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Yun S, Cotton C, Faith EF, Jacobs L, Kittler N, Monir RL, Ravi M, Richmond A, Schoch J, Workman E, Zucker J, Hunt R, Lauren CT. Management of Pustules and Vesicles in Afebrile Infants ≤60 Days Evaluated by Dermatology. Pediatrics 2024; 154:e2023064364. [PMID: 38910522 DOI: 10.1542/peds.2023-064364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 06/25/2024] Open
Abstract
OBJECTIVES To assess the management and outcomes of afebrile infants who received a pediatric dermatology consultation for pustules and/or vesicles. METHODS Medical records were reviewed for all infants 60 days of age or younger who received a pediatric dermatology consult across 6 academic institutions between September 1, 2013 and August 31, 2019 to identify those infants with pustules and/or vesicles. RESULTS Of the 879 consults, 183 afebrile infants presented with pustules and/or vesicles. No cerebrospinal fluid cultures or blood cultures were positive for bacteria. No concordant positive urine cultures were identified in infants with cutaneous infection. Nine infants were diagnosed with herpes simplex virus (HSV). Five preterm infants were diagnosed with angioinvasive fungal infections. CONCLUSIONS No serious bacterial infections attributable to a skin source were identified, yet 53% of these infants received parenteral antibiotics. HSV was diagnosed in 7% of this cohort, 77.8% (7/9) of whom were term infants and 22.2% (2 of 9) of whom were preterm. Angioinvasive fungal infection was diagnosed in 3%, all of whom (100%, 5 of 5) were extremely preterm at <28 weeks gestational age. These findings suggest that in full-term afebrile infants ≤60 days, the likelihood of a life-threatening etiology of isolated pustules or vesicles is low once HSV infection is excluded. In preterm infants with pustules and/or vesicles, a high index of suspicion must be maintained, and broad infectious evaluation is recommended. HSV testing is recommended for all infants with vesicles, grouped pustules and/or punched-out erosions.
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Affiliation(s)
- Sonora Yun
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Colleen Cotton
- Department of Dermatology, George Washington School of Medicine and Health Sciences, Washington, District of Columbia
- Division of Dermatology, Children's National Hospital, Washington, District of Columbia
| | | | - Linsey Jacobs
- Departments of Pediatrics
- Dermatology
- Palo Alto Foundation Medical Group, Palo Alto, California
| | - Nicole Kittler
- Dermatology
- University of California San Franscico, San Franscico, California
| | - Reesa L Monir
- Dermatology
- University of Florida, Gainesville, Florida
| | - Manisha Ravi
- Dermatology
- Ohio State University, Columbus, Ohio
| | - Alexandra Richmond
- Dermatology
- Medical University of South Carolina, Charleston, South Carolina
| | - Jennifer Schoch
- Departments of Pediatrics
- Dermatology
- University of Florida, Gainesville, Florida
| | - Eleanor Workman
- Dermatology
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jason Zucker
- Departments of Pediatrics
- Division of Pediatric Infectious Diseases
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- NewYork-Presbyterian Hospital, New York, New York
| | - Raegan Hunt
- Departments of Pediatrics
- Dermatology
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Christine T Lauren
- Departments of Pediatrics
- Dermatology
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- NewYork-Presbyterian Hospital, New York, New York
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Patel P, Foster CE, Stimes G, Lee SR, Wallace SS. Risk Factors for Treatment Failure in Neonates With Skin and Soft Tissue Infection: A Retrospective Cohort Study. Clin Pediatr (Phila) 2024; 63:689-696. [PMID: 37491834 DOI: 10.1177/00099228231189132] [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] [Indexed: 07/27/2023]
Abstract
We aimed to describe the frequency of treatment failure and associated risk factors for treatment failure amongst neonates with skin and soft tissue infections (SSTIs). We conducted a retrospective cohort study of neonates 0 to 28 days old with uncomplicated SSTIs presenting to the emergency department of a quaternary care children's hospital from 2009 to 2017. Data were collected via chart review. Skin and soft tissue infections included the following: cellulitis, abscess, mastitis, perirectal SSTI, carbuncle, and furuncle. Of the 202 neonates in the study, most were term, afebrile with mastitis, or perirectal SSTI. Treatment failure occurred in 8% (17/202) of neonates receiving oral antibiotics; 10 of these neonates had perirectal SSTIs and 2 had clindamycin and methicillin-resistant Staphylococcus aureus. Neonates with treatment failure had increased odds of having perirectal SSTIs (odds ratio [OR] = 4.08, 95% confidence interval [CI] = 1.46-11.31). Further studies are needed to identify strategies to prevent treatment failure in neonates with perirectal SSTIs.
