentially resulting in reduced clinical exposure for pediatric resident trainees. Improved procedural simulation during residency may augment the clinical experience.
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Tsai SJ, Ramgopal S. External Validation of an Invasive Bacterial Infection Score for Young Febrile Infants. Hosp Pediatr 2021; 11:239-244. [PMID: 33602794 DOI: 10.1542/hpeds.2020-003178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The Aronson rule is a point-based clinical decision rule for the identification of febrile infants ≤60 days of age at low risk of invasive bacterial infection (IBI) in the emergency department. This rule uses variables of temperature, age, urinalysis, and absolute neutrophil count. We sought to externally validate this decision rule. METHODS We conducted a secondary analysis of a multicenter prospective cohort of febrile infants ≤60 days old presenting to the emergency department between December 2008 and May 2013. Infants were excluded if they had clinical sepsis or chronic conditions or were missing any laboratory components of the Aronson score. Our outcome was IBI (bacteremia and/or bacterial meningitis). We assessed the accuracy of the Aronson rule by reporting metrics of diagnostic accuracy with 95% confidence intervals (CIs) at different point thresholds. RESULTS Of 4130 included patients (780 <21 days of age; 2362 boys), 87 (2.1%) had an IBI, including 65 with isolated bacteremia and 22 with meningitis. Using an Aronson cutoff score of 2 resulted in a sensitivity of 93.1% (95% CI 85.6%-97.4%), specificity of 26.6% (95% CI 25.3%-28.0%), and negative predictive value of 99.4% (95% CI 98.8%-99.8%). Six patients with IBI (3 with bacterial meningitis) were misclassified as low risk when using a threshold of 2. CONCLUSIONS The Aronson rule demonstrates metrics of diagnostic accuracy that are comparable to the derivation study. Our findings suggest that the rule may be generalizable for the risk stratification of well-appearing febrile infants.
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Affiliation(s)
- Stacy J Tsai
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and
| | - Sriram Ramgopal
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Widmer K, Schmidt S, Bakel LA, Cookson M, Leonard J, Tyler A. Use of Procalcitonin in a Febrile Infant Clinical Pathway and Impact on Infants Aged 29 to 60 Days. Hosp Pediatr 2021; 11:223-230. [PMID: 33597148 DOI: 10.1542/hpeds.2020-000380] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Recent evidence suggests that measuring the procalcitonin level may improve identification of low-risk febrile infants who may not need intervention. We describe outcomes after the implementation of a febrile infant clinical pathway recommending measurement of the procalcitonin level for risk stratification. METHODS In this single-center retrospective pre-post intervention study of febrile infants aged 29 to 60 days, we used interrupted time series analyses to evaluate outcomes of lumbar puncture (LP), antibiotic administration, hospital admission, and emergency department (ED) length of stay (LOS). A multivariable logistic regression was used to evaluate the odds of LP. RESULTS Data were analyzed between January 2017 and December 2019 and included 740 participants. Procalcitonin use increased post-pathway implementation (PI). The proportion of low-risk infants receiving an LP decreased significantly post-PI (P = .001). In the adjusted interrupted time series analysis, there was no immediate level change (shift) post-PI for LP (0.98 [95% confidence interval (CI): 0.49-1.97]), antibiotics (1.17 [95% CI: 0.56-2.43]), admission (1.07 [95% CI: 0.59-1.96]), or ED LOS (1.08 [95% CI: 0.92-1.28]), and there was no slope change post-PI versus pre-PI for any measure (LP: 1.01 [95% CI: 0.94-1.08]; antibiotics: 1.00 [95% CI: 0.93-1.08]; admission: 1.03 [95% CI: 0.97-1.09]; ED LOS: 1.01 [95% CI: 0.99-1.02]). More patients were considered high risk, and fewer had incomplete laboratory test results post-PI (P < .001). There were no missed serious bacterial infections. A normal procalcitonin level significantly decreased the odds of LP (P < .001). CONCLUSIONS Clinicians quickly adopted procalcitonin testing. Resource use for low-risk infants decreased; however, there was no change to resource use for the overall population because more infants underwent laboratory evaluation and were classified as high risk post-PI.
