Unexplained fever in young children: how to manage severe bacterial infection

Epidemiology of urinary tract infections in children: Causative bacteria and antimicrobial therapy

BACKGROUND

Urinary tract infections (UTIs) are the most common bacterial infections in children. This study aimed to review characteristics of causative bacteria and the effectiveness of antimicrobial therapy in children with febrile UTIs.

METHODS

Clinical records of 108 patients (130 episodes) with febrile UTIs admitted to the Kawasaki Medical School Hospital between July 2009 and October 2016 were retrospectively reviewed. The characteristics of the causative bacteria, antibacterial therapy, and therapeutic effect were verified.

RESULTS

Patients were aged between 0 and 183 months (median age: 3 months). Seventy-three (67.6%) were males. Sixty-three episodes (48.5%) were diagnosed with complicated UTIs. Forty-seven episodes (36.2%) were observed in patients aged <3 months; 15 of them had complicated UTIs. Escherichia coli (E. coli) was the most common pathogen, followed by Enterococcus faecalis (E. faecalis). Blood cultures were positive in three episodes. Among the 130 episodes, 62 (47.7%) were treated with a combination of ampicillin and third-generation cephalosporins, followed by third-generation cephalosporins (31 episodes, 23.8%) and sulbactam sodium / ampicillin sodium (15 episodes, 11.5%). In case of patients with uncomplicated/complicated UTIs and patients aged <3 and ≥3 months, the most common pathogen was E. coli, followed by E. faecalis. There was no difference in therapeutic effects between "combination ampicillin and third-generation cephalosporins" and "third-generation cephalosporin monotherapy" administered for the treatment of UTIs caused by E. coli.

CONCLUSIONS

Escherichia coli is the most common pathogen among pediatric UTIs. For antibacterial therapy, third-generation cephalosporin monotherapy is effective and may not require combination therapy with ampicillin.

Repeated Emergency Department Visits Among Children with Invasive Bacterial Infections

We carried out a retrospective cohort study of 271 previously healthy children younger than 14 years old diagnosed with invasive bacterial infection in an emergency department. Of them, 72 (26.6%) had previous visits to the emergency department. Not identifying children with an invasive bacterial infection and not administering antibiotics on the first visit was associated with a severe outcome.

Characteristics of children with microbiologically confirmed invasive bacterial infections in the emergency department

BACKGROUND

Determination of the characteristics of paediatric invasive bacterial infections (IBI) is essential for early identification of children requiring immediate antibiotic therapy. The main objective is to characterize the emergency presentation of the IBI among children aged younger than 14 years.

PATIENTS AND METHODS

A prospective registry-based cohort study including all patients aged younger than 14 years diagnosed with confirmed IBI (culture or genomic detection using the polymerase chain reaction) was carried out in a paediatric emergency department between 2008 and 2015. Severity criteria were as follows: death, sequelae or admission to the ICU.

RESULTS

Of the 223 IBIs reported, 187 (83.9%) corresponded to previously healthy patients (median age=19 months) and 165 (74%) were well appearing. The most common diagnoses were occult bacteraemia [60 (26.9%)] and sepsis [56 (25.1%)]. The most frequent pathogens were Streptococcus pneumoniae [68 (30.5%)] and Neisseria meningitidis [42 (18.8%)]. Four (1.8) patients died (S. pneumoniae, 2) and eight (3.5%) had sequelae (S. pneumoniae, 5). The diagnoses and clinical characteristics of the children varied significantly depending on the isolated pathogen. Duration of fever less than 24 h, symptoms other than fever and not being well-appearing upon arrival to the emergency department were independent risk factors for greater severity (area under the receiver operating characteristics curve=0.805; 95% confidence interval: 0.741-0.868).

CONCLUSION

IBIs are commonly diagnosed in previously healthy and well-appearing young children. S. pneumoniae was responsible for the majority of deaths or sequelae. Short duration of fever, symptoms other than fever and not being stable on arrival are associated with greater severity.

Clinical prediction models for young febrile infants at the emergency department: an international validation study

OBJECTIVE

To assess the diagnostic value of existing clinical prediction models (CPM; ie, statistically derived) in febrile young infants at risk for serious bacterial infections.

