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Erdem G, Watson JR, Tomatis C, Ceyhan K, Barson W. Impact of viral testing on duration of antibiotic treatment and hospitalisation of febrile infants. Acta Paediatr 2024. [PMID: 39227731 DOI: 10.1111/apa.17413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 07/27/2024] [Accepted: 08/22/2024] [Indexed: 09/05/2024]
Abstract
AIM To assess the duration of antimicrobial treatment; hospital length of stay; and invasive bacterial infections rates in hospitalised infants following the adoption of a management guideline. METHODS Faculty agreed to a standard of 24 h of antibiotic treatment for well-appearing febrile infants with proven viral infection and no growth on bacterial cultures. The outcomes were the duration of hospitalisation and antibiotic treatment of febrile infants less than 8 weeks of age who have enterovirus, parechovirus, respiratory viruses detected. We monitored re-admissions and missed invasive infections. RESULTS Of the total 1696 infants studied, the median antibiotic treatment duration decreased from 31.5 to 24.8 h in virus-infected infants ≤21 days of age (p = 0.02) and from 26 to 19.7 h in infants 22-56 days of age (p < 0.001). The decrease was less in infants not infected with a virus. No patient had an invasive infection identified after discharge. CONCLUSION The implementation of our care standard resulted in reduction in antibiotic treatment duration without known delayed diagnosis of bacterial infections. Infants without a proven viral aetiology may need further study to inform management decisions.
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Affiliation(s)
- G Erdem
- Section of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - J R Watson
- Section of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - C Tomatis
- Section of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - K Ceyhan
- Department of Neurosurgery, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - W Barson
- Section of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University School of Medicine, Columbus, Ohio, USA
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Orfanos I. Decreased incidence of urinary tract infections in febrile infants aged ≤60 days during COVID-19 pandemic. Acta Paediatr 2024; 113:1934-1939. [PMID: 38676461 DOI: 10.1111/apa.17256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024]
Abstract
AIM To investigate the incidence rate of urinary tract infections (UTIs) among febrile infants aged ≤60 days before, during, and after the COVID-19 pandemic. METHODS We conducted a retrospective study in 2 Swedish paediatric emergency departments between 2014 and 2022. We included full-term infants aged ≤60 days with fever without source. We calculated the annual incidence rate of UTI per 1000 births. RESULTS We included 1589 full-term infants with fever without source. In 2020, 89 infants were evaluated in the emergency department versus 203-259 in 2017-2019. In 2020, the incidence rate of UTI was 1.43 per 1000 births/year versus 2.18-2.37 in 2017-2019. The median age, sex, fever duration, and urine testing were similar between the years 2017 and 2020. CONCLUSION The number of febrile infants who presented to the paediatric emergency department and the incidence rate of UTIs decreased in 2020. This decrease might imply a systematic misdiagnosis of UTIs in infants with febrile viral infections. A more selective urine testing approach for febrile, previously healthy, infants should be considered to mitigate UTI misdiagnosis and its potential harmful effects.
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Affiliation(s)
- Ioannis Orfanos
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Pediatrics, Skåne University Hospital, Lund University, Lund, Sweden
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3
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Elliver M, Norrman J, Orfanos I. Low adherence to a new guideline for managing febrile infants ≤59 days. Front Pediatr 2024; 12:1401654. [PMID: 38895196 PMCID: PMC11183787 DOI: 10.3389/fped.2024.1401654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Background Management of young febrile infants is challenging. Therefore, several guidelines have been developed over the last decades. However, knowledge regarding the impact of introducing guidelines for febrile infants is limited. We assessed the impact of and adherence to a novel guideline for managing febrile infants aged ≤59 days. Methods This retrospective cross-sectional study was conducted in 2 pediatric emergency departments in Sweden between 2014 and 2021. We compared the management of infants aged ≤59 days with fever without a source (FWS) and the diagnosis of serious bacterial infections (SBIs) before and after implementing the new guideline. Results We included 1,326 infants aged ≤59 days with FWS. Among infants aged ≤21 days, urine cultures increased from 49% to 67% (p = 0.001), blood cultures from 43% to 63% (p < 0.001), lumbar punctures from 16% to 33% (p = 0.003), and antibiotics from 38% to 57% (p = 0.002). Only 39 of 142 (28%) infants aged ≤21 days received recommended management. The SBI prevalence was 16.7% (95% CI, 11.0-23.8) and 17.6% (95% CI, 11.7-24.9) before and after the implementation, respectively. Among infants aged ≤59 days, there were 3 infants (0.6%; 95% CI, 0.1-1.7) in the pre-implementation period and 3 infants (0.6%; 95% CI, 0.1-1.7) in the post-implementation period with delayed treated urinary tract infections. Conclusions Investigations and antibiotics increased significantly after implementation of the new guideline. However, doing more did not improve the diagnosis of SBIs. Thus, the low adherence to the new guideline may be considered justified. Future research should consider strategies to safely minimize interventions when managing infants with FWS.