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Affiliation(s)
- Kaitlin Widmer
- Sections of Hospital Medicine and .,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Sarah Schmidt
- Sections of Hospital Medicine and.,Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado; and
| | - Leigh Anne Bakel
- Sections of Hospital Medicine and.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Michael Cookson
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Jan Leonard
- Sections of Hospital Medicine and.,Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado; and
| | - Amy Tyler
- Sections of Hospital Medicine and.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
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25
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Blázquez-Gamero D, Epalza C, Cadenas JAA, Gero LC, Calvo C, Rodríguez-Molino P, Méndez M, Santos MDM, Fumadó V, Guzmán MF, Soriano-Arandes A, Jiménez AB, Penin M, Cobo-Vazquez E, Pareja M, Lobato Z, Serna M, Delgado R, Moraleda C, Tagarro A. Fever without source as the first manifestation of SARS-CoV-2 infection in infants less than 90 days old. Eur J Pediatr 2021; 180:2099-2106. [PMID: 33606120 PMCID: PMC7893843 DOI: 10.1007/s00431-021-03973-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 01/02/2023]
Abstract
Fever without source (FWS) in infants is a frequent cause of consultation at the emergency department, and the emergence of SARS-CoV-2 could affect the approach to those infants. The aim of this study is to define the clinical characteristics and rates of bacterial coinfections of infants < 90 days with FWS as the first manifestation of SARS-CoV-2 infection. This is a cross-sectional study of infants under 90 days of age with FWS and positive SARS-CoV2 PCR in nasopharyngeal swab/aspirate, attended at the emergency departments of 49 Spanish hospitals (EPICO-AEP cohort) from March 1 to June 26, 2020. Three hundred and thirty-three children with COVID-19 were included in EPICO-AEP. A total of 67/336 (20%) were infants less than 90 days old, and 27/67(40%) presented with FWS. Blood cultures were performed in 24/27(89%) and were negative in all but one (4%) who presented a Streptococcus mitis bacteremia. Urine culture was performed in 26/27(97%) children and was negative in all, except in two (7%) patients. Lumbar puncture was performed in 6/27(22%) cases, with no growth of bacteria. Two children had bacterial coinfections: 1 had UTI and bacteremia, and 1 had UTI. C-reactive was protein over 20 mg/L in two children (one with bacterial coinfection), and procalcitonin was normal in all. One child was admitted to the pediatric intensive care unit because of apnea episodes. No patients died.Conclusion: FWS was frequent in infants under 90 days of age with SARS-CoV-2 infection. Standardized markers to rule out bacterial infections remain useful in this population, and the outcome is generally good. What is Known: • Fever without source (FWS) in infants is a common cause of consultation at the emergency department, and young infants have a higher risk of serious bacterial infections (SBI). • The emergence of the new coronavirus SARS-CoV-2 could affect the approach to young infants with FWS in the emergency department. management of those children is a challenge because information about bacterial coinfection and prognosis is scarce. What is New: • SARS-CoV-2 infection should be ruled out in young infants (< 90 days of age) with FWS in areas with community transmission. • Bacterial coinfection rarely coexists in those infants. • Inflammatory markers were not increased in children without bacterial coinfection. • Outcome is good in most patients.
