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do Valle DA, Costa LCV, Fregonese AP, da Silva DHL, Maldonado GKS, da Silva LTT, Couto MDS. Characteristics and Risk Factors of Central Nervous System Infection in Children With Febrile Seizures. Pediatr Emerg Care 2024; 40:438-442. [PMID: 38478927 DOI: 10.1097/pec.0000000000003158] [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] [Indexed: 06/01/2024]
Abstract
OBJECTIVE The aim of the present study is to evaluate the necessity of performing lumbar puncture in patients experiencing febrile seizures, considering the epidemiology specific to Brazil. METHODS A retrospective cross-sectional study was performed from January 2017 to December 2021. RESULTS A total of 469 children with seizure and fever were analyzed. The identified event was the first in 65.9% (n = 309). A total of 54.2% (n = 254) of patients had a simple febrile seizure. Infectious focus, excluding previous central nervous system (CNS) infection, was identified in 35.6% (n = 167) patients. Meningitis was identified in 7.7% (n = 36) patients, all of them were viral. Patients with CNS infection had a higher frequency of symptoms such as nausea and vomiting, drowsiness, headache, and higher level of leukocytosis. A longer duration of fever was found to be more strongly associated with CNS infection. CONCLUSIONS When considering the use of lumbar puncture in febrile seizure, it is important to conduct a comprehensive evaluation that considers multiple factors, including clinical signs, symptoms, and the overall clinical context. Meningeal signs may be less prominent, and other symptoms such as lethargy, irritability, and vomiting may serve as more reliable indicators. Although clinical examination suggestive of meningitis remains an important factor, the recurrence of febrile seizures and a longer length of fever can provide additional insights and aid in decision-making regarding lumbar puncture.
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Stevens JP, Lively A, Jerris R, Yildirim I, Lantis P. Recognition and Outcomes of Pneumococcal Meningitis in 2 Tertiary Pediatric Hospitals Since the Introduction of the 13-Valent Pneumococcal Conjugate Vaccine. Pediatr Emerg Care 2022; 38:e354-e359. [PMID: 33181795 DOI: 10.1097/pec.0000000000002288] [Citation(s) in RCA: 2] [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 The aims of the study were to analyze the demographics, presentation, laboratory findings, and complications of pediatric Streptococcus pneumoniae meningitis since the introduction of the 13-valent pneumococcal conjugate vaccine, to improve recognition, and to minimize patient morbidity and mortality. METHODS This study used a retrospective analysis of pediatric pneumococcal meningitis cases at 2 tertiary healthcare systems in the Southeastern United States from 2010 to 2018. RESULTS We describe 21 cases of pneumococcal meningitis. All patients presented with fever, 95% had altered mental status by history or examination, and 48% had meningeal signs. Forty-three percent had seen another provider within 48 hours of admission. Forty-eight percent had delay in lumbar puncture (LP) of more than 6 hours after antibiotic administration, decreasing rates of positive cerebrospinal fluid cultures from 100% to 40% (P < 0.001). Decision to delay LP was due to either low suspicion for meningitis (n = 4) or clinical instability (n = 6) and was associated with lower rates of meningeal signs (P = 0.014) and higher rates of altered mental status on examination (P = 0.031). Fourteen patients (67%) were up-to-date on pneumococcal immunization. Serotypes were determined in 16 cases, with 2 patients (13%) immunized against the strain that infected them. Primary outcomes included seizures (48%), hearing loss (48%), cranial nerve palsy (33%), and death (5%). Delay in LP with low suspicion for meningitis was associated with longer hospital length of stay approaching statistical significance (P = 0.053). CONCLUSIONS Pneumococcal meningitis remains a relevant and potentially fatal disease despite widespread use of 13-valent pneumococcal conjugate vaccine. Its diagnosis is often delayed during interactions with physicians, which may put patients at increased risk for poor clinical outcomes.
