1
|
Alkhmees M, Van Den Bruel A, Hayward G, Blanker MH, Walker S, Holtman GA. Trends in C reactive protein testing: a retrospective cohort study in paediatric ambulatory care settings. BMJ Open 2024; 14:e081658. [PMID: 38858158 PMCID: PMC11168168 DOI: 10.1136/bmjopen-2023-081658] [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: 11/02/2023] [Accepted: 04/26/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVES This study aims to investigate C reactive protein (CRP) testing practices in paediatric ambulatory care across British primary care and accident and emergency (A&E) departments. DESIGN, SETTING, PARTICIPANTS This retrospective cohort study included children <18 years old having ≥1 CRP test at primary care or A&E departments in Oxfordshire between 2007 and 2021. OUTCOMES We estimated the frequency and annual changes in CRP testing in both settings and evaluated referral and admission patterns based on CRP levels: low (<20 mg/L), intermediate or high (≥80 mg/L). RESULTS Over 15 years, 91 540 CRP tests were requested in 63 226 children, with 33 882 (53.6%) in primary care and 29 344 (46.4%) in A&E. Both settings showed rising trends in test requests, with average annual percentage change of 3.0% (95% CI 1.2% to 4.7%) in primary care and 11.5% (95% CI 8.6% to 14.6%) in A&E. The proportion of intermediate/high-test results remained stable. In primary care, 50 709 (95.8%) of CRP tests were <20 mg/L, with 99.0% of these children managed at home. High and intermediate CRP values increased odds of referral versus low CRP (OR adjusted for age=21.80; 95% CI 16.49 to 28.81 and 4.77; 3.78 to 6.02, respectively). At A&E, 27 610 (71.5%) children had CRP<20 mg/L, of whom 42.5% were admitted while 3776 (9.8%) had CRP≥80 mg/L with 57.9% admission rate. High and intermediate CRP values increased odds of admission versus low CRP (OR adjusted for age=1.90; 95% CI 1.78 to 2.04 and 1.39; 1.32 to 1.46, respectively). CONCLUSION There are rising trends of CRP test requests in paediatric ambulatory care settings, with no evidence of increases in proportion of intermediate/high-test results in primary care. Low CRP values at primary care were linked to children managed at home, while almost half of children with low CRP values at A&E were admitted to the hospital.
Collapse
Affiliation(s)
- Mohammed Alkhmees
- Department of Primary and Long Term Care, University Medical Center Groningen, Groningen University, Groningen, The Netherlands
- Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ann Van Den Bruel
- Academic Centre of General Practice, University of Leuven, Leuven, Belgium
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marco H Blanker
- Department of Primary and Long Term Care, University Medical Center Groningen, Groningen University, Groningen, The Netherlands
| | - Sarah Walker
- NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infections, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gea A Holtman
- Department of Primary and Long Term Care, University Medical Center Groningen, Groningen University, Groningen, The Netherlands
| |
Collapse
|
2
|
Bernardi L, Bossù G, Dal Canto G, Giannì G, Esposito S. Biomarkers for Serious Bacterial Infections in Febrile Children. Biomolecules 2024; 14:97. [PMID: 38254697 PMCID: PMC10813546 DOI: 10.3390/biom14010097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Febrile infections in children are a common cause of presentation to the emergency department (ED). While viral infections are usually self-limiting, sometimes bacterial illnesses may lead to sepsis and severe complications. Inflammatory biomarkers such as C reactive protein (CRP) and procalcitonin are usually the first blood exams performed in the ED to differentiate bacterial and viral infections; nowadays, a better understanding of immunochemical pathways has led to the discovery of new and more specific biomarkers that could play a role in the emergency setting. The aim of this narrative review is to provide the most recent evidence on biomarkers and predictor models, combining them for serious bacterial infection (SBI) diagnosis in febrile children. Literature analysis shows that inflammatory response is a complex mechanism in which many biochemical and immunological factors contribute to the host response in SBI. CRP and procalcitonin still represent the most used biomarkers in the pediatric ED for the diagnosis of SBI. Their sensibility and sensitivity increase when combined, and for this reason, it is reasonable to take them both into consideration in the evaluation of febrile children. The potential of machine learning tools, which represent a real novelty in medical practice, in conjunction with routine clinical and biological information, may improve the accuracy of diagnosis and target therapeutic options in SBI. However, studies on this matter are not yet validated in younger populations, making their relevance in pediatric precision medicine still uncertain. More data from further research are needed to improve clinical practice and decision making using these new technologies.
Collapse
Affiliation(s)
| | | | | | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.B.); (G.B.); (G.D.C.); (G.G.)
| |
Collapse
|
3
|
Ngwengi Y, Ngaba GP, Nida M, Enyama D. Evaluation of CRP as a marker for bacterial infection and malaria in febrile children at the Douala Gyneco-Obstetric and Pediatric Hospital. PLoS One 2023; 18:e0289012. [PMID: 37478118 PMCID: PMC10361518 DOI: 10.1371/journal.pone.0289012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND C reactive protein (CRP), a marker for the presence of inflammation, has been extensively studied for distinguishing bacterial from non-bacterial infection in febrile patients, but its role in excluding malaria in the febrile child has not been thoroughly evaluated. METHOD This was a cross-sectional study at the Douala Gyneco-Obstetric and Pediatric Hospital which included all patients between the ages of one month and 16 years presenting with fever. Consenting patients received complete clinical examinations, then venous blood samples were collected and tested for CRP values, bacterial infection and malaria. RESULTS Samples of 220 children were analyzed. 142/220 had viral infections, 50/220 had malaria and 49/220 had bacterial infections. 7/220 had both malaria and bacterial infection. There was no significant difference between mean CRP values in malaria and bacterial infection (p = 1), but CRP means were significantly higher in malaria/bacterial infection than in viral infection (p<0.0001). Area Under the Receiver Operating Characteristics Curve (AUROC) values were 0.94 for malaria and 0.86 for bacterial infection, with a calculated cut-off of 23.6mg/L for malaria and 36.2mg/L for bacterial infection. At these cut-offs, CRP had a Positive Predictive Value (PPV) of 68.75% and 85.00% for malaria and bacterial infection respectively, with a Negative Predictive Value (NPV) of 94.74% and 89.05% respectively. CONCLUSION CRP can effectively exclude malaria and bacterial infection in febrile children in low-resource settings without the need for additional tests.