METHODS

A systematic literature review identified eight CPMs for predicting serious bacterial infections in febrile children. We validated these CPMs on four validation cohorts of febrile children in Spain (age <3 months), France (age <3 months) and two cohorts in the Netherlands (age 1-3 months and >3-12 months). We evaluated the performance of the CPMs by sensitivity/specificity, area under the receiver operating characteristic curve (AUC) and calibration studies.

RESULTS

The original cohorts in which the prediction rules were developed (derivation cohorts) ranged from 381 to 15 781 children, with a prevalence of serious bacterial infections varying from 0.8% to 27% and spanned an age range of 0-16 years. All CPMs originally performed moderately to very well (AUC 0.60-0.93). The four validation cohorts included 159-2204 febrile children, with a median age range of 1.8 (1.2-2.4) months for the three cohorts <3 months and 8.4 (6.0-9.6) months for the cohort >3-12 months of age. The prevalence of serious bacterial infections varied between 15.1% and 17.2% in the three cohorts <3 months and was 9.8% for the cohort >3-12 months of age. Although discriminative values varied greatly, best performance was observed for four CPMs including clinical signs and symptoms, urine dipstick analyses and laboratory markers with AUC ranging from 0.68 to 0.94 in the three cohorts <3 months (ranges sensitivity: 0.48-0.94 and specificity: 0.71-0.97). For the >3-12 months' cohort AUC ranges from 0.80 to 0.89 (ranges sensitivity: 0.70-0.82 and specificity: 0.78-0.90). In general, the specificities exceeded sensitivities in our cohorts, in contrast to derivation cohorts with high sensitivities, although this effect was stronger in infants <3 months than in infants >3-12 months.

CONCLUSION

We identified four CPMs, including clinical signs and symptoms, urine dipstick analysis and laboratory markers, which can aid clinicians in identifying serious bacterial infections. We suggest clinicians should use CPMs as an adjunctive clinical tool when assessing the risk of serious bacterial infections in febrile young infants.

[Construction of a diagnostic prediction model of severe bacterial infection in febrile infants under 3 months old]

INTRODUCTION

Fever is a common cause of paediatric admissions in emergency departments. An aetiological diagnosis is difficult to obtain in those less than 3 months of age, as they tend to have a higher rate of serious bacterial infection (SBI). The aim of this study is to find a predictor index of SBI in children under 3 months old with fever of unknown origin.

METHODS

A study was conducted on all children under 3 months of age with fever admitted to hospital, with additional tests being performed according to the clinical protocol. Rochester criteria for identifying febrile infants at low risk for SBI were also analysed. A predictive model for SBI and positive cultures was designed, including the following variables in the maximum model: C-reactive protein (CRP), procalcitonin (PCT), and meeting not less than four of the Rochester criteria.

RESULTS

A total of 702 subjects were included, of which 22.64% had an SBI and 20.65% had positive cultures. Children who had SBI and a positive culture showed higher values of white cells, total neutrophils, CRP and PCT. A statistical significance was observed with less than 4 Rochester criteria, CRP and PCT levels, an SBI (area under the curve [AUC] 0.877), or for positive cultures (AUC 0.888). Using regression analysis a predictive index was calculated for SBI or a positive culture, with a sensitivity of 87.7 and 91%, a specificity of 70.1 and 87.7%, an LR+ of 2.93 and 3.62, and a LR- of 0.17 and 0.10, respectively.

CONCLUSIONS

The predictive models are valid and slightly improve the validity of the Rochester criteria for positive culture in children less than 3 months admitted with fever.

Fever following immunization

Fever is a frequent systemic adverse event following immunization, especially in infants and young children. Any fever after immunization may be caused by immunization or may coincide temporally as an indication of underlying disease, usually an infectious one. The time pattern of fever attributable to immunization has characteristic features depending on the vaccine used. Comparability of fever rates associated with different vaccines, or the same vaccines in different studies, is frequently hampered by the use of different definitions and/or assessment techniques for fever. A recent analysis by the Brighton Collaboration has provided a standardized case definition for fever, the use of which should be strongly encouraged.