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Alnomasy SF, Alotaibi BS, Mujamammi AH, Hassan EA, Ali ME. Microbial aspects and potential markers for differentiation between bacterial and viral meningitis among adult patients. PLoS One 2021; 16:e0251518. [PMID: 34115780 PMCID: PMC8195399 DOI: 10.1371/journal.pone.0251518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 04/28/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES Meningitis is a medical emergency with permanent disabilities and high mortality worldwide. We aimed to determine causative microorganisms and potential markers for differentiation between bacterial and viral meningitis. METHODOLOGY Adult patients with acute meningitis were subjected to lumber puncture. Cerebrospinal fluid (CSF) microorganisms were identified using Real-time PCR. PCT and CRP levels, peripheral and CSF-leucocyte count, CSF-protein and CSF-glucose levels were assessed. RESULTS Out of 80 patients, infectious meningitis was confirmed in 75 cases; 38 cases were bacterial meningitis, 34 cases were viral meningitis and three cases were mixed infection. Higher PCT, peripheral and CSF-leukocytosis, higher CSF-protein and lower CSF-glucose levels were more significant in bacterial than viral meningitis patients. Neisseria meningitides was the most frequent bacteria and varicella-zoster virus was the most common virus. Using ROC analyses, serum PCT and CSF-parameters can discriminate bacterial from viral meningitis. Combined ROC analyses of PCT and CSF-protein significantly improved the effectiveness in predicting bacterial meningitis (AUC of 0.998, 100%sensitivity and 97.1%specificity) than each parameter alone (AUC of 0.951 for PCT and 0.996 for CSF-protein). CONCLUSION CSF-protein and serum PCT are considered as potential markers for differentiating bacterial from viral meningitis and their combination improved their predictive accuracy to bacterial meningitis.
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Affiliation(s)
- Sultan F. Alnomasy
- Department of Medical Laboratories Sciences, College of Applied Medical Sciences in Al- Quwayiyah, Shaqra University, Al- Quwayiyah, Riyadh, Saudi Arabia
| | - Bader S. Alotaibi
- Department of Medical Laboratories Sciences, College of Applied Medical Sciences in Al- Quwayiyah, Shaqra University, Al- Quwayiyah, Riyadh, Saudi Arabia
| | - Ahmed H. Mujamammi
- Department of Pathology, Clinical Biochemistry Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Elham A. Hassan
- Department of Gastroenterology and Tropical Medicine, Faculty of Medicine Assiut University, Assiut, Egypt
| | - Mohamed E. Ali
- Department of Microbiology and Immunology, Faculty of Pharmacy, Al-Azhar University, Assiut, Egypt
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Iio K, Ogawa Y, Ihara T, Horikoshi Y, Hataya H. Nuchal Rigidity in Infantile Bacterial Meningitis. J Pediatr 2019; 207:255. [PMID: 30384970 DOI: 10.1016/j.jpeds.2018.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/03/2018] [Accepted: 10/05/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Kazuki Iio
- Department of General Pediatrics Tokyo Metropolitan Children's Medical Center Tokyo, Japan
| | - Yuichi Ogawa
- Department of General Pediatrics Tokyo Metropolitan Children's Medical Center Tokyo, Japan
| | - Takateru Ihara
- Division of Pediatric Emergency Medicine Tokyo Metropolitan Children's Medical Center Tokyo, Japan
| | - Yuho Horikoshi
- Division of Infectious Diseases Tokyo Metropolitan Children's Medical Center Tokyo, Japan
| | - Hiroshi Hataya
- Department of General Pediatrics Tokyo Metropolitan Children's Medical Center Tokyo, Japan
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When the grass isn’t greener: a case series of young children with accidental marijuana ingestion. CAN J EMERG MED 2015; 18:480-483. [DOI: 10.1017/cem.2015.44] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractMarijuana is the most commonly used illicit drug in Canada, with 10% of the general population admitting to its use in the past year. This high prevalence increases risk of accidental ingestion in young children.We report four pediatric cases of accidental marijuana ingestion who presented to our local emergency department with altered mental status. Three patients had extensive testing, including one patient who underwent lumbar puncture and empirical treatment for meningitis. To our knowledge, this is the first Canadian case series since McNabb et al., published over 2 decades ago.The case series aims to highlight the importance of considering acute marijuana intoxication in the differential diagnosis when assessing young children with altered level of consciousness.