Collapse
Affiliation(s)
- Yembu Ngwengi
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Littoral, Cameroon
| | - Guy Pascal Ngaba
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Littoral, Cameroon
- Department of Biochemistry, Hematology and Microbiology, Douala Gyneco-Obstetric and Pediatric Hospital, Littoral, Cameroon
| | - Martine Nida
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Littoral, Cameroon
- Department of Infectious Diseases and Dermatology, Douala Gyneco-Obstetric and Pediatric Hospital, Littoral, Cameroon
| | - Dominique Enyama
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, West, Cameroon
- Department of Pediatrics, Douala Gyneco-Obstetric and Pediatric Hospital, Littoral, Cameroon
| |
Collapse
|
4
|
Matthes A, Wolf F, Wilde E, Bleidorn J, Markwart R. Point-of-care measurement of C-reactive protein promotes de-escalation of treatment decisions and strengthens the perceived clinical confidence of physicians in out-of-hours outpatient emergency medical services. BMJ Open 2023; 13:e069453. [PMID: 37147098 PMCID: PMC10163444 DOI: 10.1136/bmjopen-2022-069453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES Out-of-hours outpatient emergency medical services (OEMS) provide healthcare for patients with non-life-threatening conditions in need for urgent care when outpatient practices are closed. We studied the use of point-of-care-testing of C-reactive protein (CRP-POCT) at OEMS. DESIGN Cross-sectional questionnaire-based survey. SETTING Single centre OEMS practice in Hildesheim, Germany (October 2021 to March 2022). PARTICIPANTS OEMS physicians answering a questionnaire immediately after performing CRP-POCTs (CUBE-S Analyzer, Hitado) on any patients. PRIMARY AND SECONDARY OUTCOMES Impact of CRP-POCTs on clinical decision-making and perceived usefulness. RESULTS In the 6-month study period, 114 valid CRP-POCTs were performed in the OEMS practice by 18 physicians and the questionnaire was answered in 112 cases (response rate: 98.2%). CRP-POCTs were used in the diagnosis of inflammatory diseases of the gastrointestinal tract (60.0%), respiratory tract infections (17.0%), urinary tract infections (9.0%) and other non-gastrointestinal/non-specified infections (11.0%). The use of a CRP-POCT resulted in a change of the physicians' clinical decision in 83.3% of the cases. Specifically, in 13.6% and 35.1% of the cases, rapid CRP measurements led to decision changes in the (1) initiation of antimicrobial therapy and (2) other drug treatment, respectively. Notably, in 60% of all cases, the use of a CRP-POCT reportedly changed the decision on hospitalisation/non-hospitalisation of OEMS patients. In respect of antimicrobial therapy and hospitalisation, these decision changes primarily (≥73%) promoted 'step-down' decisions, that is, no antibiotic therapy and no hospital admission. In the great majority of CRP-POCT applications (≥95%), OEMS physicians reported that rapid CRP measurements increased the confidence in their diagnostic and therapeutic decision. In almost all cases (97%), physicians rated the CRP-POCT use as useful in the treatment situation. CONCLUSION Quantitative CRP-POCT promotes step-down clinical decisions and strengthens the clinical confidence of physicians in out-of-hours OEMS.
Collapse
Affiliation(s)
- Anni Matthes
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- InfectoGnostics Research Campus Jena, Jena, Germany
| | - Florian Wolf
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Elmar Wilde
- Practice Network HilMed Hildesheim, Hildesheim, Germany
| | - Jutta Bleidorn
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Robby Markwart
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- InfectoGnostics Research Campus Jena, Jena, Germany
| |
Collapse
|
5
|
Dick S, MacRae C, McFaul C, Wilson P, Turner SW. Interventions in primary and community care to reduce urgent paediatric hospital admissions: systematic review. Arch Dis Child 2023; 108:486-491. [PMID: 36804396 DOI: 10.1136/archdischild-2022-324986] [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: 10/10/2022] [Accepted: 02/08/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND There has been a rise in urgent paediatric hospital admissions and interventions to address this are required. OBJECTIVE To systemically review the literature describing community (or non-hospital)-based interventions designed to reduce emergency department (ED) visits or urgent hospital admissions. DATA SOURCES MEDLINE, Embase, OVIS SP, PsycINFO, Science Citation Index Expanded/ISI Web of Science (1981-present), the Cochrane Library database and the Database of Abstracts of Reviews of Effectiveness. STUDY ELIGIBILITY CRITERIA Randomised controlled trials (RCTs) and before-and-after studies. PARTICIPANTS Individuals aged <16 years. STUDY APPRAISAL AND SYNTHESIS METHODS Papers were independently reviewed by two researchers. Data extraction and the Critical Appraisals Skills Programme checklist was completed (for risk of bias assessment). RESULTS Seven studies were identified. Three studies were RCTs, three were a comparison between non-randomised groups and one was a before-and-after study. Interventions were reconfiguration of staff roles (two papers), telemedicine (three papers), pathways of urgent care (one paper) and point-of-care testing (one paper). Reconfiguration of staff roles resulted in reduction in ED visits in one study (with a commensurate increase in general practitioner visits) but increased hospital admissions from ED in a second. Telemedicine was associated with a reduction in children's admissions in one study and reduced ED admissions in two further studies. Interventions with pathways of care and point-of-care testing did not impact either ED visits or urgent admissions. CONCLUSIONS AND IMPLICATIONS New out-of-hospital models of urgent care for children need to be introduced and evaluated without delay. PROSPERO REGISTRATION NUMBER CRD42021274374.
