1
|
Bellini T, Brisca G, Orfanos I, Mariani M, Pezzotta F, Giordano B, Pastorino A, Misley S, Formigoni C, Fueri E, Ferretti M, Marin M, Finetti M, Piccotti E, Castagnola E, Moscatelli A. Clinical Course, Laboratory Findings, and Prognosis of SARS-CoV-2 Infection in Infants up to 90 Days of Age: A Single-Center Experience and a Proposal for a Management Pathway. Healthcare (Basel) 2024; 12:528. [PMID: 38470638 PMCID: PMC10931066 DOI: 10.3390/healthcare12050528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/03/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
AIM To provide a comprehensive description of the clinical features, biochemical characteristics, and outcomes of infants up to 90 days old with COVID-19. Moreover, to assess the severity of the disease and propose an effective management pathway. METHODS Retrospective single-center study spanning three years. Patient data includes age, sex, symptoms, comorbidities, blood and urine test results, cultures, admission, length of stay, therapies, intensive care unit admission, and mortality. RESULTS A total of 274 patients were enrolled in the study, comprising 55% males. Among them, 60 patients (22%) were under the age of 29 days, while 214 (78%) fell within the 29 to 90 days age range. The overall incidence of SARS-CoV-2 infections was 0.28 per 10,000 Pediatric Emergency Department admissions. Blood inflammatory markers showed no significant abnormalities, and there were no recorded instances of positive blood cultures. Less than 1% of infants showed urinary tract infections with positive urine cultures, and 1.5% of patients had a concurrent RSV infection. Hospitalization rates were 83% for neonates and 67% for infants, with a median length of stay (LOS) of 48 h for both age groups. None of the patients required admission to the Pediatric or Neonatal Intensive Care Unit, and only one required High Flow Nasal Cannula (HFNC). No secondary serious bacterial infections were observed, and all hospitalized patients were discharged without short-term sequelae. No deaths were reported. DISCUSSION AND CONCLUSIONS Infants with COVID-19 generally exhibit milder or asymptomatic forms of the disease, making home management a viable option in most cases. Blood tests, indicative of a mild inflammatory response, are recommended primarily for children showing symptoms of illness. Hospitalization precautions for infants without apparent illness or comorbidities are deemed unnecessary. Given the evolving nature of experiences with COVID-19 in infants, maintaining a high level of clinical suspicion remains imperative.
Collapse
Affiliation(s)
- Tommaso Bellini
- Pediatric Emergency Room and Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (M.F.); (M.M.); (M.F.)
| | - Giacomo Brisca
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (G.B.); (A.M.)
| | - Ioannis Orfanos
- Department of Clinical Sciences, Lund University, 22100 Lund, Sweden;
- Department of Pediatrics, Skåne University Hospital, 22185 Lund, Sweden
| | - Marcello Mariani
- Infectious Diseases Unit and COVID Hospital, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy (E.C.)
| | - Federico Pezzotta
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genova, Italy; (F.P.); (B.G.); (A.P.); (S.M.); (C.F.); (E.F.)
| | - Benedetta Giordano
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genova, Italy; (F.P.); (B.G.); (A.P.); (S.M.); (C.F.); (E.F.)
| | - Andrea Pastorino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genova, Italy; (F.P.); (B.G.); (A.P.); (S.M.); (C.F.); (E.F.)
| | - Silvia Misley
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genova, Italy; (F.P.); (B.G.); (A.P.); (S.M.); (C.F.); (E.F.)
| | - Clelia Formigoni
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genova, Italy; (F.P.); (B.G.); (A.P.); (S.M.); (C.F.); (E.F.)
| | - Elena Fueri
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genova, Italy; (F.P.); (B.G.); (A.P.); (S.M.); (C.F.); (E.F.)
| | - Marta Ferretti
- Pediatric Emergency Room and Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (M.F.); (M.M.); (M.F.)
| | - Marta Marin
- Pediatric Emergency Room and Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (M.F.); (M.M.); (M.F.)
| | - Martina Finetti
- Pediatric Emergency Room and Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (M.F.); (M.M.); (M.F.)
| | - Emanuela Piccotti
- Pediatric Emergency Room and Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (M.F.); (M.M.); (M.F.)
| | - Elio Castagnola
- Infectious Diseases Unit and COVID Hospital, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy (E.C.)