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Affiliation(s)
- Matilda Elliver
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Josefin Norrman
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Ioannis Orfanos
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Pediatrics, Skåne University Hospital, Lund, Sweden
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4
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Tsou PY, Hayden LP. Obstructive sleep apnea is associated with use of assisted ventilation among children with bronchopulmonary dysplasia hospitalized with respiratory illness: A nationwide inpatient cohort. Sleep Med 2023; 109:181-189. [PMID: 37467551 DOI: 10.1016/j.sleep.2023.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE (S) Children with bronchopulmonary dysplasia (BPD) are at higher risk of respiratory insufficiency during respiratory illness. We aimed to investigate whether obstructive sleep apnea (OSA) is associated with increased morbidity among children with BPD hospitalized with acute respiratory illnesses. STUDY DESIGN Hospital discharge records were obtained from the Kid's Inpatient Database for children <21 years of age with BPD hospitalized for acute respiratory illness between 1997 and 2012. Acute respiratory illnesses included bacterial and/or viral pneumonia, bronchiolitis, acute upper respiratory tract infections, aspiration pneumonia, or asthma exacerbation. The primary exposure was OSA. The primary outcome was invasive mechanical ventilation (IMV), and secondary outcomes were noninvasive mechanical ventilation (NIMV), length of hospital stay (LOS), and inflation-adjusted cost of hospitalization (IACH). Multivariable regression was conducted to ascertain the associations between OSA and primary and secondary outcomes accounting for BPD-associated comorbidities. RESULTS Among 33,640 hospitalizations of children with BPD for acute respiratory illness, there were 607 (1.8%) cases with comorbid OSA vs. 33,033 (98.2%) controls without OSA. Patients with OSA were more likely to have aspiration pneumonia, central sleep apnea, obesity, laryngeal stenosis, congenital airway, and skull/face/jaw anomalies. Multivariable regression showed that OSA was associated with IMV (OR 1.45, 95% CI 1.09-1.94, p = 0.012) and NIMV (OR 2.61, 95% CI 1.71-3.98, p < 0.001), but not LOS or IACH. CONCLUSIONS In BPD patients hospitalized with acute respiratory illness, having OSA is associated with increased risks for respiratory insufficiency requiring noninvasive or invasive mechanical ventilation. Clinicians should consider OSA, along with other BPD-associated comorbidities, in the management of this population.