Collapse
Affiliation(s)
- Smita Dick
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| | - Clare MacRae
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Claire McFaul
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| | - Philip Wilson
- Institute of Health and Wellbeing, University of Aberdeen, Aberdeen, UK
| | - Stephen W Turner
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| |
Collapse
|
6
|
Pernica JM, Kam AJ, Eltorki M, Khan S, Goldfarb DM, Smaill F, Wong J, Ewusie J, Smieja M, Sung M, Mertz D, Thabane L, Loeb M. Novel care pathway to optimise antimicrobial prescribing for uncomplicated community-acquired pneumonia: study protocol for a prospective before-after cohort study in the emergency department of a tertiary care Canadian children's hospital. BMJ Open 2022; 12:e062360. [PMID: 36396301 PMCID: PMC9677018 DOI: 10.1136/bmjopen-2022-062360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Evidence-based recommendations for paediatric community-acquired pneumonia (CAP) diagnosis and management are needed. Uncomplicated CAP is often caused by respiratory viruses, especially in younger children; these episodes self-resolve without antibiotic treatment. Unfortunately, there are no clinical criteria that reliably discriminate between viral and bacterial disease, and so the majority of children diagnosed with CAP are given antibiotics-even though these will often not help and may cause harm. We have developed a novel care pathway that incorporates point-of-care biomarkers, radiographic patterns, microbiological testing and targeted follow-up. The primary study objective is to determine if the care pathway will be associated with less antimicrobial prescribing. METHODS AND ANALYSIS A prospective, before-after, study. Previously well children aged≥6 months presenting to a paediatric emergency department (ED) that have at least one respiratory symptom/sign, receive chest radiography, and are diagnosed with CAP by the ED physician will be eligible. Those with medical comorbidities, recently diagnosed pulmonary infection, or ongoing fever after≥4 days of antimicrobial therapy will be excluded. In the control (before) phase, eligible participants will be managed as per the standard of care. In the intervention (after) phase, eligible participants will be managed as per the novel care pathway. The primary outcome will be the proportion of participants in each phase who receive antimicrobial treatment for CAP. The secondary outcomes include: clinical cure; re-presentation to the ED; hospitalisation; time to resolution of symptoms; drug adverse events; caregiver satisfaction; child absenteeism from daycare/school; and caregiver absenteeism from work. ETHICS AND DISSEMINATION All study documentation has been approved by the Hamilton Integrated Research Ethics Board and informed consent will be obtained from all participants. Data from this study will be presented at major conferences and published in peer-reviewed publications to facilitate collaborations with networks of clinicians experienced in the dissemination of clinical guidelines. TRIAL REGISTRATION NUMBER NCT05114161.
Collapse
Affiliation(s)
- Jeffrey M Pernica
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - April J Kam
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Sarah Khan
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fiona Smaill
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jacqueline Wong
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Joycelyne Ewusie
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Marek Smieja
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Melani Sung
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
7
|
Fawkner-Corbett D, Hayward G, Alkhmees M, Van Den Bruel A, Ordóñez-Mena JM, Holtman GA. Diagnostic accuracy of blood tests of inflammation in paediatric appendicitis: a systematic review and meta-analysis. BMJ Open 2022; 12:e056854. [PMID: 36328382 PMCID: PMC9639107 DOI: 10.1136/bmjopen-2021-056854] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Possible childhood appendicitis is a common emergency presentation. The exact value of blood tests is debated. This study sought to determine the diagnostic accuracy of four blood tests (white cell count (WCC), neutrophil(count or percentage), C reactive protein (CRP) and/or procalcitonin) for childhood appendicitis. DESIGN A systematic review and diagnostic meta-analysis. Data sources included MEDLINE, EMBASE, Central, Web of Science searched from inception-March 2022 with reference searching and authors contacted for missing/unclear data. Eligibility criteria was studies reporting the diagnostic accuracy of the four blood tests compared to the reference standard (histology or follow-up). Risk of bias was assessed (QUADAS-2), pooled sensitivity and specificity were generated for each test and commonly presented cut-offs. To provide insight into clinical impact, we present strategies using a hypothetical cohort. RESULTS 67 studies were included (34 839 children, 13 342 with appendicitis), all in the hospital setting. The most sensitive tests were WCC (≥10 000 cells/µL, 53 studies sensitivity 0.85 (95% CI 0.80 to 0.89)) and absolute neutrophil count (ANC) (≥7500 cells/µL, five studies sensitivity 0.90 (95% CI 0.85 to 0.94)). Combination of WCC or CRP increased sensitivity further(≥10 000 cells/µL or ≥10 mg/L, individual patient data (IPD) of 6 studies, 0.97 (95% CI 0.93 to 0.99)).Applying results to a hypothetical cohort(1000 children with appendicitis symptoms, of whom 400 have appendicitis) 60 and 40 children would be wrongly discharged based solely on WCC and ANC, respectively, 12 with combination of WCC or CRP.The most specific tests were CRP alone (≥50 mg/L, 38 studies, specificity 0.87 (95% CI 0.80 to 0.91)) or combined with WCC (≥10 000 cells/µL and ≥50 mg/L, IPD of six studies, 0.93 (95% CI 0.91 to 0.95)). CONCLUSIONS The best performing single blood tests for ruling-out paediatric appendicitis are WCC or ANC; with accuracy improved combining WCC and CRP. These tests could be used at the point of care in combination with clinical prediction rules. We provide insight into the best cut-offs for clinical application. PROSPERO REGISTRATION NUMBER CRD42017080036.
Collapse
Affiliation(s)
- David Fawkner-Corbett
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Academic Paediatric Surgery Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, UK
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DS, UK
| | - Gail Hayward
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Mohammed Alkhmees
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ann Van Den Bruel
- EPI-Centre, Academic Centre for Primary Care, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
| | - Jose M Ordóñez-Mena
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Gea A Holtman
- NIHR Community Healthcare MedTech and IVD Co-operative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
8
|
Scally BJ, Buxton G, Smith JK. Five years of outpatient parenteral antibiotic therapy with ceftriaxone in the paediatric emergency department: what clinical features are associated with need for admission? Emerg Med J 2022; 39:emermed-2021-211928. [PMID: 35879045 DOI: 10.1136/emermed-2021-211928] [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: 08/11/2021] [Accepted: 06/29/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND More children presenting to Emergency Departments (EDs) with acute infections are now directly referred for outpatient parenteral antibiotic therapy (OPAT). Sparse data exist on what clinical features in these children are associated with OPAT failure. We hypothesised that children who were younger or presented with systemic features of infection would be more likely to need admission. METHODS We conducted a service evaluation over a 5-year period (12 September 2015-12 September 2020) at a single UK tertiary centre paediatric ED formally known as the Royal Hospital for Sick Children Edinburgh. All children referred from the ED for OPAT with ceftriaxone were included. OPAT failure was defined as a decision by a senior clinician of need for admission. Univariate statistical testing and multivariate logistic regression modelling were performed. RESULTS 754 children received OPAT in the ED over a 5-year period. 95 children (13%) required admission for inpatient management. Need for admission was independently associated with having a positive blood culture (adjusted OR (aOR) 8.9; 95% CI 1.49 to 47; p=0.01) or an ultrasound performed (aOR 6.8; 95% CI 3.74 to 12.7; p<0.001). We observed no significant association between age and systemic features (fever, white cell count or C reactive protein) with need for admission in our multivariate analysis. CONCLUSION In children presenting with acute infections to our paediatric ED who were deemed suitable by senior clinicians to be managed using OPAT with ceftriaxone, younger age (above 3 months) and the presence of systemic features were not independently associated with need for admission. Overall, our service was safe and no child came to harm from early ambulation during this evaluation.