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Águeda S, Campos T, Maia A. Prediction of bacterial meningitis based on cerebrospinal fluid pleocytosis in children. Braz J Infect Dis 2013; 17:401-4. [PMID: 23602468 PMCID: PMC9428050 DOI: 10.1016/j.bjid.2012.12.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 12/10/2012] [Indexed: 10/26/2022] Open
Abstract
Children with cerebrospinal fluid pleocytosis are frequently treated with parenteral antibiotics, but only a few have bacterial meningitis. Although some clinical prediction rules, such as bacterial meningitis score, are of well-known value, the cerebrospinal fluid white blood cells count can be the initial available information. Our aim was to establish a cutoff point of cerebrospinal fluid white blood cell count that could distinguish bacterial from viral and aseptic meningitis. A retrospective study of children aged 29 days to 17 years who were admitted between January 1st and December 31th, 2009, with cerebrospinal fluid pleocytosis (white blood cell≥7μL(-1)) was conducted. The cases of traumatic lumbar puncture and of antibiotic treatment before lumbar puncture were excluded. There were 295 patients with cerebrospinal fluid pleocytosis, 60.3% females, medium age 5.0±4.3 years distributed as: 12.2% 1-3 months; 10.5% 3-12 months; 29.8% 12 months to 5 years; 47.5% >5 years. Thirty one children (10.5%) were diagnosed with bacterial meningitis, 156 (52.9%) viral meningitis and 108 (36.6%) aseptic meningitis. Bacterial meningitis was caused by Neisseria meningitidis (48.4%), Streptococcus pneumoniae (32.3%), other Streptococcus species (9.7%), and other agents (9.7%). cerebrospinal fluid white blood cell count was significantly higher in patients with bacterial meningitis (mean, 4839cells/μL) compared to patients with aseptic meningitis (mean, 159cells/μL, p<0.001), with those with aseptic meningitis (mean, 577cells/μL, p<0.001) and with all non-bacterial meningitis cases together (p<0.001). A cutoff value of 321white blood cell/μL showed the best combination of sensitivity (80.6%) and specificity (81.4%) for the diagnosis of bacterial meningitis (area under receiver operating characteristic curve 0.837). Therefore, the value of cerebrospinal fluid white blood cell count was found to be a useful and rapid diagnostic test to distinguish between bacterial and nonbacterial meningitis in children.
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Affiliation(s)
- Sofia Águeda
- Department of Pediatrics, Centro Hospitalar São João, EPE, Porto, Portugal.
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Türel O, Yıldırım C, Yılmaz Y, Külekçi S, Akdaş F, Bakır M. Clinical characteristics and prognostic factors in childhood bacterial meningitis: a multicenter study. Balkan Med J 2013; 30:80-4. [PMID: 25207074 DOI: 10.5152/balkanmedj.2012.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Accepted: 09/25/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate clinical features and sequela in children with acute bacterial meningitis (ABM). STUDY DESIGN Multicenter retrospective study. MATERIAL AND METHODS Study includes retrospective chart review of children hospitalised with ABM at 11 hospitals in İstanbul during 2005. Follow up visits were conducted for neurologic examination, hearing evaluation and neurodevelopmental tests. RESULTS Two hundred and eighty three children were included in the study. Median age was 12 months and 68.6% of patients were male. Almost all patients had fever at presentation (97%). Patients younger than 6 months tended to present with feeding difficulties (84%), while patients older than 24 months were more likely to present with vomitting (93%) and meningeal signs (84%). Seizures were present in 65 (23%) patients. 26% of patients were determined to have at least one major sequela. The most common sequelae were speech or language problems (14.5%). 6 patients were severely disabled because of meningitis. Presence of focal neurologic signs at presentation and turbid cerebrospinal fluid appearance increased sequelae significantly. Childen under 24 months of age developed neurologic sequelae more commonly than older children. CONCLUSION Symptoms and signs were largely depending on the age of the patient. Speech or language problems were the most common sequelae following meningitis.