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Affiliation(s)
- Po-Yang Tsou
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lystra P Hayden
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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5
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Mace AO, Totterdell J, Martin AC, Ramsay J, Barnett J, Ferullo J, Hazelton B, Ingram P, Marsh JA, Wu Y, Richmond P, Snelling TL. FeBRILe3: Safety Evaluation of Febrile Infant Guidelines Through Prospective Bayesian Monitoring. Hosp Pediatr 2023; 13:865-875. [PMID: 37609781 DOI: 10.1542/hpeds.2023-007160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVES Despite evidence supporting earlier discharge of well-appearing febrile infants at low risk of serious bacterial infection (SBI), admissions for ≥48 hours remain common. Prospective safety monitoring may support broader guideline implementation. METHODS A sequential Bayesian safety monitoring framework was used to evaluate a new hospital guideline recommending early discharge of low-risk infants. Hospital readmissions within 7 days of discharge were regularly assessed against safety thresholds, derived from historic rates and expert opinion, and specified a priori (8 per 100 infants). Infants aged under 3 months admitted to 2 Western Australian metropolitan hospitals for management of fever without source were enrolled (August 2019-December 2021), to a prespecified maximum 500 enrolments. RESULTS Readmission rates remained below the prespecified threshold at all scheduled analyses. Median corrected age was 34 days, and 14% met low-risk criteria (n = 71). SBI was diagnosed in 159 infants (32%), including urinary tract infection (n = 140) and bacteraemia (n = 18). Discharge occurred before 48 hours for 192 infants (38%), including 52% deemed low-risk. At study completion, 1 of 37 low-risk infants discharged before 48 hours had been readmitted (3%), for issues unrelated to SBI diagnosis. In total, 20 readmissions were identified (4 per 100 infants; 95% credible interval 3, 6), with >0.99 posterior probability of being below the prespecified noninferiority threshold, indicating acceptable safety. CONCLUSIONS A Bayesian monitoring approach supported safe early discharge for many infants, without increased risk of readmission. This framework may be used to embed safety evaluations within future guideline implementation programs to further reduce low-value care.
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Affiliation(s)
- Ariel O Mace
- Departments of General Paediatrics
- Department of Paediatrics, Fiona Stanley Hospital, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute
| | - James Totterdell
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Jessica Ramsay
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute
| | | | - Jade Ferullo
- Department of Paediatrics, Fiona Stanley Hospital, Western Australia, Australia
| | - Briony Hazelton
- Infectious Diseases, Perth Children's Hospital, Western Australia, Australia
- Department of Microbiology, PathWest Laboratory Medicine, Western Australia, Australia
| | - Paul Ingram
- Pathology and Laboratory Medicine
- Department of Microbiology, PathWest Laboratory Medicine, Western Australia, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute
- Centre for Child Health Research, The University of Western Australia, Western Australia, Australia
| | - Yue Wu
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter Richmond
- Departments of General Paediatrics
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute
- Schools of Medicine
| | - Thomas L Snelling
- Infectious Diseases, Perth Children's Hospital, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Menzies School of Health Research, Charles Darwin University, Northern Territory, Australia
- Curtin University, Western Australia, Australia
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Masarweh K, Bentur L, Bar-Yoseph R, Kassis I, Dabaja-Younis H, Gur M. The Impact of Respiratory Symptoms on the Risk of Serious Bacterial Infection in Febrile Infants < 60 Days Old. J Clin Med 2023; 12:4636. [PMID: 37510751 PMCID: PMC10380775 DOI: 10.3390/jcm12144636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVES We aimed to evaluate the impact of respiratory symptoms and positive viral testing on the risk of serious bacterial infections (SBIs). METHODS A retrospective study was conducted that included infants (0-60 days) presenting with a fever between 2001 and 2022 at a tertiary hospital in northern Israel. Demographic, clinical, and laboratory parameters were collected, and risk factors for SBIs were analyzed. RESULTS Data from a total of 3106 infants, including data from blood, urine, and CSF cultures, were obtained in 96.6%, 89%, and 29% of cases, respectively. A fever without respiratory symptoms (fever only) was present in 1312 infants, while 1794 had a fever and respiratory symptoms-427 were positive for a respiratory virus (virus+), 759 tested negative (virus-), and 608 were not tested. The SBI rate was 5.1% vs. 7.5% in the fever-and-respiratory group vs. the fever-only group (p = 0.004, OR = 0.65 (95% CI = 0.49-0.88)) and 2.8% vs. 7% in the virus+ vs. virus- group (p = 0.002, OR = 0.385, (95% CI = 0.203-0.728)). The male gender, an age < 1 month, leukocytosis > 15 × 109/L, or a CRP > 2 mg/dL increased the risk of SBIs. Respiratory symptoms or a confirmed viral infection reduced the risk of SBIs in the presence of the above risk factors. CONCLUSIONS Respiratory symptoms and a positive viral test decreased the risk of SBIs. Combining rapid viral testing with clinical variables may identify low-risk infants. Despite the relatively low risk of SBIs in individuals with viral infections, conducting prospective studies remains essential for accurately predicting the occurrence of these potentially life-threatening infections.