Collapse
Affiliation(s)
- Benjamin J Scally
- Emergency Department, Victoria Hospital Kirkcaldy, NHS Fife, Kirkcaldy, UK
| | - Gemma Buxton
- Immunology and Infectious Diseases Department, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Jennifer K Smith
- Emergency Department, Royal Hospital for Children and Young People, Edinburgh, UK
| |
Collapse
|
9
|
Rotem G, Zur-Aviran N, Sherr-Lurie N, Weltsch D, Schindler A, Tenenbaum S, Givon U. Treatment of Septic Arthritis of the Hip Joint Using Repeated Aspirations: When Should We Operate? Indian J Orthop 2022; 56:1090-1095. [PMID: 35669032 PMCID: PMC9123145 DOI: 10.1007/s43465-022-00616-5] [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: 11/29/2021] [Accepted: 02/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The well-accepted treatment of septic arthritis of the hip joint (SAHJ) is surgical drainage of the joint, but repeated aspirations of the hip joint under sonography, have been used for over twenty years with significant success in some centers, including ours. In recent years, we identified some children who did not respond to aspirations and had to undergo arthrotomies. We were concerned that some children may have reached the operating room after a longer than ideal time. OBJECTIVE Identification of the characteristics of patients who did not respond to repeated aspirations and development of a treatment algorithm that expedites decision-making regarding the necessity of surgery. METHODS This is a single-center retrospective cohort analysis. All the patients diagnosed with SAHJ between 2007 and 2019 were identified. Patients who responded to repeated aspirations were compared to those who did not improve and required surgery. Demographic and clinical data and laboratory results were obtained from the patients' electronic medical records. RESULTS Forty-eight children (88.9%) were treated successfully with repeated aspirations and six children (11.1%) did not improve after aspirations and underwent hip arthrotomies. Five out of 48 children from the aspiration group (10.4%) and 4 out of 6 from the arthrotomy group (66.7%) had chronic comorbidities (p = 0.0051). The mean duration of fever over 38.5 degrees centigrade and the length of stay were higher in the arthrotomy group (p = 0.0040, p = 0.0301, respectively). When we examined the change in C-reactive protein (CRP) levels before and after the first aspiration (Delta CRP), we found a decrease in the aspiration group and an increase in the arthrotomy group (p = 0.0044). CONCLUSION The new algorithm which we present allows an expeditious assessment of the patient's response to the repeated aspiration method and thus prevents unnecessary surgeries for the treatment of SAHJ. Patients with chronic comorbidities, prolonged fever, and an increase in CRP level following the first aspiration, are at risk of treatment failure and should be treated with an arthrotomy. LEVEL OF EVIDENCE FOR CLINICAL ARTICLES Level 4-cohort study.
Collapse
Affiliation(s)
- Gilad Rotem
- Orthopedic Division, Hand Surgery Department, Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel Aviv University, Tel-Hashomer, 5262100 Ramat Gan, Israel
| | - Noa Zur-Aviran
- Pediatric Orthopedics Unit, Sheba Medical Center, Affiliated to Sackler School of Medicine, Safra Hospital for Children, Ramat Gan, Israel
| | - Nir Sherr-Lurie
- Pediatric Orthopedics Unit, Sheba Medical Center, Affiliated to Sackler School of Medicine, Safra Hospital for Children, Ramat Gan, Israel
| | - Daniel Weltsch
- Pediatric Orthopedics Unit, Sheba Medical Center, Affiliated to Sackler School of Medicine, Safra Hospital for Children, Ramat Gan, Israel
| | - Amos Schindler
- Pediatric Orthopedics Unit, Sheba Medical Center, Affiliated to Sackler School of Medicine, Safra Hospital for Children, Ramat Gan, Israel
| | - Shay Tenenbaum
- Orthopedic Division, Sheba Medical Center, Affiliated to Sackler School of Medicine, Ramat Gan, Israel
| | - Uri Givon
- Pediatric Orthopedics Unit, Sheba Medical Center, Affiliated to Sackler School of Medicine, Safra Hospital for Children, Ramat Gan, Israel
| |
Collapse
|
10
|
Levinson T, Zehavi NT, Berliner S, Zeltser D, Shapira I, Shenhar-Tsarfaty S, Wasserman A, Goldiner I, Rogowski O, Shtark M. Point of care detection of infection/inflammation in the diabetic clinic. EUR J INFLAMM 2022. [DOI: 10.1177/1721727x221091323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction: Patients with diabetes are prone to infections. An elevated C-reactive protein (CRP) level indicates an underlying infection/inflammation; hence, a reliable point-of-care (POC) CRP measurement, independent of glucose level, would be advantageous in rapid detection of an inflammatory process and allowing for appropriate therapy in a timely manner. Methods: A validation study of patients with type 2 diabetes mellitus diagnosed with an inflammatory condition either infectious or non-infectious underwent a capillary CRP measurement on the same blood drop used for the measurement of capillary glucose level. Results: 154 samples from patients with diabetes across a broad range of CRP levels that underwent capillary CRP measurement, demonstrating a linear profile of the dynamic range compared with the wide range CRP assay, with significant correlation of R2 = 0.9 and a slope of 0.98 (95% C.I: 0.91–1). Bland Altman analysis, presents a positive bias profile; the total difference between assays is 6.6 mg/L. The mean bias between methods is 13.34% (C.I 95% 9.8–17.5%). The total agreement between the methods is 89%, the observed Kappa index is: 0.71 with confidence interval of 0.57–0.84 indicating substantial agreement between the methods. C-reactive protein level is independent of glucose concentration. Conclusion: Point-of-care capillary CRP testing is a useful mean of early detection of infection/inflammation in patients with diabetes and enables the treating physician to rapidly assess and treat the patients underlying inflammatory process.