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Affiliation(s)
- Ozden Türel
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Canan Yıldırım
- Department of Pediatrics, Section of Pediatric Neurology, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Yüksel Yılmaz
- Department of Pediatrics, Section of Pediatric Neurology, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Sezer Külekçi
- Department of Audiology, Faculty of Medicine, Marmara University, İstanbul, Turkey İstanbul, Turkey
| | - Ferda Akdaş
- Department of Audiology, Faculty of Medicine, Marmara University, İstanbul, Turkey İstanbul, Turkey
| | - Mustafa Bakır
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Faculty of Medicine, Marmara University, İstanbul, Turkey
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Abstract
BACKGROUND The diagnostic accuracy of the classic symptoms and signs of meningitis in infants and children has not been established. METHODS All children aged 2 months to 16 years with clinically suspected meningitis were eligible for this prospective cohort study at 2 large medical centers between February 2006 and October 2007. Exclusion criteria were severe chronic disease, severe immune deficiency, or idiopathic intracranial hypertension. The emergency department physician obtained information on clinical symptoms and signs and cerebrospinal fluid analysis. Meningitis was defined as white blood cell count of 6 or higher per microliter of cerebrospinal fluid. RESULTS A total of 108 patients with suspected meningitis were enrolled. Meningitis was diagnosed in 58 patients (53.7%; 6 bacterial and 52 aseptic). Sensitivity and specificity were 76% and 53% for headache (among the verbal patients) and 71% and 62% for vomiting, respectively. Photophobia was highly specific (88%) but had low sensitivity (28%). Clinical examination revealed nuchal rigidity (in patients without open fontanel) in 32 (65%) of the patients with meningitis and in 10 (33%) of the patients without meningitis. Brudzinski and Kernig signs were present in 51% and 27% of the patients with meningitis, respectively, and had relatively high positive predictive values (81% and 77%, respectively). Bulging fontanel in patients with open fontanel was present in 50% of the patients with meningitis but had a positive predictive value of only 38%. CONCLUSIONS Classic clinical diagnostic signs have limited value in establishing the diagnosis of meningitis in children and should not be the sole determinants for referral to further diagnostic testing and lumbar puncture.
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Abstract
Bacterial meningitis continues to be an important cause of mortality and morbidity in neonates and children throughout the world. The introduction of the protein conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has changed the epidemiology of bacterial meningitis. Suspected bacterial meningitis is a medical emergency and needs empirical antimicrobial treatment without delay, but recognition of pathogens with increasing resistance to antimicrobial drugs is an important factor in the selection of empirical antimicrobial regimens. At present, strategies to prevent and treat bacterial meningitis are compromised by incomplete understanding of the pathogenesis. Further research on meningitis pathogenesis is thus needed. This Review summarises information on the epidemiology, pathogenesis, new diagnostic methods, empirical antimicrobial regimens, and adjunctive treatment of acute bacterial meningitis in infants and children.
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Affiliation(s)
- Kwang Sik Kim
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Ward MA, Greenwood TM, Kumar DR, Mazza JJ, Yale SH. Josef Brudzinski and Vladimir Mikhailovich Kernig: signs for diagnosing meningitis. Clin Med Res 2010; 8:13-7. [PMID: 20305144 PMCID: PMC2842389 DOI: 10.3121/cmr.2010.862] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Michael A. Ward
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Tonia M. Greenwood
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David R. Kumar
- Clinical Research Center, Marshfield Clinic Research Foundation, Marshfield Wisconsin
| | - Joseph J. Mazza
- Clinical Research Center, Marshfield Clinic Research Foundation, Marshfield Wisconsin
| | - Steven H. Yale
- Clinical Research Center, Marshfield Clinic Research Foundation, Marshfield Wisconsin
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Cerebrospinal fluid pleocytosis in children in the era of bacterial conjugate vaccines: distinguishing the child with bacterial and aseptic meningitis. Pediatr Emerg Care 2009; 25:112-7; quiz 118-20. [PMID: 19225382 DOI: 10.1097/pec.0b013e318196faeb] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although bacterial meningitis remains an important cause of childhood morbidity and mortality, the incidence of bacterial meningitis has greatly decreased with the advent of polysaccharide-protein conjugate vaccines in the past 2 decades. Most children with cerebrospinal fluid pleocytosis have aseptic rather than bacterial meningitis, raising the possibility that some patients may be managed as outpatients. In this article, we review the changing epidemiology of bacterial meningitis as well as the available clinical decision rules that may assist the clinician in distinguishing aseptic from bacterial meningitis in patients with cerebrospinal fluid pleocytosis.