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (G.B.); (A.M.)
| |
Collapse
|
2
|
Wilcox H, Umana E, Fauteux-Lamarre E, Velasco R, Waterfield T. Conundrums in the Management of Febrile Infants under Three Months of Age and Future Research. Antibiotics (Basel) 2024; 13:88. [PMID: 38247647 PMCID: PMC10812496 DOI: 10.3390/antibiotics13010088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/23/2024] Open
Abstract
Febrile infants under three months of age pose a diagnostic challenge to clinicians. Unlike in older children, the rates of invasive bacterial infections (IBIs), such as bacteraemia or meningitis, are high. This greater risk of IBI combined with the practical challenges of assessing young infants results in a cautious approach with many febrile infants receiving parenteral antibiotics "just in case". However, there is a range of validated tailored care guidelines that support targeted investigation and management of febrile infants, with a cohort identified as lower risk suitable for fewer invasive procedures and observation without parenteral antibiotics. This manuscript outlines five common conundrums related to the safe application of tailored-care guidelines for the assessment and management of febrile infants under three months of age. It also explores future research which aims to further refine the management of febrile infants.
Collapse
Affiliation(s)
- Helena Wilcox
- St. Georges University Hospital NHS Foundation Trust, London SW17 0QT, UK;
| | - Etimbuk Umana
- Wellcome Wolfson Institute of Experimental Medicine, Queen’s University Belfast, Belfast BT9 7BL, UK;
| | | | - Roberto Velasco
- Pediatric Emergency Unit, Hospital Universitari Parc Tauli, Institut d’Investigació i Innovació I3PT, 08208 Sabadell, Spain;
| | - Thomas Waterfield
- Wellcome Wolfson Institute of Experimental Medicine, Queen’s University Belfast, Belfast BT9 7BL, UK;
| |
Collapse
|
3
|
Miyake R, Ikegawa K, Hataya H, Morikawa Y. Proportion of Successful Lumbar Punctures in Infants Younger Than Three Months. Cureus 2024; 16:e51507. [PMID: 38304639 PMCID: PMC10831920 DOI: 10.7759/cureus.51507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2024] [Indexed: 02/03/2024] Open
Abstract
It is important to perform lumbar punctures (LPs) without a single traumatic tap in infants younger than three months owing to the risk of serious complications. The proportion of LPs in which clear cerebrospinal fluid (CSF) was obtained has been previously reported, but some of the procedures involved a traumatic tap. The present study aimed to identify the proportion of LPs in which clear CSF was obtained without a single traumatic tap and the factors associated with successful LPs in infants younger than three months. This retrospective, observational study included children younger than three months who underwent an LP in the pediatric emergency department between April 2018 and March 2021. The primary outcome was the proportion of successful LPs, defined as LPs obtaining clear CSF without a single traumatic tap. Multiple logistic regression analysis was used to identify factors related to successful LPs. Of 126 eligible patients, 121 were included. Among these, 83 (69%) were in the successful group. No factors significantly associated with successful LPs were found. Larger studies based on an accurate definition of successful LPs, such as that provided by this study, are needed to investigate related factors to increase the rate of successful LPs in this age group.
Collapse
Affiliation(s)
- Rei Miyake
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | - Kento Ikegawa
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | - Hiroshi Hataya
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | - Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| |
Collapse
|
4
|
Cahn RT, Winkie M, John C, Lynch JD. Close Canine Contact: A Case of Infantile Pasteurella Meningitis. Cureus 2023; 15:e40710. [PMID: 37485098 PMCID: PMC10359760 DOI: 10.7759/cureus.40710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
This case report presents an interesting and rare cause of meningitis in young infants, Pasteurella multocida. Not only is the organism unusual but the well appearance of the infant made this diagnosis surprising. The 2021 American Academy of Pediatrics (AAP) clinical practice guidelines on well-appearing febrile infants brought a national guideline on the evaluation and management of fever in infants. However, providers should be aware that there is room for shared decision-making and that the guideline will miss a very small percentage of well-appearing infants with invasive bacterial infections.