Collapse
Affiliation(s)
- Tal Levinson
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious diseases unit, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir Tal Zehavi
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Berliner
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Zeltser
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itzhak Shapira
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shani Shenhar-Tsarfaty
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Wasserman
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilana Goldiner
- Clinical Laboratory Services, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Rogowski
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Shtark
- Clinical Laboratory Services, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
11
|
August DL, Kandasamy Y, Ray R, Lindsay D, New K. Fresh Perspectives on Hospital-Acquired Neonatal Skin Injury Period Prevalence From a Multicenter Study: Length of Stay, Acuity, and Incomplete Course of Antenatal Steroids. J Perinat Neonatal Nurs 2021; 35:275-283. [PMID: 32826705 DOI: 10.1097/jpn.0000000000000513] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this study was to explore neonatal skin injury period prevalence, classification, and risk factors. Skin injury period prevalence over 9 months and χ2, Mann-Whitney U, and independent-samples t tests compared injured and noninjured neonates, with P values less than .05 considered statistically significant. Injury prediction models were developed using Classification and Regression Tree (CART) analysis for the entire cohort and separately for those classified as high or low acuity. The study took place in 3 Australian and New Zealand units. Neonates enrolled (N = 501) had a mean birth gestational age of 33.48 ± 4.61 weeks and weight of 2138.81 ± 998.92 g. Of the 501 enrolled neonates, 206 sustained skin injuries (41.1%), resulting in 391 injuries to the feet (16.4%; n = 64), cheek (12.5%; n = 49), and nose (11.3%; n = 44). Medical devices were directly associated with 61.4% (n = 240) of injuries; of these medical devices, 50.0% (n = 120) were unable to be repositioned and remained in a fixed position for treatment duration. The strongest predictor of skin injury was birth gestation of 30 weeks or less, followed by length of stay of more than 12 days, and birth weight of less than 1255 g. Prediction for injury based on illness acuity identified neonates less than 30 weeks' gestation and length of stay more than 39 days were at a greater risk (high acuity), as well as neonates less than 33 weeks' gestation and length of stay of more than 9 days (low acuity). More than 40% of hospitalized neonates acquired skin injury, of which the majority skin injuries were associated with medical devices required to sustain life. Increased neonatal clinician education and improved skin injury frameworks, informed by neonatal epidemiological data, are vital for the development of effective prevention strategies.
Collapse
Affiliation(s)
- Deanne L August
- College of Medicine and Dentistry (Ms August and Drs Kandasamy and Ray) and College of Public Health, Medical and Vet Sciences (Dr Lindsay), James Cook University, Townsville, Queensland, Australia; The Townsville Hospital and Health Service, Neonatology, Townsville, Queensland, Australia (Dr Kandasamy); and School of Nursing, Midwifery; and Social Work, University of Queensland, Brisbane, Queensland, Australia (Dr New)
| | | | | | | | | |
Collapse
|
12
|
Escadafal C, Incardona S, Fernandez-Carballo BL, Dittrich S. The good and the bad: using C reactive protein to distinguish bacterial from non-bacterial infection among febrile patients in low-resource settings. BMJ Glob Health 2021; 5:bmjgh-2020-002396. [PMID: 32467355 PMCID: PMC7259834 DOI: 10.1136/bmjgh-2020-002396] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/29/2022] Open
Abstract
C reactive protein (CRP), a marker for the presence of an inflammatory process, is the most extensively studied marker for distinguishing bacterial from non-bacterial infections in febrile patients. A point-of-care test for bacterial infections would be of particular use in low-resource settings where other laboratory diagnostics are not always available, antimicrobial resistance rates are high and bacterial infections such as pneumonia are a leading cause of death. This document summarises evidence on CRP testing for bacterial infections in low-income and middle-income countries (LMICs). With a push for universal health coverage and prevention of antimicrobial resistance, it is important to understand if CRP might be able to do the job. The use of CRP polarised the global health community and the aim of this document is to summarise the ‘good and the bad’ of CRP in multiple settings in LMICs. In brief, the literature that was reviewed suggests that CRP testing may be beneficial in low-resource settings to improve rational antibiotic use for febrile patients, but the positive predictive value is insufficient to allow it to be used alone as a single tool. CRP testing may be best used as part of a panel of diagnostic tests and algorithms. Further studies in low-resource settings, particularly with regard to impact on antibiotic prescribing and cost-effectiveness of CRP testing, are warranted.