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Affiliation(s)
- Kamal Masarweh
- Pediatric Pulmonary Institute, CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Lea Bentur
- Pediatric Pulmonary Institute, CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3109601, Israel
| | - Ronen Bar-Yoseph
- Pediatric Pulmonary Institute, CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3109601, Israel
| | - Imad Kassis
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3109601, Israel
- Pediatric Infectious Diseases Unit, Rappaport Children's Hospital, Haifa 3109601, Israel
- Department of Pediatrics B, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Halima Dabaja-Younis
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3109601, Israel
- Pediatric Infectious Diseases Unit, Rappaport Children's Hospital, Haifa 3109601, Israel
| | - Michal Gur
- Pediatric Pulmonary Institute, CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3109601, Israel
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Van Winkle PJ, Lee SN, Chen Q, Baecker AS, Ballard DW, Vinson DR, Greenhow TL, Nguyen THP, Young BR, Alabaster AL, Huang J, Park S, Sharp AL. Clinical management and outcomes for febrile infants 29-60 days evaluated in community emergency departments. J Am Coll Emerg Physicians Open 2022; 3:e12754. [PMID: 35765310 PMCID: PMC9206108 DOI: 10.1002/emp2.12754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 11/06/2022] Open
Abstract
Objective Describe emergency department (ED) management and patient outcomes for febrile infants 29-60 days of age who received a lumbar puncture (LP), with focus on timing of antibiotics and type of physician performing LP. Methods Retrospective observational study of 35 California EDs from January 1, 2010 through December 31, 2019. Primary analysis was among patients with successful LP and primary outcome was hospital length of stay (LOS). Logistic regression analysis included variables associated with LOS of at least 2 days. Secondary outcomes were bacterial meningitis, hospital admission, length of antibiotics, and readmission. Results Among 2569 febrile infants (median age 39 days), 667 underwent successful LP and 633 received intravenous antibiotics. Most infants (n = 559, 88.3%) had their LP before intravenous antibiotic administration. Pediatricians performed 54% of LPs and emergency physicians 34%. Sixteen infants (0.6% of 2569) were diagnosed with bacterial meningitis, and none died. Five hundred and fifty-eight (88%) infants receiving an LP were hospitalized. Among patients receiving an LP and antibiotics (n = 633), 6.5% were readmitted within 30 days. Patients receiving antibiotics before LP had a longer length of antibiotics (+ 7.9 hours, 95% confidence interval [CI] 3.8-13.4). Primary analysis found no association between timing of antibiotics and LOS (odds ratio [OR] 0.67, 95% CI 0.34-1.30), but shorter LOS when emergency physicians performed the LP (OR 0.66, 95% CI 0.45-0.97). Conclusions Febrile infants in the ED had no deaths and few cases of bacterial meningitis. In community EDs, where a pediatrician is often not available, successful LP by emergency physician was associated with reduced inpatient LOS.