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Affiliation(s)
- Daniel Blázquez-Gamero
- Pediatric Infectious Diseases Unit, Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Hospital Universitario 12 de Octubre, Universidad Complutense, Madrid, Spain. .,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain.
| | - Cristina Epalza
- Pediatric Infectious Diseases Unit, Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Hospital Universitario 12 de Octubre, Universidad Complutense, Madrid, Spain ,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain
| | | | | | - Cristina Calvo
- Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,Pediatric and Infectious Diseases Department, Hospital Universitario La Paz, Fundación IdiPaz, Madrid, Spain
| | - Paula Rodríguez-Molino
- Pediatric and Infectious Diseases Department, Hospital Universitario La Paz, Fundación IdiPaz, Madrid, Spain
| | - María Méndez
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitari Germans Trias i Pujol de Badalona, Badalona, Spain
| | - Maria del Mar Santos
- Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Victoria Fumadó
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Antoni Soriano-Arandes
- Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute, Barcelona Hospital Campus, Barcelona, Spain
| | - Ana B. Jiménez
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Maria Penin
- Hospital Príncipe de Asturias, Alcalá de Henares, Spain
| | | | - Marta Pareja
- Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Zulema Lobato
- Althaia, Xarxa Assistencial Universitària de Manresa, Barcelona, Spain
| | - Miquel Serna
- Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,Pediatric Research and Clinical Trials Unit. Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain, Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Rafael Delgado
- Microbiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Cinta Moraleda
- Pediatric Infectious Diseases Unit, Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Hospital Universitario 12 de Octubre, Universidad Complutense, Madrid, Spain ,Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,Pediatric Research and Clinical Trials Unit. Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain, Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Alfredo Tagarro
- Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain ,Pediatric Research and Clinical Trials Unit. Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain, Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain ,Pediatrics Department. Hospital Universitario Infanta Sofía. Pediatrics Research Group, Universidad Europea de Madrid, Madrid, Spain
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Singhal T. "Rationalization of Empiric Antibiotic Therapy" - A Move Towards Preventing Emergence of Resistant Infections. Indian J Pediatr 2020; 87:945-950. [PMID: 31912460 DOI: 10.1007/s12098-019-03144-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/25/2019] [Indexed: 12/24/2022]
Abstract
Antimicrobial resistance is a key factor leading to emerging/ re-emerging infections. Rational antimicrobial therapy or antimicrobial stewardship is one of the important interventions to prevent emergence of resistance. Choosing correct empiric therapy is crucial not only to prevent antimicrobial resistance but also to achieve good treatment outcomes. Antimicrobial therapy can be broadly classified as empiric, definitive/ targeted and preventive. It is in choice of empiric therapy that the largest margin of error exists. Paradoxically, empiric therapy is the most commonly employed therapy since microbiologic results are either not available at initiation of treatment or cannot be sent due to logistic reasons or are negative. In the Indian setting, where penetration of microbiologic diagnostic methods in small cities, towns and rural areas is still fairly low, therapy is largely empiric. Choice of empiric therapy is governed by various factors including likely pathogens, antimicrobial resistance, degree of sickness, site of infection and host co-morbidities. These principles can be applied to any clinical syndrome whether it is fever without focus, infections of the respiratory tract, gastrointestinal tract, abdomen, central nervous system, bone and joint, skin and soft tissue, urinary tract as well as neonatal sepsis and healthcare associated infections. Adherence to published guidelines for syndromic management such as that by the Indian Academy of Pediatrics and Indian Council of Medical Research is strongly recommended. One can tailor these guidelines and suggestions made in this article to an individual setting.
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Affiliation(s)
- Tanu Singhal
- Department of Pediatrics and Infectious Disease, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India.