Collapse
Affiliation(s)
- Camille Escadafal
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Sandra Incardona
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | | | - Sabine Dittrich
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland .,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
13
|
Zhang Q, Hu WT, Yin F, Qian H, Wang Y, Li BR, Qian J, Tang YJ, Ning BT. The Clinical Characteristics of ARDS in Children With Hematological Neoplasms. Front Pediatr 2021; 9:696594. [PMID: 34307258 PMCID: PMC8295493 DOI: 10.3389/fped.2021.696594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/31/2021] [Indexed: 12/27/2022] Open
Abstract
In order to explore the clinical characteristics of pediatric patients admitted to the pediatric intensive care unit (PICU) who suffered from hematological neoplasms complicated with acute respiratory distress syndrome (ARDS), we retrospectively analyzed 45 ARDS children with hematological neoplasms who were admitted to the PICU of Shanghai Children's Medical Center from January 1, 2014, to December 31, 2020. The 45 children were divided into a survival group and a non-survival group, a pulmonary ARDS group and an exogenous pulmonary ARDS group, and an agranulocytosis group and a non-agranulocytosis group, for statistical analysis. The main clinical manifestations were fever, cough, progressive dyspnea, and hypoxemia; 55.6% (25/45) of the children had multiple organ dysfunction syndrome (MODS). The overall mortality rate was 55.6% (25/45). The vasoactive inotropic score (VIS), pediatric critical illness scoring (PCIS), average fluid volume in the first 3 days and the first 7 days, and the incidence of MODS in the non-survival group were all significantly higher than those in the survival group (P < 0.05). However, total length of mechanical ventilation and length of hospital stay and PICU days in the non-survival group were significantly lower than those in the survival group (P < 0.05). The PCIS (OR = 0.832, P = 0.004) and the average fluid volume in the first 3 days (OR = 1.092, P = 0.025) were independent risk factors for predicting death. Children with exogenous pulmonary ARDS were more likely to have MODS than pulmonary ARDS (P < 0.05). The mean values of VIS, C-reactive protein (CRP), and procalcitonin (PCT) in children with exogenous pulmonary ARDS were also higher (P < 0.05). After multivariate analysis, PCT was independently related to exogenous pulmonary ARDS. The total length of hospital stay, peak inspiratory pressure (PIP), VIS, CRP, and PCT in the agranulocytosis group were significantly higher than those in the non-agranulocytosis group (P < 0.05). Last, CRP and PIP were independently related to agranulocytosis. In conclusion, children with hematological neoplasms complicated with ARDS had a high overall mortality and poor prognosis. Children complicated with MODS, positive fluid balance, and high VIS and PCIS scores were positively correlated with mortality. In particular, PCIS score and average fluid volume in the first 3 days were independent risk factors for predicting death. Children with exogenous pulmonary ARDS and children with agranulocytosis were in a severely infected status and more critically ill.
Collapse
Affiliation(s)
- Qiao Zhang
- Department of Intensive Care Medicine, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wen-Ting Hu
- Department of Hematology and Oncology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fan Yin
- Department of Intensive Care Medicine, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Han Qian
- Department of Intensive Care Medicine, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ying Wang
- Department of Intensive Care Medicine, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bi-Ru Li
- Department of Intensive Care Medicine, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Juan Qian
- Department of Intensive Care Medicine, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan-Jing Tang
- Department of Hematology and Oncology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bo-Tao Ning
- Department of Intensive Care Medicine, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Shanghai Engineering Research Center of Intelligence Pediatrics (SERCIP), Shanghai, China
| |
Collapse
|
14
|
Waterfield T, Maney JA, Lyttle MD, McKenna JP, Roland D, Corr M, Patenall B, Shields MD, Woolfall K, Fairley D. Diagnostic test accuracy of point-of-care procalcitonin to diagnose serious bacterial infections in children. BMC Pediatr 2020; 20:487. [PMID: 33087092 PMCID: PMC7576699 DOI: 10.1186/s12887-020-02385-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/13/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) have called for research into the role of biomarkers, and specifically procalcitonin (PCT), for the early diagnosis of serious bacterial infections (SBI) in children. The aim of this study was to compare the diagnostic test accuracy of C-reactive protein (CRP) and PCT for the diagnosis of SBI in children. METHODS Data was collected prospectively from four UK emergency departments (ED) between November 2017 and June 2019. Consecutive children under 18 years of age with fever and features of possible sepsis and/or meningitis were eligible for inclusion. The index tests were PCT and CRP and the reference standard was the confirmation of SBI. RESULTS 213 children were included in the final analysis. 116 participants (54.5%) were male, and the median age was 2 years, 9 months. Parenteral antibiotics were given to 100 (46.9%), three (1.4%) were admitted to a paediatric intensive care unit and there were no deaths. There were ten (4.7%) confirmed SBI. The area under the curve for PCT and CRP for the detection of SBI was identical at 0.70. CONCLUSIONS There was no difference in the performance of PCT and CRP for the recognition of SBI in this cohort. TRIAL REGISTRATION Registered at https://www.clinicaltrials.gov (trial registration: NCT03378258 ) on the 19th of December 2017.
Collapse
Affiliation(s)
- Thomas Waterfield
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK.
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, UK.
| | - Julie-Ann Maney
- Emergency Department, Royal Belfast Hospital for Sick Children, 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
| | - James P McKenna
- Department of Microbiology, Belfast Health and Social Care Trust, Belfast, UK
| | - Damian Roland
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
- Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Michael Corr
- Belfast Health and Social Care Trust, Belfast, UK
| | | | - Michael D Shields
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Kerry Woolfall
- Institute of Population Health and Society, University of Liverpool, Liverpool, UK
| | - Derek Fairley
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, UK
- Department of Microbiology, Belfast Health and Social Care Trust, Belfast, UK
| |
Collapse
|
15
|
Corr M, Waterfield T, Fairley D, McKenna J, Shields MD. A protocol for a systematic review and meta-analysis of the diagnostic accuracy of mid-regional pro-adrenomedullin in predicting invasive bacterial infection in children. Syst Rev 2020; 9:69. [PMID: 32241288 PMCID: PMC7119004 DOI: 10.1186/s13643-020-01338-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 03/19/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The early recognition of invasive bacterial infections (IBI) in children can be difficult. Clinically it is often challenging to differentiate between the early stages of an IBI and a benign self-limiting viral infection. These challenges mandate a cautious approach resulting in the overuse of antimicrobial drugs with resultant antimicrobial resistance. Due to these challenges, there is growing research into the role of biomarkers for the early identification of children with IBI. Earlier and more accurate diagnoses may lead to improved clinical outcomes for children and reduced antimicrobial resistance. Mid-regional pro-adrenomedullin (MR-proADM) is a biomarker that has been shown to be elevated in patients with IBI. The aim of this systematic review is to determine the diagnostic accuracy of MR-proADM at identifying children with IBI. METHODS To identify relevant studies we will search MEDLINE, Embase, Web of Science and Scopus from 1980 to the present day for all human clinical trials involving children that report the test accuracy of MR-proADM. We will include case-control studies, cohort studies and randomised control trials reported in any language. In addition, we will hand-search reference lists and grey literature including conference abstracts and web searches. Two reviewers will independently screen study titles and abstracts for eligibility followed by full-text assessment and data extraction including population, setting, timing and use of index test and reference standard used. Methodological quality will be assessed, by two authors, according to the revised tool for the quality assessment of diagnostic accuracy studies (QUADAS-2), any discrepancies will be resolved by a third author. The following test characteristics will be extracted into 2 × 2 tables for all included studies: true positives, false positives, true negatives and false negatives. Study-specific estimates of sensitivity and specificity with 95% confidence intervals will be displayed in forest plots. DISCUSSION This review will report the normal ranges for MR-proADM in health and the diagnostic accuracy of MR-proADM at identifying children with IBI. The review will help to define where in the diagnostic pathway MR-proADM could be useful including potential as a point-of-care test for children at first presentation with IBI. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018096295.