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Krasnianski M, Tacik P, Müller T, Zierz S. Attenuation of Kernig's sign by concomitant hemiparesis: forgotten aspects of a well known clinical test. J Neurol Neurosurg Psychiatry 2007; 78:1413-4. [PMID: 18024700 PMCID: PMC2095623 DOI: 10.1136/jnnp.2007.127837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Faustini A, Fano V, Muscillo M, Zaniratti S, La Rosa G, Tribuzi L, Perucci CA. An outbreak of aseptic meningitis due to echovirus 30 associated with attending school and swimming in pools. Int J Infect Dis 2006; 10:291-7. [PMID: 16458563 DOI: 10.1016/j.ijid.2005.06.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2004] [Revised: 06/13/2005] [Accepted: 06/14/2005] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To identify the risk factors of an outbreak of meningitis associated with echovirus 30-infection that occurred in Rome, Italy, in late 1997 among children from two different schools. METHODS A case-control study was carried out. A case was defined as a child from either of the two schools, A or B, who presented meningitis-like (fever, headache and vomiting), diarrhea, or respiratory tract symptoms. All asymptomatic students were included in the analysis as controls. RESULTS Among 446 pupils (80%) who answered the questionnaire, 68 met the case definition. Twenty pupils developed a meningitis-like illness. Echovirus 30 was isolated from cerebrospinal fluid (CSF) in four and from stools in six. Forty-eight pupils reported other symptoms. The attack rate was 10.8% in school A and 0.8% in school B for meningitis-like illness; it was 12% and 10%, respectively, for other enterovirus-like illnesses. The risk of meningitis-like illness was higher among children attending school A (crude OR = 14.9; 95% CI = 4.3-52.1), among children using any public pool (OR = 3.8; 95% CI = 1.5-9.9) and those using an outside swimming pool X (OR=13.4; 95% CI=2.7-65.8 versus no swimming pool and OR = 8.3; 95% CI = 1.1-62.6 versus other pools). The epidemic curve appears to suggest a person-to-person transmission. CONCLUSIONS The epidemic occurred by person-to-person transmission in a number of classrooms and at swimming pool X.
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Affiliation(s)
- Annunziata Faustini
- Department of Epidemiology, Local Health Agency RME, v. S. Costanza No. 53, 00198 Rome, Italy.
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Oostenbrink R, Moons KGM, Bleeker SE, Moll HA, Grobbee DE. Diagnostic research on routine care data: prospects and problems. J Clin Epidemiol 2003; 56:501-6. [PMID: 12873643 DOI: 10.1016/s0895-4356(03)00080-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A diagnosis in practice is a sequential process starting with a patient with a particular set of signs and symptoms. To serve practice, diagnostic research should aim to quantify the added value of a test to clinical information that is commonly available before the test will be applied. Routine care databases commonly include all documented patient information, and therefore seem to be suitable to quantify a tests' added value to prior information. It is well known, however, that retrospective use of routine care data in diagnostic research may cause various methodologic problems. But, given the increased attention of electronic patient records including data from routine patient care, we believe it is time to reconsider these problems. We discuss four problems related to routine care databases. First, most databases do not label patients by their symptoms or signs but by their final diagnosis. Second, in routine care the diagnostic workup of a patient is by definition determined by previous diagnostic (test) results. Therefore, routinely documented data are subject to so-called workup bias. Third, in practice, the reference test is always interpreted with knowledge of the preceding test information, such that in scientific studies using routine data the diagnostic value of a test under evaluation is commonly overestimated. Fourth, routinely documented databases are likely to suffer from missing data. Per problem we discuss methods that are presently available and may (partly) overcome each problem. All this could contribute to more frequent and appropriate use of routine care data in diagnostic research. The discussed methods to overcome the above problems may well be similarly useful to prospective diagnostic studies.
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Affiliation(s)
- Rianne Oostenbrink
- Erasmus MC Rotterdam, Sophia Children's Hospital, Outpatient Department of Pediatrics, Dr. Molewaterplein 60, Room Sh 2015, Rotterdam 3015 GJ, The Netherlands.