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Impact of clinical guidance and rapid molecular pathogen detection on evaluation and outcomes of febrile or hypothermic infants. Infect Control Hosp Epidemiol 2020; 41:1285-1291. [PMID: 32880255 DOI: 10.1017/ice.2020.317] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To quantify the impact of clinical guidance and rapid respiratory and meningitis/encephalitis multiplex polymerase chain reaction (mPCR) testing on the management of infants. DESIGN Before-and-after intervention study. SETTING Tertiary-care children's hospital. PATIENTS Infants ≤90 days old presenting with fever or hypothermia to the emergency department (ED). METHODS The study spanned 3 periods: period 1, January 1, 2011, through December 31, 2014; period 2, January 1, 2015, through April 30, 2018; and period 3, May 1, 2018, through June 15, 2019. During period 1, no standardized clinical guideline had been established and no rapid pathogen testing was available. During period 2, a clinical guideline was implemented, but no rapid testing was available. During period 3, a guideline was in effect, plus mPCR testing using the BioFire FilmArray respiratory panel 2 (RP 2) and the meningitis encephalitis panel (MEP). Outcomes included antimicrobial and ancillary test utilization, length of stay (LOS), admission rate, 30-day mortality. Outcomes were compared across periods using Kruskal-Wallis and Pearson tests and interrupted time series analysis. RESULTS Overall 5,317 patients were included: 2,514 in period 1, 2,082 in period 2, and 721 in period 3. Over the entire study period, we detected reductions in the use of chest radiographs, lumbar punctures, LOS, and median antibiotic duration. After adjusting for temporal trends, we observed that the introduction of the guideline was associated with reductions in ancillary tests and lumbar punctures. Use of mPCR testing with the febrile infant clinical guideline was associated with additional reductions in ancillary testing for all patients and a higher proportion of infants 29-60 days old being managed without antibiotics. CONCLUSIONS Use of mPCR testing plus a guideline for young infant evaluation in the emergency department was associated with less antimicrobial and ancillary test utilization compared to the use of a guideline alone.
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28
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Diagnostic Accuracy of Biomarkers for Early-Onset Neonatal Bacterial Infections: Evaluation of Serum Procalcitonin Reference Curves. Diagnostics (Basel) 2020; 10:diagnostics10100839. [PMID: 33081061 PMCID: PMC7603239 DOI: 10.3390/diagnostics10100839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/11/2020] [Accepted: 10/18/2020] [Indexed: 01/08/2023] Open
Abstract
To date, no clinical studies have compared the accuracy of serum procalcitonin (PCT) reference curves. We aimed to validate the diagnostic accuracy of previously reported serum PCT reference curves and to determine which biomarkers among a cut-off value over the 95th percentile in the serum PCT reference curve, white blood cell (WBC) count, and C-reactive protein (CRP) and immunoglobulin M (IgM) levels, have the highest diagnostic accuracy for early-onset neonatal bacterial infections. This retrospective cohort study assessed 16 preterm and 23 term infants with suspected bacterial infections within 72 h after birth. Each infant group was divided into two subgroups: confirmed- and non-infection. The diagnostic accuracy was determined using the Youden index. The reference curves by Fukuzumi et al. in preterm and term infants had the highest Youden indexes: 1.000 and 0.324, respectively. Among preterm infants, the Youden index for PCT was 1.000. Among term infants, the Youden index for a combination of PCT, CRP, and WBC and/or IgM was 1.000. In conclusion, a serum PCT level over the 95th percentile on the reference curve for preterm infants and a combination of PCT and CRP levels with WBC count and/or IgM levels for term infants provided sufficient diagnostic accuracy.
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Porturas T, Taylor RA. Forty years of emergency medicine research: Uncovering research themes and trends through topic modeling. Am J Emerg Med 2020; 45:213-220. [PMID: 33059985 DOI: 10.1016/j.ajem.2020.08.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/05/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022] Open
Abstract
STUDY OBJECTIVE Topic identification can facilitate knowledge curation, discover thematic relationships, trends, and predict future direction. We aimed to determine through an unsupervised, machine learning approach to topic modeling the most common research themes in emergency medicine over the last 40 years and summarize their trends and characteristics. METHODS We retrieved the complete reference entries including article abstracts from Ovid for all original research articles from 1980 to 2019 within emergency medicine for six widely-cited journals. Abstracts were processed through a natural language pipeline and analyzed by a latent Dirichlet allocation topic modeling algorithm for unsupervised topic discovery. Topics were further examined through trend analysis, word associations, co-occurrence metrics, and two-dimensional embeddings. RESULTS We retrieved 47,158 articles during the defined time period that were filtered to 20,528 articles for further analysis. Forty topics covering methodologic and clinical areas were discovered. These topics separated into distinct clusters when embedded in two-dimensional space and exhibited consistent patterns of interaction. We observed the greatest increase in popularity in research themes involving risk factors (0.4% to 5.2%), health utilization (1.2% to 5.0%), and ultrasound (0.7% to 3.3%), and a relative decline in research involving basic science (8.9% to 1.1%), cardiac arrest (6.5% to 2.2%), and vitals (6.3% to 1.3%) over the past 40 years. Our data show only very modest growth in mental health and substance abuse research (1.0% to 1.6%), despite ongoing crises. CONCLUSIONS Topic modeling via unsupervised machine learning applied to emergency medicine abstracts discovered coherent topics, trends, and patterns of interaction.