Collapse
Affiliation(s)
- Michael Corr
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen’s University Belfast, 97 Lisburn Road, Belfast, BT9 7AE UK
| | - Thomas Waterfield
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen’s University Belfast, 97 Lisburn Road, Belfast, BT9 7AE UK
| | | | | | - Michael D. Shields
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen’s University Belfast, 97 Lisburn Road, Belfast, BT9 7AE UK
| |
Collapse
|
16
|
Abstract
Meningitis is a critical diagnosis not to miss in children presenting with fever. Since the early 20th century, classical clinical signs have been used to aid the diagnosis of meningitis. These classical signs are nuchal rigidity, Kernig's sign and Brudzinski's sign. Each of these relies on the principle that stretching the inflamed meningeal membranes causes clinically detectable irritation. Several primary studies have quantified the diagnostic performance of clinical examination in detecting meningitis in children. The results of these studies vary significantly due to methodological differences, clinical heterogeneity and interobserver variability. However, their findings demonstrate that positive meningitic signs increase the likelihood of a diagnosis of meningitis, and the absence of meningitic signs reduces this probability. These signs have greatest utility when combined with other features in the history and examination to contribute to a comprehensive clinical assessment.
Collapse
Affiliation(s)
- Alexander Tracy
- General Paediatrics, Birmingham Children's Hospital, Birmingham, UK
| | - Thomas Waterfield
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| |
Collapse
|
17
|
van de Maat JS, Peeters D, Nieboer D, van Wermeskerken AM, Smit FJ, Noordzij JG, Tramper-Stranders G, Driessen GJA, Obihara CC, Punt J, van der Lei J, Polinder S, Moll HA, Oostenbrink R. Evaluation of a clinical decision rule to guide antibiotic prescription in children with suspected lower respiratory tract infection in The Netherlands: A stepped-wedge cluster randomised trial. PLoS Med 2020; 17:e1003034. [PMID: 32004317 PMCID: PMC6993966 DOI: 10.1371/journal.pmed.1003034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 01/06/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Optimising the use of antibiotics is a key component of antibiotic stewardship. Respiratory tract infections (RTIs) are the most common reason for antibiotic prescription in children, even though most of these infections in children under 5 years are viral. This study aims to safely reduce antibiotic prescriptions in children under 5 years with suspected lower RTI at the emergency department (ED), by implementing a clinical decision rule. METHODS AND FINDINGS In a stepped-wedge cluster randomised trial, we included children aged 1-60 months presenting with fever and cough or dyspnoea to 8 EDs in The Netherlands. The EDs were of varying sizes, from diverse geographic and demographic regions, and of different hospital types (tertiary versus general). In the pre-intervention phase, children received usual care, according to the Dutch and NICE guidelines for febrile children. During the intervention phase, a validated clinical prediction model (Feverkidstool) including clinical characteristics and C-reactive protein (CRP) was implemented as a decision rule guiding antibiotic prescription. The intervention was that antibiotics were withheld in children with a low or intermediate predicted risk of bacterial pneumonia (≤10%, based on Feverkidstool). Co-primary outcomes were antibiotic prescription rate and strategy failure. Strategy failure was defined as secondary antibiotic prescriptions or hospitalisations, persistence of fever or oxygen dependency up to day 7, or complications. Hospitals were randomly allocated to 1 sequence of treatment each, using computer randomisation. The trial could not be blinded. We used multilevel logistic regression to estimate the effect of the intervention, clustered by hospital and adjusted for time period, age, sex, season, ill appearance, and fever duration; predicted risk was included in exploratory analysis. We included 999 children (61% male, median age 17 months [IQR 9 to 30]) between 1 January 2016 and 30 September 2018: 597 during the pre-intervention phase and 402 during the intervention phase. Most children (77%) were referred by a general practitioner, and half of children were hospitalised. Intention-to-treat analyses showed that overall antibiotic prescription was not reduced (30% to 25%, adjusted odds ratio [aOR] 1.07 [95% CI 0.57 to 2.01, p = 0.75]); strategy failure reduced from 23% to 16% (aOR 0.53 [95% CI 0.32 to 0.88, p = 0.01]). Exploratory analyses showed that the intervention influenced risk groups differently (p < 0.01), resulting in a reduction in antibiotic prescriptions in low/intermediate-risk children (17% to 6%; aOR 0.31 [95% CI 0.12 to 0.81, p = 0.02]) and a non-significant increase in the high-risk group (47% to 59%; aOR 2.28 [95% CI 0.84 to 6.17, p = 0.09]). Two complications occurred during the trial: 1 admission to the intensive care unit during follow-up and 1 pleural empyema at day 10 (both unrelated to the study intervention). Main limitations of the study were missing CRP values in the pre-intervention phase and a prolonged baseline period due to logistical issues, potentially affecting the power of our study. CONCLUSIONS In this multicentre ED study, we observed that a clinical decision rule for childhood pneumonia did not reduce overall antibiotic prescription, but that it was non-inferior to usual care. Exploratory analyses showed fewer strategy failures and that fewer antibiotics were prescribed in low/intermediate-risk children, suggesting improved targeting of antibiotics by the decision rule. TRIAL REGISTRATION Netherlands Trial Register NTR5326.