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Affiliation(s)
- Patrick J. Van Winkle
- Department of PediatricsKaiser Permanente Southern California, Anaheim Medical CenterAnaheimCaliforniaUSA
- Department of Clinical ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCaliforniaUSA
| | - Samantha N. Lee
- Undergraduate in Biological SciencesUniversity of CA, Los AngelesLos AngelesCaliforniaUSA
| | - Qiaoling Chen
- Department of Research and EvaluationSouthern California Permanente Medical GroupPasadenaCaliforniaUSA
| | - Aileen S. Baecker
- Department of Research and EvaluationSouthern California Permanente Medical GroupPasadenaCaliforniaUSA
| | - Dustin W. Ballard
- Department of Emergency Medicine and the Division of ResearchThe Permanente Medical Group, Kaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - David R. Vinson
- Department of Emergency Medicine and the Division of ResearchThe Permanente Medical Group, Kaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Tara L. Greenhow
- Department of Pediatric Infectious DiseasesKaiser Permanente Northern CASan FranciscoCaliforniaUSA
| | - Tran H. P. Nguyen
- Department of Inpatient PediatricsKaiser Permanente Northern CARosevilleCaliforniaUSA
| | - Beverly R. Young
- Department of Inpatient PediatricsKaiser Permanente Northern CARosevilleCaliforniaUSA
| | - Amy L. Alabaster
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Jie Huang
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Stacy Park
- Department of Research and EvaluationSouthern California Permanente Medical GroupPasadenaCaliforniaUSA
| | - Adam L. Sharp
- Department of Clinical ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCaliforniaUSA
- Department of Research and EvaluationSouthern California Permanente Medical GroupPasadenaCaliforniaUSA
- Department of Emergency MedicineKaiser Permanente Southern California, Los Angeles Medical CenterLos AngelesCaliforniaUSA
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8
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Stephens JR, Hall M, Cotter JM, Molloy MJ, Tchou MJ, Markham JL, Shah SS, Steiner MJ, Aronson PL. Trends and Variation in Length of Stay Among Hospitalized Febrile Infants ≤60 Days Old. Hosp Pediatr 2021; 11:915-926. [PMID: 34385333 DOI: 10.1542/hpeds.2021-005936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Researchers in recent studies suggest that hospitalized febrile infants aged ≤60 days may be safely discharged if bacterial cultures are negative after 24-36 hours of incubation. We aimed to describe trends and variation in length of stay (LOS) for hospitalized febrile infants across children's hospitals. METHODS We conducted a multicenter retrospective cohort study of febrile infants aged ≤60 days hospitalized from 2016 to 2019 at 39 hospitals in the Pediatric Health Information System database. We excluded infants with complex chronic conditions, bacterial infections, lower respiratory tract viral infections, and those who required ICU admission. The primary outcomes were trends in LOS overall and for individual hospitals, adjusted for patient demographics and clinical characteristics. We also evaluated the hospital-level association between LOS and 30-day readmissions. RESULTS We identified 11 868 eligible febrile infant encounters. The adjusted mean LOS for the study cohort decreased from 44.0 hours in 2016 to 41.9 hours in 2019 (P < .001). There was substantial variation in adjusted mean LOS across children's hospitals, range 33.5-77.9 hours in 2016 and 30.4-100.0 hours in 2019. The change from 2016 to 2019 in adjusted mean LOS across individual hospitals also varied widely (-23.9 to +26.7 hours; median change -1.8 hours, interquartile range: -5.4 to 0.3). There was no association between hospital-level LOS and readmission rates (P = .70). CONCLUSIONS The LOS for hospitalized febrile infants decreased marginally between 2016 and 2019, although overall LOS and change in LOS varied substantially across children's hospitals. Continued quality improvement efforts are needed to reduce LOS for hospitalized febrile infants.
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Affiliation(s)
- John R Stephens
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Jillian M Cotter
- Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Matthew J Molloy
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Michael J Tchou
- Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Jessica L Markham
- Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, Missouri
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Michael J Steiner
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, School of Medicine, Yale University, New Haven, Connecticut
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9
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Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, O'Leary ST, Okechukwu K, Woods CR. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics 2021; 148:peds.2021-052228. [PMID: 34281996 DOI: 10.1542/peds.2021-052228] [Citation(s) in RCA: 194] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This guideline addresses the evaluation and management of well-appearing, term infants, 8 to 60 days of age, with fever ≥38.0°C. Exclusions are noted. After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active investigators, 21 key action statements were derived. For each key action statement, the quality of evidence and benefit-harm relationship were assessed and graded to determine the strength of recommendations. When appropriate, parents' values and preferences should be incorporated as part of shared decision-making. For diagnostic testing, the committee has attempted to develop numbers needed to test, and for antimicrobial administration, the committee provided numbers needed to treat. Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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Affiliation(s)
- Robert H Pantell
- Department of Pediatrics, School of Medicine, University of California San Francisco, San Francisco, California
| | - Kenneth B Roberts
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - William G Adams
- Boston Medical Center/Boston University School of Medicine, Deparment of Pediatrics, Boston, Massachusetts
| | - Benard P Dreyer
- Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatric, School of Medicine, University of California, Davis School of Medicine, Sacramento, California
| | - Sean T O'Leary
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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10
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Implementation of Febrile Infant Management Guidelines Reduces Hospitalization. Pediatr Qual Saf 2020; 5:e252. [PMID: 32190797 PMCID: PMC7056289 DOI: 10.1097/pq9.0000000000000252] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 12/18/2019] [Indexed: 12/21/2022] Open
Abstract
Supplemental Digital Content is available in the text. The clinical management of well-appearing febrile infants 7−60 days of age remains variable due in part to multiple criteria differentiating the risk of a serious bacterial infection. The purpose of this quality improvement study was to standardize risk stratification in the emergency department and length of stay in the inpatient unit by implementing an evidence-based clinical practice guideline (CPG).