Collapse
Affiliation(s)
- Rachel T Cahn
- Dermatology, West Virginia University School of Medicine, Morgantown, USA
| | | | - Collin John
- Pediatrics and Internal Medicine, West Virginia University, Morgantown, USA
| | | |
Collapse
|
5
|
Orfanos I, Sotoca Fernandez J, Elfving K, Alfvén T, Eklund EA. Paediatric emergency departments should manage young febrile and a febrile infants the same if they have a fever before presenting. Acta Paediatr 2022; 111:2004-2009. [PMID: 35808896 PMCID: PMC9539858 DOI: 10.1111/apa.16483] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/04/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022]
Abstract
Aim Our aim was to evaluate the risk of bacterial meningitis, bacteremia, and urinary tract infection (UTI) in infants ≤60 days who presented to paediatric emergency departments (PEDs) after having fever at home. We also investigated any differences between infants who were afebrile or febrile on presentation. Methods This was a multicenter retrospective study of infants ≤60 days presented to four Swedish PEDs during 2014–2020 with reported fever at home. We used relative risks (RR) to compare the prevalence of UTI, bacteremia, and bacterial meningitis between the infants who were afebrile and the infants who were still febrile when they presented to the PED. Results The cohort comprised 1926 infants, and 702 (36%) were afebrile on presentation. The prevalence of UTI in the afebrile and febrile infants was 6.1% [95% confidence interval (CI) 4.5–8.2] versus 14.2% (95% CI 12.3–16.2), corresponding to an RR of 0.43 (95% CI 0.31–0.59). In infants ≤28 days, the RR for meningitis was 1.05 (95% CI 0.18–6.23) for afebrile versus febrile infants. Five times more febrile infants underwent a lumbar puncture. Conclusion Infants who were afebrile on presentation underwent fewer lumbar punctures, but they had similar rates of bacterial meningitis to febrile infants. Different management approaches are not justified.
Collapse
Affiliation(s)
- Ioannis Orfanos
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Pediatrics, Skåne University Hospital, Lund, Sweden
| | | | - Kristina Elfving
- Department of Pediatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Tobias Alfvén
- Dept. of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Erik A Eklund
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Pediatrics, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
6
|
Tham D, Davis C, Hopper SM. Infrared thermometers and infants: The device is hot the baby maybe not. J Paediatr Child Health 2022; 58:624-629. [PMID: 34694041 DOI: 10.1111/jpc.15787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/22/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022]
Abstract
AIM The risk of serious illness in febrile infants (<60 days old) is high, and so fever often warrants aggressive management. Infrared thermometers are unreliable in young infants despite their ubiquity. We aim to describe the: (i) frequency of infrared thermometer usage; (ii) progression to documented fever in the emergency department (ED) and (iii) rate of serious illness (meningitis, urinary tract infection and bacteremia). METHODS In this single-centre retrospective chart review at The Royal Children's Hospital, Melbourne, we audited medical records of infants (<60 days old) presenting to the ED with pre-hospital fever on history over a 12-month period. We described the type of thermometer used at home (tympanic or forehead, 'infrared' vs. axillary or rectal, 'direct') correlated to peak temperature in ED, investigations, treatment and diagnosis. The primary outcome was subsequent fever in ED. RESULTS Of 159 infants, two of three had infrared temperature measurement at home. Fifty-one (32.1%) developed fever in ED (direct 28/54, 52% vs. infrared 23/105, 22% RR 2.36 (95% CI 1.52-3.69)). Investigations (75%) and admission (60%) were common. Pre-hospital fever alone was less likely to be associated with serious illness, with fever in ED a much stronger predictor. CONCLUSIONS In young infants, infrared thermometer use is common and less likely to predict subsequent fever. Twenty-two percent of infants with fever via infrared measurement had fever in ED. History of fever without confirmation is less likely to signal serious illness. Education to public and health-care providers is required to avoid usage of infrared devices in this population.