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Badger MJ, Lookinland S, Tiedeman M, Anderson V, Eggett D. Nurse practitioners' treatment of febrile infants in Utah: comparison to physician practice nationally. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2002; 14:540-53. [PMID: 12567922 DOI: 10.1111/j.1745-7599.2002.tb00088.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine nurse practitioners' (NPs') knowledge of published guidelines involving the treatment of infants with fever without a source and to compare the practice of NPs in Utah to physicians nationally. DATA SOURCES Using a comparative descriptive design, a survey was sent to 450 NPs in Utah replicating the methodology of a 1998 survey of physicians. The NPs were asked about their evaluation decisions and management strategies for various ages of infants/toddlers with fever without a source. CONCLUSIONS The practice decisions of NPs in Utah and physicians nationally were similar. Family NPs' clinical decisions aligned more closely with family practice medical doctors and pediatric NPs' with pediatricians. Overall, the younger the patient, the more likely were NPs to order labs and antibiotics or to hospitalize/refer to a physician. The fact that management decisions were not based upon existing protocols may account for the practice variation seen among NPs. IMPLICATIONS FOR PRACTICE Management of a febrile infant is a common clinical scenario for the primary care provider. Although evidence-based protocols exist, the treatment of febrile infants remains controversial. Overall, NPs' evaluation and management of these infants were not shown to differ from physicians. Further studies are needed to determine why clinical guidelines are not being followed.
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Maria Mòdol J, Tudela P, Veny A, Carles Sahuquillo J, Tor J, Giménez M. Indicaciones y rendimiento diagnóstico de la punción lumbar en urgencias. Med Clin (Barc) 2002. [DOI: 10.1016/s0025-7753(02)72267-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Trainor JL, Hampers LC, Krug SE, Listernick R. Children with first-time simple febrile seizures are at low risk of serious bacterial illness. Acad Emerg Med 2001; 8:781-7. [PMID: 11483452 DOI: 10.1111/j.1553-2712.2001.tb00207.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the rates of serious bacterial illness (SBI) in children presenting to emergency departments (EDs) with first-time uncomplicated febrile seizures. METHODS The ED visits from seven Chicago metropolitan area hospitals (two tertiary pediatric EDs, five community general EDs) for all pediatric patients seen between July 1995 and December 1997 with a discharge diagnosis including the term "seizure" were retrospectively identified. Records of patients who met criteria for simple, first-time febrile seizure were reviewed (age 6-60 months; temperature > or =38.0 degrees C; single, generalized, tonic-clonic seizure <20 minutes; absence of known central nervous system disease). Rates of bacteremia, urinary tract infection, bacterial meningitis, and pneumonia were determined. RESULTS Four hundred fifty-five children were identified who had first-time simple febrile seizures. The study participants had a mean age of 21 months and a mean temperature of 39.6 degrees C, and 64% were male. Seventy-three percent were seen in a community hospital setting. Blood cultures were obtained for 315 children (69%). Four children (1.3% [95% CI = 0.1% to 2.5%]) were bacteremic, all with Streptococcus pneumoniae; the rate of bacteremia did not differ in the subset at highest risk for bacteremia (6-36 months, temperature >39 degrees C). No demographic or laboratory data distinguished the bacteremic children from those with negative blood cultures. One hundred seventy-one children (38%) had urine cultures obtained; 5.9% [95% CI = 2.4% to 9.4%] of the cultures grew >100,000 colony-forming units/mL of a single pathogenic organism. One hundred thirty-five children (30%) had cerebrospinal fluid cultures performed. None of these cultures grew a bacterial pathogen [95% CI = 0% to 2.2%]. Two hundred eight children (45.7%) had chest x-rays performed; 12.5% [95% CI = 10.2% to 14.8%] (n = 26) of the x-rays were read as consistent with pneumonia by the radiologist at the treating institution. None of the blood cultures performed on children with abnormal radiographs were positive (cultures drawn on 23 of 26 patients, 88%). Stool cultures were performed on 14 children (3.1%); two cultures (14.3% [95% CI = 0% to 32.6%]) grew a bacterial pathogen, both Shigella. CONCLUSIONS Rates of SBI in this multi-institution population of children with first-time simple febrile seizures were low and are consistent with those published in the literature for febrile children without seizures.
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Affiliation(s)
- J L Trainor
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Memorial Hospital, Northwestern University Medical School, Chicago, IL 60614, USA.