Collapse
Affiliation(s)
- Josephine S. van de Maat
- Department of General Paediatrics, Erasmus MC–Sophia Children’s Hospital, Rotterdam, The Netherlands
- * E-mail:
| | - Daphne Peeters
- Department of Paediatrics, HAGA–Juliana Children’s Hospital, Den Haag, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Frank J. Smit
- Department of Paediatrics, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - Jeroen G. Noordzij
- Department of Paediatrics, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | | | | | - Charlie C. Obihara
- Department of Paediatrics, Elisabeth–TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Jeanine Punt
- Department of Paediatrics, LangeLand Ziekenhuis, Zoetermeer, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus MC, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Henriette A. Moll
- Department of General Paediatrics, Erasmus MC–Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC–Sophia Children’s Hospital, Rotterdam, The Netherlands
| |
Collapse
|
18
|
Abstract
Biomarkers have become an integral part of the clinical decision-making process of clinicians dealing with febrile children. C-reactive protein, procalcitonin and white blood cell count are probably the most studied ones. Crucial to using biomarkers is the understanding of how a test result will alter post-test probabilities and then impact on clinical decision making. Improved analytical and computational platforms have enabled the next generation of advanced biomarker discovery studies. Promising combinations of candidate biomarkers for a diverse spectrum of febrile illnesses, such as viral and bacterial infections, have been identified using proteomics, RNA gene expression and metabolomics.
Collapse
|
19
|
Abstract
A 3-month-old baby is brought to the paediatric emergency department by their parents because of a fever. You decide to check their inflammatory markers. Their C-reactive protein (CRP) level comes back as 20 mg/L. Does this affect whether or not you start antibiotic therapy? Does it influence your decision to admit or discharge the patient? CRP is a commonly used biochemical test and yet its use is constantly debated and challenged. We look at the current evidence and suggest the best way to use this test in clinical practice.
Collapse
Affiliation(s)
| | - Thomas Waterfield
- Queen's University Belfast School of Medicine Dentistry and Biomedical Sciences, Belfast, UK
| | - Hannah Baynes
- King's College London School of Medical Education, London, UK
| |
Collapse
|
20
|
Waterfield T, Maney JA, Hanna M, Fairley D, Shields MD. Point-of-care testing for procalcitonin in identifying bacterial infections in young infants: a diagnostic accuracy study. BMC Pediatr 2018; 18:387. [PMID: 30541505 PMCID: PMC6292055 DOI: 10.1186/s12887-018-1349-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 11/19/2018] [Indexed: 11/23/2022] Open
Abstract
Background The primary objective of this study was to report on the diagnostic accuracy of point-of-care testing (POCT) for procalcitonin (PCT) in identifying invasive bacterial infections in young infants. Invasive bacterial infection was defined as the isolation of a bacterial pathogen in blood or cerebrospinal fluid culture. Methods This was a prospective observational diagnostic accuracy study. Young infants less than 90 days of age presenting to the Royal Belfast Hospital for Sick Children with signs of possible bacterial infection were eligible for inclusion. Eligible infants underwent point-of-care testing for procalcitonin in the emergency department. Testing was performed by clinical staff using 0.5 ml of whole blood. Results were available within 20 min. Results 126 children were included over a 5-month period between September 2017 and January 2018. There were 14 children diagnosed with bacterial infections (11.1%). Of these 4 children were diagnosed with invasive bacterial infections (3.2%). POCT procalcitonin demonstrated an excellent diagnostic accuracy for identifying children with invasive bacterial infection area under the curve (AUC) of 0.97(95% CI, 0.94 to 1.0). At a cut-off value of 1.0 ng/ml is highly accurate at identifying infants at risk of invasive bacterial infection with a sensitivity and specificity of 1.00 and 0.92 respectively. Conclusions Point-of-care procalcitonin can be performed quickly in the emergency department and demonstrates an excellent diagnostic accuracy for the identification of young infants with invasive bacterial infections. Trial registration NCT03509727 Retrospectively registered on 26th April 2018.
Collapse
Affiliation(s)
- Thomas Waterfield
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7AE, UK.
| | | | | | | | - Michael D Shields
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7AE, UK
| |
Collapse
|
21
|
Schot MJC, Dekker ARJ, Giorgi WG, Hopstaken RM, de Wit NJ, Verheij TJM, Cals JWL. Diagnostic value of signs, symptoms and diagnostic tests for diagnosing pneumonia in ambulant children in developed countries: a systematic review. NPJ Prim Care Respir Med 2018; 28:40. [PMID: 30367067 PMCID: PMC6203790 DOI: 10.1038/s41533-018-0104-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/03/2018] [Accepted: 08/23/2018] [Indexed: 11/13/2022] Open
Abstract
Identifying a child with pneumonia in the large group of children with acute respiratory tract infections can be challenging for primary care physicians. Knowledge on the diagnostic value of specific signs and symptoms may guide future decision rules and guidelines for clinicians. We aimed to identify and systematically review available evidence for the diagnostic value of signs, symptoms, and additional tests to diagnose pneumonia in children in an ambulatory setting in developed countries. We conducted a systematic review, searching in the electronic databases of PubMed and Embase. Quality assessment of studies was done using the QUADAS-2 criteria. After data extraction from selected studies, we calculated and summarized test characteristics (sensitivity, specificity, negative and positive predictive values) of all available signs, symptoms, additional laboratory tests, and chest ultrasonography. The original search yielded 4665 records, of which 17 articles were eligible for analysis: 12 studies on signs and symptoms, 4 on additional laboratory tests, and 6 on ultrasonography. All included studies were performed in a secondary care setting. Risk of bias was present in the majority of studies in the domain of patient selection. Prevalence of pneumonia varied from 3.4% to 71.7%. The diagnostic value of the available 27 individual signs and symptoms to identify pneumonia was low. In a low prevalence setting, (4 studies, pneumonia prevalence <10%) clinically ill appearance of the child and oxygen saturation <94% can aid a physician. In a high prevalence setting (10 studies, pneumonia >10%), additional diagnostic tests such as oxygen saturation, C-reactive protein, and white blood cell count are more promising. Chest ultrasonography showed high diagnostic value in settings with higher prevalence of pneumonia. Single signs and symptoms from medical history and physical examination or individual additional diagnostic tests are insufficient to diagnose pneumonia in ambulant children. Very few diagnostic studies are conducted in settings with low prevalence of pneumonia. Future research in low prevalence settings should focus on the diagnostic value of the combination of clinical features and additional testing possibly using meta-analysis of individual data.
Collapse
Affiliation(s)
- Marjolein J C Schot
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Anne R J Dekker
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wesley G Giorgi
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | | | - Niek J de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
22
|
Affiliation(s)
- Santiago Mintegi
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain.,Department of Pediatrics, University of the Basque Country, Bilbao, Spain
| |
Collapse
|