Collapse
Affiliation(s)
- Doris Tham
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Sunshine Paediatric Emergency Department, Western Health, Melbourne, Victoria, Australia
| | - Conor Davis
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Medical Retrieval and Consultation Centre, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Sandy M Hopper
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
7
|
Orfanos I, Alfvén T, Mossberg M, Tenland M, Sotoca Fernandez J, Eklund EA, Elfving K. Age- and sex-specific prevalence of serious bacterial infections in febrile infants ≤60 days, in Sweden. Acta Paediatr 2021; 110:3069-3076. [PMID: 34310741 DOI: 10.1111/apa.16043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/30/2021] [Accepted: 07/22/2021] [Indexed: 11/30/2022]
Abstract
AIM The aim of the study was to describe age- and sex-specific prevalence of serious bacterial infections (SBI: urinary tract infection, bacteraemia, meningitis) among febrile infants ≤60 days in Sweden. METHODS This is a retrospective study in 4 Pediatric Emergency Departments from 2014 to 2017, in previously healthy, full-term infants ≤60 days with fever without a source. RESULTS Of the 1,701 included infants, 214 (12.6%; 95% CI, 11.1-14.3) had an SBI. Urinary tract infection (UTI) was diagnosed in 196 (11.5%; 95% CI, 10.0-13.1) patients. In the ≤28 and 29-60 days age-groups, meningitis prevalence was 0.9% (95% CI, 0.3-2.0) and 0.3% (95% CI, 0.1-0.8), whereas bacteraemia prevalence was 3.2% (95% CI, 1.9-4.9) and 0.6% (95% CI, 0.2-1.3). The SBI prevalence was higher in boys 16.0% (95% CI, 13.8-18.5) than girls 8.0% (95% CI, 6.2-10.2; p<0.001), due to 2-fold higher UTI risk. The prevalence of meningitis in boys was 0.3% (95% CI, 0.1- 0.9) vs. 0.7% (95% CI, 0.2-1.6) in girls and of bacteraemia 1.8% (95% CI, 1.0-2.8) vs. 1.0% (95% CI, 0.4-2.0), respectively. CONCLUSIONS The total SBI prevalence was 12.6%, and UTI represented the vast majority. The prevalence of bacteraemia and meningitis was low, particularly in the 29-60 days age group, without significant difference between boys and girls.
Collapse
Affiliation(s)
- Ioannis Orfanos
- Department of Clinical Sciences Lund University Lund Sweden
- Department of Pediatrics Skåne University Hospital Lund Sweden
| | - Tobias Alfvén
- Department of Global Public Health Karolinska Institutet Stockholm Sweden
- Sachs’ Children and Youth Hospital Stockholm Sweden
| | - Maria Mossberg
- Department of Clinical Sciences Lund University Lund Sweden
- Department of Pediatrics Skåne University Hospital Lund Sweden
| | | | | | - Erik A. Eklund
- Department of Clinical Sciences Lund University Lund Sweden
- Department of Pediatrics Skåne University Hospital Lund Sweden
| | - Kristina Elfving
- Department of Pediatrics Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- School of Public Health and Community Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| |
Collapse
|
8
|
Lentz JF, Lee JH, Weingrow DM, Schriger DL. Assessment of a third neonatal lumbar puncture position by ultrasound measurement. Acad Emerg Med 2021; 29:109-111. [PMID: 34245647 DOI: 10.1111/acem.14332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Jacob F Lentz
- Department of Emergency Medicine, UCLA, Los Angeles, California, USA
| | - James H Lee
- Department of Pediatrics, UCLA, Los Angeles, California, USA
| | - Daniel M Weingrow
- Department of Emergency Medicine, UCLA, Los Angeles, California, USA
| | - David L Schriger
- Department of Emergency Medicine, UCLA, Los Angeles, California, USA
| |
Collapse
|
9
|
Velasco R, Gomez B, Torre M, Benito J, Mintegi S. A positive nitrite test was an independent risk factor for invasive bacterial infections in infants under 90 days of age with fever without source. Acta Paediatr 2020; 109:2316-2323. [PMID: 32061143 DOI: 10.1111/apa.15230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/01/2020] [Accepted: 02/13/2020] [Indexed: 12/13/2022]
