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Rajoo KP, Sutiman N, Shih S, Khoo ZX, Ong GYK, Wong L, Piragasam R, Ganapathy S, Chong SL. Delayed presentation is associated with serious bacterial infections among febrile infants: A prospective cohort study. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:286-292. [PMID: 38920220 DOI: 10.47102/annals-acadmedsg.2023350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Febrile young infants are at risk of serious bacterial infections (SBIs), which are potentially life-threatening. This study aims to investigate the association between delayed presentation and the risk of SBIs among febrile infants. Method We performed a prospective cohort study on febrile infants ≤90 days old presenting to a Singapore paediatric emergency department (ED) between November 2017 and July 2022. We defined delayed presentation as presentation to the ED >24 hours from fever onset. We compared the proportion of SBIs in infants who had delayed presentation compared to those without, and their clinical outcomes. We also performed a multivariable logistic regression to study if delayed presentation was independently associated with the presence of SBIs. Results Among 1911 febrile infants analysed, 198 infants (10%) had delayed presentation. Febrile infants with delayed presentation were more likely to have SBIs (28.8% versus [vs] 16.3%, P<0.001). A higher proportion of infants with delayed presentation required intravenous antibiotics (64.1% vs 51.9%, P=0.001). After adjusting for age, sex and severity index score, delayed presentation was independently associated with the presence of SBI (adjusted odds ratio [AOR] 1.78, 95% confidence interval 1.26-2.52, P<0.001). Conclusion Febrile infants with delayed presentation are at higher risk of SBI. Frontline clinicians should take this into account when assessing febrile infants.
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Affiliation(s)
- Karthigha Pon Rajoo
- Department of Children's Emergency, KK Women's and Children's Hospital, Singapore
| | - Natalia Sutiman
- Department of Children's Emergency, KK Women's and Children's Hospital, Singapore
| | - Stephanie Shih
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - Zi Xean Khoo
- Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
- SingHealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Gene Yong-Kwang Ong
- Department of Children's Emergency, KK Women's and Children's Hospital, Singapore
- SingHealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
- SingHealth-Duke NUS Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Lena Wong
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | - Rupini Piragasam
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | - Sashikumar Ganapathy
- Department of Children's Emergency, KK Women's and Children's Hospital, Singapore
- SingHealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
- SingHealth-Duke NUS Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Shu-Ling Chong
- Department of Children's Emergency, KK Women's and Children's Hospital, Singapore
- SingHealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
- SingHealth-Duke NUS Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore
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Chong SL, Niu C, Ong GYK, Piragasam R, Khoo ZX, Koh ZX, Guo D, Lee JH, Ong MEH, Liu N. Febrile infants risk score at triage (FIRST) for the early identification of serious bacterial infections. Sci Rep 2023; 13:15845. [PMID: 37740004 PMCID: PMC10516995 DOI: 10.1038/s41598-023-42854-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023] Open
Abstract
We aimed to derive the Febrile Infants Risk Score at Triage (FIRST) to quantify risk for serious bacterial infections (SBIs), defined as bacteremia, meningitis and urinary tract infections. We performed a prospective observational study on febrile infants < 3 months old at a tertiary hospital in Singapore between 2018 and 2021. We utilized machine learning and logistic regression to derive 2 models: FIRST, based on patient demographics, vital signs and history, and FIRST + , adding laboratory results to the same variables. SBIs were diagnosed in 224/1002 (22.4%) infants. Among 994 children with complete data, age (adjusted odds ratio [aOR] 1.01 95%CI 1.01-1.02, p < 0.001), high temperature (aOR 2.22 95%CI 1.69-2.91, p < 0.001), male sex (aOR 2.62 95%CI 1.86-3.70, p < 0.001) and fever of ≥ 2 days (aOR 1.79 95%CI 1.18-2.74, p = 0.007) were independently associated with SBIs. For FIRST + , abnormal urine leukocyte esterase (aOR 16.46 95%CI 10.00-27.11, p < 0.001) and procalcitonin (aOR 1.05 95%CI 1.01-1.09, p = 0.009) were further identified. A FIRST + threshold of ≥ 15% predicted risk had a sensitivity of 81.8% (95%CI 70.5-91.0%) and specificity of 65.6% (95%CI 57.8-72.7%). In the testing dataset, FIRST + had an area under receiver operating characteristic curve of 0.87 (95%CI 0.81-0.94). These scores can potentially guide triage and prioritization of febrile infants.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
- Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
| | - Chenglin Niu
- Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Rupini Piragasam
- KK Research Centre, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Zi Xean Khoo
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Department of Paediatrics, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital, 1 Hospital Crescent, Outram Road, Singapore, 169608, Singapore
| | - Dagang Guo
- Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, 1 Hospital Crescent, Outram Road, Singapore, 169608, Singapore
| | - Jan Hau Lee
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Marcus Eng Hock Ong
- Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, 1 Hospital Crescent, Outram Road, Singapore, 169608, Singapore
- Health Services Research Centre, Singapore Health Services, 8 College Road, Singapore, 169857, Singapore
| | - Nan Liu
- Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, 1 Hospital Crescent, Outram Road, Singapore, 169608, Singapore
- Health Services Research Centre, Singapore Health Services, 8 College Road, Singapore, 169857, Singapore
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Chong SL, Niu C, Piragasam R, Koh ZX, Guo D, Lee JH, Ong GYK, Ong MEH, Liu N. Adding heart rate n-variability (HRnV) to clinical assessment potentially improves prediction of serious bacterial infections in young febrile infants at the emergency department: a prospective observational study. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:6. [PMID: 36760240 PMCID: PMC9906196 DOI: 10.21037/atm-22-3303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022]
Abstract
Background We aim to investigate the utility of heart rate variability (HRV) and heart rate n-variability (HRnV) in addition to vital signs and blood biomarkers, among febrile young infants at risk of serious bacterial infections (SBIs). Methods We performed a prospective observational study between December 2017 and November 2021 in a tertiary paediatric emergency department (ED). We included febrile infants <90 days old with a temperature ≥38 ℃. We obtained HRV and HRnV parameters via a single lead electrocardiogram. HRV measures beat-to-beat (R-R) oscillation and reflects autonomic nervous system (ANS) regulation. HRnV includes overlapping and non-overlapping R-R intervals and provides additional physiological information. We defined SBIs as meningitis, bacteraemia and urinary tract infections (UTIs). We performed area under curve (AUC) analysis to assess predictive performance. Results We recruited 330 and analysed 312 infants. The median age was 35.5 days (interquartile range 13.0-61.0); 74/312 infants (23.7%) had SBIs with the most common being UTIs (66/72, 91.7%); 2 infants had co-infections. No patients died and 32/312 (10.3%) received fluid resuscitation. Adding HRV and HRnV to demographics and vital signs at ED triage successively improved the AUC from 0.765 [95% confidence interval (CI): 0.705-0.825] to 0.776 (95% CI: 0.718-0.835) and 0.807 (95% CI: 0.752-0.861) respectively. The final model including demographics, vital signs, HRV, HRnV and blood biomarkers had an AUC of 0.874 (95% CI: 0.828-0.921). Conclusions Addition of HRV and HRnV to current assessment tools improved the prediction of SBIs among febrile infants at ED triage. We intend to validate our findings and translate them into tools for clinical care in the ED.
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Affiliation(s)
- Shu-Ling Chong
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - Rupini Piragasam
- KK Research Centre, KK Women's and Children's Hospital, Singapore, Singapore
| | - Zhi Xiong Koh
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Dagang Guo
- Duke-NUS Medical School, Singapore, Singapore
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore, Singapore.,Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Gene Yong-Kwang Ong
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Nan Liu
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Health Services Research Centre, Singapore Health Services, Singapore, Singapore
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Tan VSR, Ong GYK, Lee KP, Ganapathy S, Chong SL. Correction: Pyrexia in a young infant - is height of fever associated with serious bacterial infection? BMC Pediatr 2022; 22:343. [PMID: 35705935 PMCID: PMC9199123 DOI: 10.1186/s12887-022-03374-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Victoria Shi Rui Tan
- Department of Paediatrics, KK Women's and Children's Hospital Singapore, 100, Bukit Timah Road, Singapore, 229899, Singapore.
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Sashikumar Ganapathy
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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