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Affiliation(s)
| | - R Andrew Taylor
- Department of Emergency Medicine, Yale University School of Medicine, United States.
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30
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Reynolds MS, Dunaway A, Stevens C, Shoemaker D, Buckingham D, Spencer SP. Triage Standing Orders Decrease Time to Antibiotics in Neonates in Pediatric Emergency Department. J Emerg Nurs 2020; 46:768-778. [PMID: 32981747 DOI: 10.1016/j.jen.2020.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Infants aged 0 days to 28 days are at high risk for serious bacterial infection and require an extensive evaluation, including blood, urine, and cerebrospinal fluid cultures, and admission for empiric antibiotics. Although there are no guidelines that recommend a specific time to antibiotics for these infants, quicker administration is presumed to improve care and outcomes. At baseline, 19% of these infants in our emergency department received antibiotics within 120 minutes of arrival, with an average time to antibiotics of 192 minutes. A quality improvement team convened to increase our percentage of infants who receive antibiotics within 120 minutes of arrival. METHODS The team evaluated all infants aged 0 days to 28 days who received a diagnostic evaluation for a serious bacterial infection and empiric antibiotics in our emergency department. A nurse-driven team implemented multiple Plan-Do-Study-Act cycles to improve use of triage standing orders and improve time to antibiotics. Data were analyzed using statistical process control charts. RESULTS Through use of triage standing orders and multiple educational interventions, the team surpassed initial goals, and 84% of the infants undergoing a serious bacterial infection evaluation received antibiotics within 120 minutes of ED arrival. The average time to antibiotics improved to 74 minutes. DISCUSSION The use of triage standing orders improves time to antibiotics for infants undergoing a serious bacterial infection evaluation. Increased use, associated with nurse empowerment to drive the flow of these patients, leads to a joint-responsibility model within the emergency department. The cultural shift to allow nurse-initiated work-ups leads to sustained improvement in time to antibiotics.
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Lyons TW, Garro AC, Cruz AT, Freedman SB, Okada PJ, Mahajan P, Balamuth F, Thompson AD, Kulik DM, Uspal NG, Arms JL, Nigrovic LE. Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections. Pediatrics 2020; 145:peds.2019-3538. [PMID: 32205466 DOI: 10.1542/peds.2019-3538] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The ability of the decades-old Boston and Philadelphia criteria to accurately identify infants at low risk for serious bacterial infections has not been recently reevaluated. METHODS We assembled a multicenter cohort of infants 29 to 60 days of age who had cerebrospinal fluid (CSF) and blood cultures obtained. We report the performance of the modified Boston criteria (peripheral white blood cell count [WBC] ≥20 000 cells per mm3, CSF WBC ≥10 cells per mm3, and urinalysis with >10 WBC per high-power field or positive urine dip result) and modified Philadelphia criteria (peripheral WBC ≥15 000 cells per mm3, CSF WBC ≥8 cells per mm3, positive CSF Gram-stain result, and urinalysis with >10 WBC per high-power field or positive urine dip result) for the identification of invasive bacterial infections (IBIs). We defined IBI as bacterial meningitis (growth of pathogenic bacteria from CSF culture) or bacteremia (growth from blood culture). RESULTS We applied the modified Boston criteria to 8344 infants and the modified Philadelphia criteria to 8131 infants. The modified Boston criteria identified 133 of the 212 infants with IBI (sensitivity 62.7% [95% confidence interval (CI) 55.9% to 69.3%] and specificity 59.2% [95% CI 58.1% to 60.2%]), and the modified Philadelphia criteria identified 157 of the 219 infants with IBI (sensitivity 71.7% [95% CI 65.2% to 77.6%] and specificity 46.1% [95% CI 45.0% to 47.2%]). The modified Boston and Philadelphia criteria misclassified 17 of 53 (32.1%) and 13 of 56 (23.3%) infants with bacterial meningitis, respectively. CONCLUSIONS The modified Boston and Philadelphia criteria misclassified a substantial number of infants 29 to 60 days old with IBI, including those with bacterial meningitis.