Abstract
AIM This study analysed the association between a positive nitrite dipstick test and an invasive bacterial infection (IBI) in infants younger than 90 days of age with fever without source (FWS). METHODS We performed a secondary analysis of data from a prospective multicentre study of infants up to 90 days of age with FWS undergoing care in 19 paediatric EDs between October 2011 and September 2013. Invasive bacterial infection was defined as a positive blood or cerebrospinal fluid culture. RESULTS The dipstick urinalysis was positive for nitrite or leucocyte esterase in 766 (22.5%) of the 3401 infants we studied, and 270 (35.2%) had a dipstick test that was just positive for nitrite. Overall, 107 were diagnosed with an IBI (3.1%). The IBI prevalence was 2.2% among patients with a normal urine dipstick, 4.4% if they had positive leucocyte esterase test results, 8.3% where the nitrite test was positive and 10.6% when both tests were positive. After multivariate analysis, a positive nitrite test remained an independent risk factor for IBI (odds ratio 2.7, 95% confidence interval 1.4-4.9). CONCLUSION In infants under 90 days of age with FWS, a positive nitrite urine dipstick test was an independent risk factor for IBI.
Collapse
Affiliation(s)
- Roberto Velasco
- Pediatric Emergency Department Rio Hortega Universitary Hospital Valladolid Spain
| | - Borja Gomez
- Pediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao Spain
| | - Mercedes Torre
- Pediatric Emergency Department Niño Jesús University Hospital Madrid Spain
| | - Javier Benito
- Pediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao Spain
| | - Santiago Mintegi
- Pediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao Spain
| |
Collapse
|
10
|
Raba AA, Krebit I. Definite bacterial infection in recently vaccinated febrile infants. J Paediatr Child Health 2020; 56:889-892. [PMID: 31898374 DOI: 10.1111/jpc.14770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/10/2019] [Accepted: 12/18/2019] [Indexed: 11/27/2022]
Abstract
AIM There is insufficient evidence regarding the best approach to evaluating recently vaccinated (RV) infants presenting to the paediatric emergency department with fever. The aim of the present study is to determine the prevalence of bacterial infections in infants presenting with fever within 72 h after vaccination. METHODS We retrospectively reviewed the electronic medical record of infants aged between 6 and 12 weeks who presented with a fever ≥38°C to the emergency department from January 2016 to December 2018. Febrile infants who were vaccinated within 72 h prior to their emergency department presentation were matched to those who had not received their vaccines in the previous 72 h. Definite serious bacterial infection was diagnosed based on culture results. RESULTS A total of 198 infants (age: 9 ± 1.84 weeks, male: 119 (60.1%)) were enrolled in this study. Overall, 60 of 138 (30.3%) had received their vaccines within the previous 72 h. The prevalence of bacterial infection in RV infants was 5% compared to 15.2% in non-RV infants (P = 0.056). Interestingly, all vaccinated infants who had proven bacterial infection presented to the emergency department with fever within 24 h of vaccination, and all bacterial infections in that group were urinary tract infections. CONCLUSIONS The prevalence of bacterial infection among non-RV febrile infants is relatively higher than those RV. However, fever should not be attributed only to the vaccinations, and all febrile RV infants should be carefully evaluated, and at least urine testing should be performed regardless of the time of vaccination.