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Affiliation(s)
- Purva Patel
- Divisions of Pediatric Hospital Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Catherine E Foster
- Departments of Infectious Diseases and Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Grant Stimes
- Departments of Infectious Diseases and Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pharmacy, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Su Rin Lee
- Divisions of Pediatric Hospital Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pharmacy, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Sowdhamini S Wallace
- Divisions of Pediatric Hospital Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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Hester G, King E, Nickel A, Smedshammer S, Wageman K. Omphalitis Hospitalizations at a US Children's Hospital. Hosp Pediatr 2022; 12:e423-e427. [PMID: 36353854 DOI: 10.1542/hpeds.2022-006623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To describe demographics, presentation, resource use, and outcomes of patients diagnosed with omphalitis. METHODS This was a retrospective descriptive study of infants with omphalitis at a children's hospital system between January 2006 and December 2020. Presentation, resource use, and outcomes (omphalitis complications [eg, necrotizing fasciitis], 30-day related cause revisit, and death) were described. RESULTS Ninety-one patients had a primary or secondary International Classification of Diseases, Ninth or 10th Revision, code for omphalitis. Seventy-eight patients were included in analysis (47 with omphalitis as primary reason for admission). Patients with omphalitis as the primary reason for admission presented with rash (44 of 47, 93.6%), fussiness/irritability (19 of 47, 40.4%), and fever (6 of 47, 12.8%). C-reactive protein was minimally elevated, with a median of 0.4 mg/dL (interquartile range 0.29-0.85).Among all patients, blood cultures were positive in 3 (3 of 78, 3.8%) and most had positive wound cultures (70 of 78, 89.7%), with primarily gram-positive organisms. Median duration of intravenous antibiotics was 5 days (interquartile range 3-7). No patients had complications of omphalitis or death. Five patients (5 of 78, 6.4%) had a 30-day revisit for a related cause. CONCLUSIONS We found variation in presentation and management of patients with omphalitis at our tertiary children's hospital system. Wound cultures, but not blood tests, were helpful in guiding management in the majority of cases. There were no complications of omphalitis or deaths.
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Affiliation(s)
| | - Erin King
- Children's Minnesota, Minneapolis, Minnesota
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Haffner DN, Machie M, Hone E, Said RR, Maitre NL. Predictors of Neurodevelopmental Impairment After Neonatal Bacterial Meningitis. J Child Neurol 2021; 36:968-973. [PMID: 34256644 DOI: 10.1177/08830738211026053] [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: 11/17/2022]
Abstract
BACKGROUND Neonatal bacterial meningitis has high rates of morbidity and mortality. Early clinical signs and neuroimaging suggest adverse outcomes, but little is known about their combined predictive properties. We evaluated the combination of findings most associated with death and neurodevelopmental impairment. METHODS Single-center retrospective cohort study of term and late preterm neonates with bacterial meningitis. Predictors of death and neurodevelopmental impairment were identified on univariate analysis and incorporated into Lasso models to identify variables best predicting adverse outcomes. RESULTS Of 103 neonates, 6 died acutely; 30% of survivors had neurodevelopmental impairment. Clinical variables (seizures, pressor support) predicted death and neurodevelopmental impairment better than the neuroimaging or combined findings (area under the curve 0.88 vs 0.79 and 0.83, respectively). Among survivors, neuroimaging findings (cerebrovascular lesions, ventriculomegaly) predicted neurodevelopmental impairment better than clinical or combined findings (area under the curve 0.82 vs 0.80 and 0.77, respectively). CONCLUSIONS Seizures are important predictors of adverse outcomes in neonatal bacterial meningitis. Among survivors, neuroimaging findings help predict neurodevelopmental impairment.