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Affiliation(s)
- Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts;
| | - Aris C Garro
- Departments of Pediatrics and Emergency Medicine, Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Andrea T Cruz
- Sections of Pediatric Emergency Medicine and Pediatric Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital and Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pamela J Okada
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Fran Balamuth
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy D Thompson
- Departments of Pediatrics and Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Dina M Kulik
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Neil G Uspal
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Joseph L Arms
- Department of Pediatrics, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Lee TG, Yu ST, So CH. Predictive value of C-reactive protein for the diagnosis of meningitis in febrile infants under 3 months of age in the emergency department. Yeungnam Univ J Med 2020; 37:106-111. [PMID: 31914719 PMCID: PMC7142029 DOI: 10.12701/yujm.2019.00402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/16/2019] [Indexed: 12/02/2022] Open
Abstract
Background Fever is a common cause of pediatric consultation in the emergency department. However, identifying the source of infection in many febrile infants is challenging because of insufficient presentation of signs and symptoms. Meningitis is a critical cause of fever in infants, and its diagnosis is confirmed invasively by lumbar puncture. This study aimed to evaluate potential laboratory markers for meningitis in febrile infants. Methods We retrospectively analyzed infants aged <3 months who visited the emergency department of our hospital between May 2012 and May 2017 because of fever of unknown etiology. Clinical information and laboratory data were evaluated. Receiver operating characteristic (ROC) curves were constructed. Results In total, 145 febrile infants aged <3 months who underwent lumbar punctures were evaluated retrospectively. The mean C-reactive protein (CRP) level was significantly higher in the meningitis group than in the non-meningitis group, whereas the mean white blood cell count or absolute neutrophil count (ANC) did not significantly differ between groups. The area under the ROC curve (AUC) for CRP was 0.779 (95% confidence interval [CI], 0.701–0.858). The AUC for the leukocyte count was 0.455 (95% CI, 0.360–0.550) and that for ANC was 0.453 (95% CI, 0.359–0.547). The CRP cut-off value of 10 mg/L was optimal for identifying possible meningitis. Conclusion CRP has an intrinsic predictive value for meningitis in febrile infants aged <3 months. Despite its invasiveness, a lumbar puncture may be recommended to diagnose meningitis in young, febrile infants with a CRP level >10 mg/L.