Collapse
Affiliation(s)
- Ali A Raba
- Paediatric Emergency Department, Tallaght University Hospital, Dublin, Ireland.,School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland.,School of Medicine, Misurata University, Misurata, Libya
| | - Ibraheem Krebit
- Paediatric Emergency Department, Tallaght University Hospital, Dublin, Ireland
| |
Collapse
|
11
|
Ramgopal S, Wilson PM. Automated Versus Manual Band Counts for the Diagnosis of Invasive Bacterial Infections in Infants Who Are Febrile. J Pediatr 2020; 221:246-250.e3. [PMID: 32145966 DOI: 10.1016/j.jpeds.2020.01.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/09/2020] [Accepted: 01/30/2020] [Indexed: 01/25/2023]
Abstract
We conducted a secondary analysis of a prospective study of infants ≤60 days of age who were febrile to assess the diagnostic accuracy of automated vs manual immature neutrophils for invasive bacterial infections. Although manual counts were superior compared with automated counts, bands had suboptimal accuracy overall and had significant variability in test characteristics based on methodology.
Collapse
Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Chicago, IL.
| | - Paria M Wilson
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH; Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
12
|
Ramgopal S, Noorbakhsh KA, Pruitt CM, Aronson PL, Alpern ER, Hickey RW. Outcomes of Young Infants with Hypothermia Evaluated in the Emergency Department. J Pediatr 2020; 221:132-137.e2. [PMID: 32446472 DOI: 10.1016/j.jpeds.2020.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/11/2020] [Accepted: 03/02/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To assess the prevalence of serious infections and mortality among infants ≤90 days of age presenting to the emergency department with hypothermia. STUDY DESIGN We performed a cross-sectional cohort study of infants ≤90 days presenting to any of 40 EDs in the Pediatric Health Information Systems between January 1, 2009, and December 31, 2018. Infants with an International Classification of Diseases, ninth or tenth edition, admission/discharge diagnosis code of hypothermia were included. We determined the prevalence of serious bacterial infection (urinary tract infection, bacteremia, and/or bacterial meningitis), pneumonia, herpes simplex virus (HSV) infection, and emergency department/hospital mortality. RESULTS We included 3565 infants (1633 male [50.9%] and 3225 ≤30 days of age [90.5%]). Most (65.0%) presented in the first week of life. There were 389 infants (10.8%) with a complex chronic condition. The prevalence of serious bacterial infection was 8.0% (n = 284), including 2.4% (n = 87) with urinary tract infection, 5.6% (n = 199) with bacteremia, and 0.3% (n = 11) with bacterial meningitis. There were 7 patients (0.2%) with neonatal HSV and 9 (0.3%) with pneumonia; 0.2% (n = 6) died. The presence of a complex chronic condition was associated with the presence of serious bacterial infection (P < .001) and was present in 3 of 6 patients who died. In a sensitivity analysis including patients with any diagnosis code of hypothermia (n = 8122), 14.9% had serious bacterial infection, 0.6% had HSV, and 3.3% had pneumonia; 2.0% died. CONCLUSIONS Of infants with hypothermia ≤90 days of age, 8.3% had serious bacterial infections or HSV. Compared with literature from febrile infants, hypothermia is associated with a high mortality rate. Complex chronic conditions were particularly associated with poor outcomes. Additional research is required to risk stratify young infants with hypothermia.
Collapse
Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Kathleen A Noorbakhsh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Paul L Aronson
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT; Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| |
Collapse
|
13
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
14
|
Nugent J, Childers M, Singh-Miller N, Howard R, Allard R, Eberly M. Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis. J Pediatr 2019; 212:102-110.e5. [PMID: 31230888 DOI: 10.1016/j.jpeds.2019.04.053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/11/2019] [Accepted: 04/25/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine the risk of bacterial meningitis in infants aged 29-90 days with evidence of urinary tract infection (UTI). METHODS PubMed (MEDLINE), Embase, and the Cochrane Library were systematically searched for studies reporting rates of meningitis in infants aged 29-90 days with abnormal urinalysis or urine culture. Observational studies in infants with evidence of UTI who underwent lumbar puncture (LP) reporting age-specific event rates of bacterial meningitis and sterile cerebrospinal fluid pleocytosis were included. Prevalence estimates for bacterial meningitis in infants with UTI were pooled in a random effects meta-analysis. RESULTS Three prospective and 17 retrospective cohort studies were included in the meta-analysis. The pooled prevalence of concomitant bacterial meningitis in infants with UTI was 0.25% (95% CI, 0.09%-0.70%). Rates of sterile pleocytosis ranged from 0% to 29%. Variation in study methods precluded calculation of a pooled estimate for sterile pleocytosis. In most studies, the decision to perform a LP was up to the provider, introducing selection bias into the prevalence estimate. CONCLUSIONS The risk of bacterial meningitis in infants aged 29-90 days with evidence of UTI is low. A selective approach to LP in infants identified as low risk for meningitis by other clinical criteria may be indicated.