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Affiliation(s)
- Darrah N Haffner
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital and the Ohio State University, Columbus, OH, USA.,Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Neurology, Department of Pediatrics, University of Texas Southwestern Medical School/Children's Health, Dallas, TX, USA
| | - Michelle Machie
- Division of Neurology, Department of Pediatrics, University of Texas Southwestern Medical School/Children's Health, Dallas, TX, USA
| | - Emily Hone
- Biostatistics Core, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rana R Said
- Division of Neurology, Department of Pediatrics, University of Texas Southwestern Medical School/Children's Health, Dallas, TX, USA
| | - Nathalie L Maitre
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital and the Ohio State University, Columbus, OH, USA
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Foradori DM, Lopez MA, Hall M, Cruz AT, Markham JL, Colvin JD, Nead JA, Queen MA, Raphael JL, Wallace SS. Invasive Bacterial Infections in Infants Younger Than 60 Days With Skin and Soft Tissue Infections. Pediatr Emerg Care 2021; 37:e301-e306. [PMID: 30130340 DOI: 10.1097/pec.0000000000001584] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to describe the frequency of invasive bacterial infections (IBIs) in young infants with skin and soft tissue infections (SSTIs) and the impact of IBI evaluation on disposition, length of stay (LOS), and cost. METHODS This retrospective (2009-2014) cohort study used data from 35 children's hospitals in the Pediatric Health Information System. We included infants younger than 60 days who presented to an emergency department (ED) with SSTI. Invasive bacterial infection was defined as bacteremia/sepsis, bone/joint infection, or bacterial meningitis. Readmission and return ED visits within 30 days were evaluated to identify missed IBIs for infants. RESULTS A total of 2734 infants were included (median age, 33 days; interquartile range [IQR], 21-44); 62% were hospitalized. Invasive bacterial infection was identified in 2%: bacteremia (1.8%), osteomyelitis (0.1%), and bacterial meningitis (0.1%). Hospitalization occurred in 78% of infants with blood cultures, 95% with cerebrospinal fluid cultures, and 23% without cultures. Median hospitalization LOS was 2 days (IQR, 1-3). Median cost was US $4943 for infants with cerebrospinal fluid cultures (IQR, US $3475-6780) compared with US $419 (IQR, US $215-1149) for infants without IBI evaluations (P < 0.001). Five infants (0.2%) returned to the ED within 30 days with new IBI diagnoses (4 bacteremia, 1 meningitis). CONCLUSIONS Invasive bacterial infection occurs infrequently in infants younger than 60 days who present to children's hospital EDs with SSTI. Bacteremia is the most common IBI. More extensive evaluation for IBI is associated with increased rate of admission, LOS, and cost. Further studies are needed to evaluate the safety of a limited IBI evaluation in young infants with SSTI.