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Affiliation(s)
- Tae Gyoung Lee
- Department of Pediatrics, Wonkwang University School of Medicine, Iksan, Korea
| | - Seung Taek Yu
- Department of Pediatrics, Wonkwang University School of Medicine, Iksan, Korea
| | - Cheol Hwan So
- Department of Pediatrics, Wonkwang University School of Medicine, Iksan, Korea
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Prevalence of Bacterial Infection in Febrile Infant 61-90 Days Old Compared With Younger Infants. Pediatr Infect Dis J 2019; 38:1163-1167. [PMID: 31568251 DOI: 10.1097/inf.0000000000002461] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective is to compare the prevalence of serious bacterial infection (SBI) and invasive bacterial infection (IBI) in febrile infants <60 days of age and in those between 61 and 90 days. METHODS Prospective registry-based cohort study including all the infants ≤90 days with fever without a source evaluated in a pediatric emergency department between 2003 and 2017. We compared the prevalence of SBI and IBI in febrile infants <60 days of age and those between 61 and 90 days. RESULTS We included 3,301 infants. Overall, 605 (18.3%) had a SBI (mainly urinary tract infection), of these 81 (2.5%) had an IBI (bacteremia 60, meningitis 12, sepsis 9). The prevalence of SBI in infants >60 days old was 18.5% (95% CI: 16.4-20.7) versus 16.6% (95% CI: 14.7-18.7; n.s.) in those between 29 and 60 days and versus 21.5% (95% CI: 18.6-24.7; n.s.) in those <28 days of age. The prevalence of IBI among infants >60 days old was 1.1% (95% CI: 0.6-2.2) versus 2.3% (95% CI: 1.6-3.3; P < 0.05) in those between 29 and 60 days and 5.1% (95% CI: 3.7-7.0; P < 0.05) in those <28 days of age. The prevalence of IBI in well appearing >60 days was 1.0% (versus 4.5% in those <28 days old, P < 0.01; and 2.0% in those between 29 and 60 days, P = 0.06). All bacterial meningitis, except one, were diagnosed in infants <28 days. CONCLUSIONS The prevalence of IBI in febrile infants between 61 and 90 days of age is high enough to support the recommendation for obtaining urine and blood tests in this population.
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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]
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Early Blood Biomarkers to Improve Sepsis/Bacteremia Diagnostics in Pediatric Emergency Settings. ACTA ACUST UNITED AC 2019; 55:medicina55040099. [PMID: 30974881 PMCID: PMC6524067 DOI: 10.3390/medicina55040099] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 03/13/2019] [Accepted: 04/04/2019] [Indexed: 02/07/2023]
Abstract
Background: Sepsis is the leading cause of death in children worldwide. Early recognition and treatment are essential for preventing progression to lethal outcomes. CRP and Complete Blood Count (CBC) are the initial preferred tests to distinguish between bacterial and viral infections. Specific early diagnostic markers are still missing. Aim: To investigate diagnostic value of Neutrophil-Lymphocyte Ratio (NLR), Mean Platelet Volume (MPV) and Platelet-MPV ratio (PLT/MPV) to distinguish sepsis/bacteremia and viral infection. Methods: We conducted a retrospective data analysis of case records of 115 children from 1 month to 5 years of age. All cases were divided into two groups-sepsis/bacteremia (n = 68) and viral (n = 47) patients, and further subdivided according to the time of arrival into early or late (≤12 or 12-48 h post the onset of fever, respectively). Analysis of CBC and CRP results was performed. NLR and PLT/MPV were calculated. Results: Sepsis/bacteremia group demonstrated higher absolute platelets count (370.15 ± 134.65 × 10⁸/L versus 288.91 ± 107.14 × 10⁸/L; p = 0.001), NLR (2.69 ± 2.03 versus 1.83 ± 1.70; p = 0.006), and PLT/MPV (41.42 ± 15.86 versus 33.45 ± 17.97; p = 0.001). PLT/MPV was increased in early arrival sepsis/bacteremia infants (42.70 ± 8.57 versus 31.01 ± 8.21; p = 0.008). NLR and MPV were significantly lower in infants (≤12 months) with viral infection on late arrival (1.16 ± 1.06 versus 1.90 ± 1.25, p = 0.025 for NLR and 8.94 ± 0.95fl versus 9.44 ± 0.85fl, p = 0.046 for MPV). Conclusion: Together with standard blood biomarkers, such as CRP, neutrophils, or platelets count, PLT/MPV is a promising biomarker for clinical practice to help discriminate between viral disease or sepsis/bacteremia in all children, especially in early onset of symptoms. NLR and MPV could support exclusion of sepsis/bacteremia in late arrival cases.