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11
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Pathak A, Upadhayay R, Mathur A, Rathi S, Lundborg CS. Incidence, clinical profile, and risk factors for serious bacterial infections in children hospitalized with fever in Ujjain, India. BMC Infect Dis 2020; 20:162. [PMID: 32085751 PMCID: PMC7035762 DOI: 10.1186/s12879-020-4890-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/17/2020] [Indexed: 11/29/2022] Open
Abstract
Background Fever is a cause for concern for both parents and the treating pediatrician and a common reason for antibiotic overuse. However, the proportion of children hospitalized for fever with serious bacterial infection (SBI) is uncertain. We aimed to evaluate the epidemiological, clinical, hematological, and biochemical risks for SBI among the children admitted with fever. Method This prospective study was conducted in a rural teaching hospital in India on consecutive children, aged 3 months–12 years, presenting with fever 100 °F (37.7 °C) or higher. The presence of SBI was confirmed with one of the following criteria: (a) a positive blood culture; (b) roentgenographically confirmed pneumonia with high titres of C-reactive protein; (c) a culture-confirmed urinary tract infection; (d) enteric fever diagnosed clinically in addition to either a positive blood culture or high Widal titers; and (e) meningitis diagnosed clinically in addition to either a positive blood culture or cerebrospinal fluid culture. A predefined questionnaire was filled. Results A total of 302 children were included in the study, out of which 47% (95% CI 41.4–52.7%) presented with SBI. The factors associated with confirmed SBI in bivariate analysis were history of previous hospitalization, history of chronic illness, history of medication in the previous 1 week, a partially immunized child, history of common cold, moderate-grade fever, toxic look, significant lymphadenopathy, absence of BCG scar, delayed development, irritability, breathlessness, respiratory distress, poor feeding, significant weight loss, suspected urinary tract infection, hyponatremia, hypokalemia, and abnormal leucocyte count. The final generalized logistic regression model revealed partially immunized child (RR 4.26), breathlessness (RR 1.80), weight loss (RR 2.28), and suspected urinary tract infection (RR 1.95) as risk factors for the increased risk of SBI. Conclusion The study identified multiple risk factors for SBI. Pediatricians can be made aware of these risk factors. Further studies are warranted to identify age-specific risk factors for SBI because most clinicians depend on clinical signs and symptoms to identify SBI.
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Affiliation(s)
- Ashish Pathak
- Department of Paediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain, Madhya Pradesh, 456010, India. .,Department of Women and Children's Health, International Maternal and Child Health Unit, Uppsala University, Uppsala, Sweden. .,Department of Global Public Health, Health Systems and Policy: Medicines Focusing Antibiotics, Karolinska Institutet, Stockholm, Sweden.
| | - Radika Upadhayay
- Department of Paediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain, Madhya Pradesh, 456010, India
| | - Aditya Mathur
- Department of Paediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain, Madhya Pradesh, 456010, India
| | - Sunil Rathi
- Department of Paediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain, Madhya Pradesh, 456010, India
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy: Medicines Focusing Antibiotics, Karolinska Institutet, Stockholm, Sweden
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