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Affiliation(s)
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | | | - Jessica L Markham
- Children's Mercy Kansas City, University of Missouri, Kansas City School of Medicine, Kansas City, MO
| | - Jeffrey D Colvin
- Children's Mercy Kansas City, University of Missouri, Kansas City School of Medicine, Kansas City, MO
| | | | - Mary Ann Queen
- Children's Mercy Kansas City, University of Missouri, Kansas City School of Medicine, Kansas City, MO
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Schaeffer AJ, Cartwright PC, Lau GA, Ebert MD, Fino NF, Nkoy FL, Hess R. Utilization of Radiographic Imaging for Infant Hydronephrosis over the First 12 Months of Life. Adv Urol 2020; 2020:2108362. [PMID: 32802050 PMCID: PMC7414334 DOI: 10.1155/2020/2108362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/15/2020] [Accepted: 06/29/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The workup and surveillance strategies for infant hydronephrosis (HN) vary, although this could be due to grade-dependent differences in imaging intensity. We aimed to describe the frequency of imaging studies for HN within the first year of life, stratified by initial HN grade, within a large regional healthcare system. Study Design and Data Source. Retrospective cohort using Intermountain Healthcare Data Warehouse. Inclusion criteria: (1) birth between 1/1/2005 and 12/31/2013, (2) CPT code for HN, and (3) ultrasound (U/S) confirmed HN within four months of birth. Data Collection. Grade of HN on initial postnatal U/S; number of HN-associated radiologic studies (renal U/Ss, voiding cystourethrograms (VCUGs), and diuretic renal scans); demographic and medical variables. Primary Outcome. Sum of radiologic studies within the first year of life or prior to pyeloplasty. Statistical Analysis. Multivariate poisson regression to analyze association between the primary outcome and the initial HN grade. RESULTS Of 1,380 subjects (993 males and 387 females), 990 (72%), 230 (17%), and 160 (12%) had mild, moderate, and severe HN, respectively. Compared with those with mild HN, patients with moderate (RR: 1.57; 95% CI: 1.42-1.73) and severe (RR: 2.09; 95% CI: 1.88-2.32) HN had a significantly higher rate of imaging use over 12 months (or prior to surgery) after controlling for potential confounders. CONCLUSIONS In a large regional healthcare system, imaging use for HN is proportional to its initial grade. This suggests that within our system, clinicians treating this condition are using a risk-stratified approach to imaging.
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Affiliation(s)
- Anthony J. Schaeffer
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Patrick C. Cartwright
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Glen A. Lau
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Mark D. Ebert
- Intermountain Pediatric Imaging SLC, UT/Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Nora F. Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Flory L. Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Rachel Hess
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
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Chappell-Campbell L, Schwenk HT, Capdarest-Arest N, Schroeder AR. Reporting and Categorization of Blood Culture Contaminants in Infants and Young Children: A Scoping Review. J Pediatric Infect Dis Soc 2020; 9:110-117. [PMID: 30544178 DOI: 10.1093/jpids/piy125] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/15/2018] [Indexed: 11/13/2022]
Abstract
BACKGROUND Blood cultures are obtained routinely for infants and young children for the evaluation for serious bacterial infection. Isolation of organisms that represent possible contaminants poses a management challenge. The prevalence of bacteremia reported in this population is potentially biased by inconsistent contaminant categorization reported in the literature. Our aim was to systematically review the definition and reporting of contaminants within the literature regarding infant bacteremia. METHODS A search of studies published between 1986 and mid-September 2016 was conducted using Medline/PubMed. Included studies examined children aged 0 to 36 months for whom blood culture was performed as part of a serious bacterial infection evaluation. Studies that involved children in an intensive care unit, prematurely born children, and immunocompromised children or those with an indwelling catheter/device were excluded. Data extracted included contaminant designation methodology, organisms classified as contaminants and pathogens, and contamination and bacteremia rates. DISCUSSION Our search yielded 1335 articles, and 69 of them met our inclusion criteria. The methodology used to define contaminants was described in 37 (54%) study reports, and 16 (23%) reported contamination rates, which ranged from 0.5% to 22.8%. Studies defined contaminants according to organism species (n = 22), according to the patient's clinical management (n = 4), and using multifactorial approaches (n = 11). Many common organisms, particularly Gram-positive cocci, were inconsistently categorized as pathogens or contaminants. CONCLUSIONS Reporting and categorization of blood culture contamination are inconsistent within the pediatric bacteremia literature, which limits our ability to estimate the prevalence of bacteremia. Although contaminants are characterized most frequently according to organism, we found inconsistency regarding the classification of certain common organisms. A standardized approach to contaminant reporting is needed.