Collapse
Affiliation(s)
- James Nugent
- General Pediatrics, Joint Base Langley-Eustis, Hampton, VA; Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Molly Childers
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD
| | | | - Robin Howard
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, MD
| | - Rhonda Allard
- James A. Zimble Learning Resource Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Matthew Eberly
- Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| |
Collapse
|
15
|
Aronson PL, McCulloh RJ, Tieder JS, Nigrovic LE, Leazer RC, Alpern ER, Feldman EA, Balamuth F, Browning WL, Neuman MI. Application of the Rochester Criteria to Identify Febrile Infants With Bacteremia and Meningitis. Pediatr Emerg Care 2019; 35:22-27. [PMID: 29406479 PMCID: PMC6915062 DOI: 10.1097/pec.0000000000001421] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Rochester criteria were developed to identify febrile infants aged 60 days or younger at low-risk of bacterial infection and do not include cerebrospinal fluid (CSF) testing. Prior studies have not specifically assessed criteria performance for bacteremia and bacterial meningitis (invasive bacterial infection). Our objective was to determine the sensitivity of the Rochester criteria for detection of invasive bacterial infection. METHODS Retrospective cohort study of febrile infants aged 60 days or younger with invasive bacterial infections evaluated at 8 pediatric emergency departments from July 1, 2012, to June 30, 2014. Potential cases were identified from the Pediatric Health Information System using International Classification of Diseases, Ninth Revision diagnosis codes for bacteremia, meningitis, urinary tract infection, and fever. Medical record review was then performed to confirm presence of an invasive bacterial infection and to evaluate the Rochester criteria: medical history, symptoms or ill appearance, results of urinalysis, complete blood count, CSF testing (if obtained), and blood, urine, and CSF culture. An invasive bacterial infection was defined as growth of pathogenic bacteria from blood or CSF culture. RESULTS Among 82 febrile infants aged 60 days or younger with invasive bacterial infection, the sensitivity of the Rochester criteria were 92.7% (95% confidence interval [CI], 84.9%-96.6%) overall, 91.7% (95% CI, 80.5%-96.7%) for neonates 28 days or younger, and 94.1% (95% CI, 80.9%-98.4%) for infants aged 29 to 60 days old. Six infants with bacteremia, including 1 neonate with bacterial meningitis, met low-risk criteria. CONCLUSIONS The Rochester criteria identified 92% of infants aged 60 days or younger with invasive bacterial infection. However, 1 neonate 28 days or younger with meningitis was classified as low-risk.