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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.
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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
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Chiu IM, Huang LC, Chen IL, Tang KS, Huang YH. Diagnostic values of C-reactive protein and complete blood cell to identify invasive bacterial infection in young febrile infants. Pediatr Neonatol 2019; 60:197-200. [PMID: 30089532 DOI: 10.1016/j.pedneo.2018.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/02/2018] [Accepted: 06/08/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Newborn infants younger than 3 months old with a fever are frequently evaluated for the risk of invasive bacterial infections (IBIs), which include bacteremia and/or bacterial meningitis, in the pediatric emergency department (PED). The purpose of this study was to determine the individual complete blood cell count and biochemistry levels associated with IBIs in febrile infants. METHODS We carried out this retrospective study using a pediatric emergency department at a tertiary medical center in southern Taiwan, where we also evaluated the clinical characteristics and routine blood tests between experimental groups. RESULTS We enrolled 1231 febrile infants under the age of 3 months old in this study. We found higher body temperature, neutrophil percentage, and C-Reactive protein (CRP) values and a lower hemoglobin level in the IBIs group. Furthermore, a CRP value greater than 25 mg/L can predict IBIs at a better rate than the group with values lower than 25 mg/L (11.7% vs. 2.1%, Odds ratio 6.3, p < 0.001). CONCLUSION This study provides evidence that a CRP level greater than 25 mg/L can more accurately predict IBIs in febrile infants. Furthermore, lower hemoglobin levels were also found in IBIs. Nevertheless, additional laboratory tests are needed to identify young febrile infants with IBIs.
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Affiliation(s)
- I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Lin-Chi Huang
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, Taiwan
| | - I-Lun Chen
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, Taiwan
| | - Kuo-Su Tang
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, Taiwan
| | - Ying-Hsien Huang
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, Taiwan; Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Burstein B, Gravel J, Aronson PL, Neuman MI. Emergency department and inpatient clinical decision tools for the management of febrile young infants among tertiary paediatric centres across Canada. Paediatr Child Health 2018; 24:e142-e154. [PMID: 31110465 DOI: 10.1093/pch/pxy126] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/10/2018] [Indexed: 01/06/2023] Open
Abstract
Objectives With no nationally-endorsed guidelines and the emergence of newer diagnostic tools, there exists significant variation in the management of febrile infants <90 days. We sought to evaluate the prevalence and content of clinical decision tools (CDTs) for the emergency department (ED) and inpatient management of febrile young infants across Canada. Methods We undertook a cross-sectional analysis of febrile young infant CDTs from ED and inpatient units at all 16 Canadian tertiary paediatric hospitals. Additional data were collected using an electronic survey of ED and inpatient representatives, characterizing their clinical settings and diagnostic test availability. Content of all existent CDTs was independently reviewed using list items determined a priori. The primary outcome was the proportion of EDs and inpatient units with CDTs. Results Information regarding CDTs was gathered from all 16 EDs and 16 inpatient units. CDTs were infrequently available (9/32, 28%), and were more common in the ED than inpatient setting (8/16 versus 1/16, P=0.02). Review of existing CDTs revealed inter-centre differences for inclusion ages, treatment regimens, lumbar puncture recommendations, diagnostic testing and normal laboratory values. Despite availability reported at nearly all centres, C-reactive protein and respiratory virus testing were recommended in 3/9 and 5/9 CDTs, respectively. Procalcitonin testing was available at only 2/16 (13%) centres, and not incorporated into any CDTs. Conclusions CDTs for the management of febrile young infants are infrequently available among Canadian tertiary paediatric centres, and rarely incorporate newer diagnostic tests. Heterogeneity among existent CDTs highlights the need for evidence-based unified ED and inpatient national guidelines.
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Affiliation(s)
- Brett Burstein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec.,T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Jocelyn Gravel
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Centre hospitalier universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec
| | - Paul L Aronson
- Departments of Pediatrics and of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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