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Affiliation(s)
| | - Hayden T Schwenk
- Division of Infectious Diseases, Stanford University School of Medicine, California
| | | | - Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, California
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Markham JL, Hall M, Queen MA, Aronson PL, Wallace SS, Foradori DM, Hester G, Nead J, Lopez MA, Cruz AT, McCulloh RJ. Variation in Antibiotic Selection and Clinical Outcomes in Infants <60 Days Hospitalized With Skin and Soft Tissue Infections. Hosp Pediatr 2019; 9:30-38. [PMID: 30578271 PMCID: PMC6303086 DOI: 10.1542/hpeds.2017-0237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe variation in empirical antibiotic selection in infants <60 days old who are hospitalized with skin and soft-tissue infections (SSTIs) and to determine associations with outcomes, including length of stay (LOS), 30-day returns (emergency department revisit or readmission), and standardized cost. METHODS Using the Pediatric Health Information System, we conducted a retrospective study of infants hospitalized with SSTI from 2009 to 2014. We analyzed empirical antibiotic selection in the first 2 days of hospitalization and categorized antibiotics as those typically administered for (1) staphylococcal infection, (2) neonatal sepsis, or (3) combination therapy (staphylococcal infection and neonatal sepsis). We examined the association of antibiotic selection and outcomes using generalized linear mixed-effects models. RESULTS A total of 1319 infants across 36 hospitals were included; the median age was 30 days (interquartile range [IQR]: 17-42 days). We observed substantial variation in empirical antibiotic choice, with 134 unique combinations observed before categorization. The most frequently used antibiotics included staphylococcal therapy (50.0% [IQR: 39.2-58.1]) and combination therapy (45.4% [IQR: 36.0-56.0]). Returns occurred in 9.2% of infants. Compared with administration of staphylococcal antibiotics, use of combination therapy was associated with increased LOS (adjusted rate ratio: 1.35; 95% confidence interval: 1.17-1.53) and cost (adjusted rate ratio: 1.39; 95% confidence interval: 1.21-1.58), but not with 30-day returns. CONCLUSIONS Infants who are hospitalized with SSTI experience wide variation in empirical antibiotic selection. Combination therapy was associated with increased LOS and cost, with no difference in returns. Our findings reveal the need to identify treatment strategies that can be used to optimize resource use for infants with SSTI.
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Affiliation(s)
| | - Matthew Hall
- Children's Mercy Kansas City, Kansas City, Missouri
- Children's Hospital Association, Lenexa, Kansas
| | | | - Paul L Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - Dana M Foradori
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Gabrielle Hester
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota; and
| | - Jennifer Nead
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York
| | - Michelle A Lopez
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Aronson PL. Afebrile neonates with pustules should not be managed as febrile infants. Pediatr Dermatol 2018; 35:696-697. [PMID: 29974504 DOI: 10.1111/pde.13573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Paul L Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, School of Medicine, Yale University, New Haven, CT, USA
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Abstract
PURPOSE OF REVIEW The approach to febrile young infants remains challenging. This review serves as an update on the care of febrile infants less than 90 days of age with a focus on the changing epidemiology of serious bacterial infection (SBI), refinement of management strategies based on biomarkers, and the development of novel diagnostics. RECENT FINDINGS There is high variability in the emergency department management of febrile young infants without significant differences in outcomes. C-reactive protein (CRP) and procalcitonin have emerged as valuable risk-stratification tests to identify high-risk infants. When interpreting automated urinalyses for suspected urinary tract infection (UTI), urine concentration influences the diagnostic value of pyuria. Novel diagnostics including RNA biosignatures and protein signatures show promise in better identifying young febrile infants at risk of serious infection. SUMMARY The majority of febrile infants with an SBI will have a UTI but the diagnosis of invasive bacterial infection in infants continues to be challenging. The use of procalcitonin and CRP as biomarkers in prediction algorithms facilitates identification of low-risk infants.
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Periumbilical Skin and Soft-Tissue Infections Resulting From a Newborn Tracking Device. Infect Control Hosp Epidemiol 2016; 38:245-246. [PMID: 27917724 DOI: 10.1017/ice.2016.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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