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Oostenbrink R, Moons KG, Theunissen CC, Derksen-Lubsen G, Grobbee DE, Moll HA. Signs of meningeal irritation at the emergency department: how often bacterial meningitis? Pediatr Emerg Care 2001; 17:161-4. [PMID: 11437138 DOI: 10.1097/00006565-200106000-00003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although signs of meningeal irritation are highly indicative of meningitis, they are not pathognomonic. In this study, we described the final diagnoses in children with signs of meningeal irritation, and we assessed the frequency of bacterial meningitis related to specific signs of meningeal irritation. METHODS Information was collected from records of 326 patients (aged 1 month to 15 years) who visited the emergency department of the Sophia Children's Hospital between 1988 and 1998 with signs of meningeal irritation, assessed by either the general practitioner or the pediatrician. RESULTS Bacterial meningitis was diagnosed in 99 patients (30%), viral or aseptic meningitis in 43 (13%). Other diagnoses were pneumonia (8%), other serious bacterial infections (2%), and upper respiratory tract infections or other self-limiting diseases (46 %). Presence of one of the signs of meningeal irritation assessed by the pediatrician was related to bacterial meningitis in 39%. Specific tests eliciting meningeal irritation, such as Brudzinski's and Kernig's signs, were not related to a higher frequency of bacterial meningitis than neck stiffness and the tripod phenomenon. In children < or =1 year, bacterial meningitis is more frequently related to presence of irritability and a bulging fontanel. CONCLUSION Bacterial meningitis is present in 30% of children with signs of meningeal irritation. Presence of meningeal irritation as assessed by the pediatrician is related to bacterial meningitis in 39%. A better prediction of bacterial meningitis was not achieved by using more specific tests for signs of meningeal irritation.
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MESH Headings
- Adolescent
- Child
- Child, Preschool
- Emergency Service, Hospital/statistics & numerical data
- Female
- Hospitals, Pediatric
- Humans
- Infant
- Male
- Meningism/etiology
- Meningitis, Aseptic/diagnosis
- Meningitis, Aseptic/epidemiology
- Meningitis, Bacterial/diagnosis
- Meningitis, Bacterial/epidemiology
- Meningitis, Bacterial/etiology
- Meningitis, Viral/diagnosis
- Meningitis, Viral/epidemiology
- Netherlands/epidemiology
- Respiratory Tract Infections/complications
- Respiratory Tract Infections/diagnosis
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Affiliation(s)
- R Oostenbrink
- Department of Pediatrics, Sophia Children's Hospital, Rotterdam, The Netherlands.
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Slater M, Krug SE. Evaluation of the infant with fever without source: an evidence based approach. Emerg Med Clin North Am 1999; 17:97-126, viii-ix. [PMID: 10101343 DOI: 10.1016/s0733-8627(05)70049-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The infant with fever without an obvious source upon physical examination offers a challenging clinical problem. A combination of detailed history, physical examination, and selected laboratory tests allows the clinician to discern which infants are at lower risk for bacterial illness. Implications for management and future research are discussed herein.
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Affiliation(s)
- M Slater
- Division of Emergency Medicine, Northwestern University Medical School, Chicago, Illinois, USA
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Lipton JD, Schafermeyer RW. Evolving concepts in pediatric bacterial meningitis--Part I: Pathophysiology and diagnosis. Ann Emerg Med 1993; 22:1602-15. [PMID: 8214845 DOI: 10.1016/s0196-0644(05)81268-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- J D Lipton
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina
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25
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Abstract
This report emphasizes new clinical information about bacterial meningitis in infants and children. Important elements of diagnosis include examination for the presence of shock and increased intracranial pressure. In such cases, initial treatment should focus on appropriate fluid therapy, administration of oxygen, reduction of intracranial pressure and use of corticosteroids. Currently, antibiotics of choice include ampicillin plus either cefotaxime or ceftriaxone in young infants, and one of these cephalosporins in older patients (beyond 3 months of age). Shorter durations of therapy (5 to 7 days for meningococcus, 7 days for haemophilus and 7-10 days for pneumococcus) are now commonly employed. In many centers, dexamethasone is started before the first dose of antibiotic and continued for 4 days to reduce neurologic and audiologic sequelae. Future trends will include studies of endotoxin neutralizers and non-steroidal anti-inflammatory drugs to reduce further tissue injury in meningitis. Prevention of meningitis is the ultimate goal. Since Haemophilus influenzae vaccination can now begin at 2 months, this approach may bring important results soon.
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Affiliation(s)
- M I Marks
- Department of Pediatrics, University of California, Irvine
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Dave A. Diseases that mimic meningitis. Clin Pediatr (Phila) 1990; 29:485. [PMID: 2208911 DOI: 10.1177/000992289002900815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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