Analgésicos, antipiréticos e anti-inflamatórios não esteroides em prescrições pediátricas

O uso de analgésicos, antipiréticos e anti-inflamatórios não esteroides por crianças muitas vezes não tem aprovação das agências reguladoras, nem respaldo das evidências científicas. Prescrições pediátricas podem ser influenciadas por fatores que não favorecem o uso racional dos medicamentos desta classe. O objetivo deste trabalho foi avaliar a utilização de analgésicos, antipiréticos e anti-inflamatórios não esteroides em crianças, considerando os setores público (SUS) e privado (N-SUS). A amostra foi composta por 150 prescrições (101 SUS e 49 N-SUS) seguidas de entrevista aos cuidadores, em dezoito locais (nove drogarias privadas e nove Unidades de Saúde do SUS). Os medicamentos foram prescritos de forma apropriada, segundo faixa etária, somente em 21,8% (SUS) e 29,6% (N-SUS) das prescrições. Mais de 95% das receitas, independente da origem, não atenderam aos critérios estabelecidos para avaliação do uso racional, com erros de dose, frequência e duração do tratamento. A análise das prescrições de analgésicos, antipiréticos e anti-inflamatórios não esteroides para crianças não apresentou diferenças significantes nos setores público e privado.

A Cross-Sectional Study on Reference Ranges of Normal Oral Temperatures Among Students in Singapore

Introduction: During the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak, all schools in Singapore implemented twice-daily temperature monitoring for students to curtail the spread of the disease. Students were not allowed to attend school if their temperature readings were >37.8oC for students ≤12 years old, or ≥37.5oC for students >12 years old. These values had been arbitrarily determined with professional inputs. The aim of this study is to determine the reference ranges of normal oral temperatures of students in Singapore and recommend the cut-off values for febrile patients. This may be used in another similar outbreak of an infectious disease with fever. Materials and Methods: Four co-ed primary schools and 4 co-ed secondary schools were selected for this study. Four thousand and two hundred primary 1 to secondary 3 students responded (96.8%) and participated in this cross-sectional study. The mean ages of the students in the lowest (primary 1) and highest educational levels (secondary 3) were 7.4 years old and 15.3 years old, respectively. Twelve oral temperature readings per student (i.e. measurements taken 4 times a day in 3 consecutive days) were collected. Forty-six thousand seven hundred and eighty-three (92.8%) out of 50,400 temperature readings were used for the analysis as missing data were excluded. A quantile regression model was applied to estimate reference ranges of normal oral temperatures for students with adjustment for potential confounding factors. Results: The age-specific reference ranges of normal oral temperature from this study for students ≤12 years old and >12 years old were 35.7oC to 37.7oC and 35.6oC to 37.4oC, respectively. Temperatures of 37.8oC and 37.5oC are therefore recommended as the oral temperature cut-offs for those ≤12 years old and >12 years old, respectively. Conclusion: This study has provided empirical data on normal oral temperature cut-offs which could be used during temperature screening in schools. Key words: Cut-offs, Infectious diseases, SARS

Randomized trial of a clinical decision support system: impact on the management of children with fever without apparent source

OBJECTIVE

To assess compliance with a clinical decision support system (CDSS) for diagnostic management of children with fever without apparent source and to study the effects of application of the CDSS on time spent in the emergency department (ED) and number of laboratory tests.

DESIGN

The CDSS was used by ED nursing staff to register children presenting with fever. The CDSS identified children that met inclusion criteria (1-36 months and fever without apparent source (FWS)) and provided patient-specific diagnostic management advice. Children at high risk for serious bacterial infection were randomized for the 'intervention' (n = 74) or the 'control' (n = 90) group. In the intervention group, the CDSS provided the advice to immediately order laboratory tests and in the control group the ED physician first assessed the children and then decided on ordering laboratory tests.

RESULTS

Compliance with registration of febrile children was 50% (683/1,399). Adherence to the advice to order laboratory tests was 82% (61/74). Children in the intervention group had a median (25(th)-75(th) percentile) length of stay at the ED of 138 (104-181) minutes. The median length of stay at the ED in the control group was 123 (83-179) minutes. Laboratory tests were significantly more frequently ordered in the intervention group (82%) than in the control group (44%, p < 0.001, chi(2) test).

CONCLUSION

Implementation of a CDSS for diagnostic management of young children with fever without apparent source was successful regarding compliance and adherence to CDSS recommendations, but had unexpected effects on patient outcome in terms of ED length of stay and number of laboratory tests. The use of the current CDSS was discontinued.

Validating and updating a prediction rule for serious bacterial infection in patients with fever without source

AIM

To externally validate and update a previously developed rule for predicting the presence of serious bacterial infections in children with fever without apparent source.

METHODS

Patients, 1-36 mo, presenting with fever without source, were prospectively enrolled. Serious bacterial infection included bacterial meningitis, sepsis, bacteraemia, pneumonia, urinary tract infection, bacterial gastroenteritis, osteomyelitis/ethmoiditis. The generalizability of the original rule was determined. Subsequently, the prediction rule was updated using all available data of the patients with fever without source (1996-1998 and 2000-2001, n = 381) using multivariable logistic regression.

RESULTS

the generalizability of the rule appeared insufficient in the new patients (n = 150). In the updated rule, independent predictors from history and examination were duration of fever, vomiting, ill clinical appearance, chest-wall retractions and poor peripheral circulation (ROC area (95%CI): 0.69 (0.63-0.75)). Additional independent predictors from laboratory were serum white blood cell count and C-reactive protein, and in urinalysis > or = 70 white bloods (ROC area (95%CI): 0.83 (0.78-0.88).

CONCLUSIONS

A previously developed prediction rule for predicting the presence of serious bacterial infection in children with fever without apparent source was updated. Its clinical score can be used as a first screening tool. Additional laboratory testing may specify the individual risk estimate (range: 4-54%) further.

[Factors predicting serious bacterial infections in febrile infants less than three months old: multivariate analysis]

AIM

To identify predictive factors of the presence of a serious bacterial infection (SBI) in febrile infants less than three months old.

METHODS

Retrospective analysis of the medical files of 315 consecutive consultations of febrile infants less than three months old in the pediatric emergency department of a French hospital, with logistic regression multivariate analysis of the different criteria routinely considered and C-reactive protein (CRP).

RESULTS

SBI were diagnosed in 79 (25.1%) infants, primarily urinary tract infections (71; 22.5%). One of these 79 children had pneumococcal meningitis but met the classical criteria for low risk of SBI: he died because antibiotics were not prescribed sufficiently early. Factors significantly associated with SBI were: male sex; temperature >38.5 degrees C and lasting >24 hours; poor general condition; absence of ear, nose and throat symptoms; high white blood cell count with >50% neutrophils; and serum CRP concentration >20 mg/l. Multivariate analysis entering all these items retained only the latter two (respectively, OR: 13.5, 95% CI: [6.5-28.2] and OR: 2.9; 95% CI: [1.3-6.3]). CRP <20 mg/l and <50% neutrophils had a negative-predictive value of 93.1% for the absence of SBI.

CONCLUSIONS

At present, no factor(s) is(are) able to predict with 100% accuracy the absence of SBI in febrile infants less than three months old. The risk of severe sequelae or death caused by untreated SBI would seem to justify the prescription of antibiotics until microbacterial culture results become available.

How antibiotics can make us sick: the less obvious adverse effects of antimicrobial chemotherapy

Antimicrobial agents are associated with side-effects, which are usually tolerated because the benefits of treatment outweigh the toxic effects. Clinicians know about these side-effects but are less likely to understand additional adverse events, such as the overgrowth of resistant microorganisms. Overgrowth can itself precipitate a secondary infection, which can be more difficult to treat. Resistant organisms then spread to other patients and the environment, and contribute to increasing antimicrobial resistance worldwide. Organisms exposed to antibiotics undergo molecular changes that might enhance virulence. Enhanced pathogenicity would affect patients, particularly if the organism is also multiply resistant. Clinicians have a responsibility to select the correct antibiotic as soon as they have diagnosed infection, but an absence of microbiological understanding and ignorance of the potential environmental effects have contributed to inappropriate prescribing. The less obvious results of antimicrobial consumption probably go unrecognised in routine clinical care.