Collapse
Affiliation(s)
- Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT,§ Address Correspondence to: Paul L. Aronson, MD, Section of Pediatric Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511. Phone: 203-737-7443, Fax: 203-737-7447,
| | - Russell J. McCulloh
- Division of Infectious Diseases, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri–Kansas City School of Medicine, Kansas City, MO
| | - Joel S. Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA,University of Washington School of Medicine, Seattle, WA
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Rianna C. Leazer
- Division of Hospital Medicine, Department of Pediatrics, Children’s Hospital of the King’s Daughters, Norfolk, VA
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Fran Balamuth
- The Center for Pediatric Clinical Effectiveness and Division of Emergency Medicine, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Whitney L. Browning
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Mark I. Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | | |
Collapse
|
16
|
Richardson KM, Fouquet SD, Kerns E, McCulloh RJ. Impact of Mobile Device-Based Clinical Decision Support Tool on Guideline Adherence and Mental Workload. Acad Pediatr 2019; 19:828-834. [PMID: 30853573 PMCID: PMC6732014 DOI: 10.1016/j.acap.2019.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/05/2019] [Accepted: 03/02/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the individual-level impact of an electronic clinical decision support (ECDS) tool, PedsGuide, on febrile infant clinical decision making and cognitive load. METHODS A counterbalanced, prospective, crossover simulation study was performed among attending and trainee physicians. Participants performed simulated febrile infant cases with use of PedsGuide and with standard reference text. Cognitive load was assessed using the NASA-Task Load Index (NASA-TLX), which determines mental, physical, temporal demand, effort, frustration, and performance. Usability was assessed with the System Usability Scale (SUS). Scores on cases and NASA-TLX scores were compared between condition states. RESULTS A total of 32 participants completed the study. Scores on febrile infant cases using PedsGuide were greater compared with standard reference text (89% vs 72%, P = .001). NASA-TLX scores were lower (ie, more optimal) with use of PedsGuide versus control (mental 6.34 vs 11.8, P < .001; physical 2.6 vs 6.1, P = .001; temporal demand 4.6 vs 8.0, P = .003; performance 4.5 vs 8.3, P < .001; effort 5.8 vs 10.7, P < .001; frustration 3.9 vs 10, P < .001). The SUS had an overall score of 88 of 100 with rating of acceptable on the acceptability scale. CONCLUSIONS Use of PedsGuide led to increased adherence to guidelines and decreased cognitive load in febrile infant management when compared with the use of a standard reference tool. This study employs a rarely used method of assessing ECDS tools using a multifaceted approach (medical decision-making, assessing usability, and cognitive workload,) that may be used to assess other ECDS tools in the future.
Collapse
Affiliation(s)
| | - Sarah D Fouquet
- Department of Medical Informatics and Telemedicine, Children’s Mercy Kansas City, Kansas City, MO, USA
| | - Ellen Kerns
- Department of Pediatrics, Children’s Hospital & Medical Center, 8200 Dodge Street, Omaha, NE, 68114, USA,Affiliation at the time work was completed: Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, USA
| | - Russell J McCulloh
- Department of Pediatrics, Children’s Hospital & Medical Center, 8200 Dodge Street, Omaha, NE, 68114, USA,Affiliation at the time work was completed: Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, USA
| |
Collapse
|
17
|
Mahajan P, Browne LR, Levine DA, Cohen DM, Gattu R, Linakis JG, Anders J, Borgialli D, Vitale M, Dayan PS, Casper TC, Ramilo O, Kuppermann N. Risk of Bacterial Coinfections in Febrile Infants 60 Days Old and Younger with Documented Viral Infections. J Pediatr 2018; 203:86-91.e2. [PMID: 30195552 PMCID: PMC7094460 DOI: 10.1016/j.jpeds.2018.07.073] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/17/2018] [Accepted: 07/20/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections. STUDY DESIGN Planned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants. RESULTS Of the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The rate of bacterial meningitis tended to be lower in the virus-positive group (0.4%) than in the viral-negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6), was significantly associated with SBI in multivariable analysis. CONCLUSIONS Febrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis.
Collapse
Affiliation(s)
- Prashant Mahajan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI.
| | - Lorin R. Browne
- Department of Pediatrics and Emergency Medicine, Children's Hospital of Wisconsin, Medical College of Wisconsin, Wauwatosa, WI
| | - Deborah A. Levine
- Department of Emergency Medicine and Pediatrics, Bellevue Hospital New York University Langone Medical Center, Bellevue Hospital Center, New York, NY
| | - Daniel M. Cohen
- Section of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Rajender Gattu
- Division of Emergency Medicine, Department of Pediatrics, University of Maryland Medical Center, Baltimore, MD
| | - James G. Linakis
- Department of Emergency Medicine and Pediatrics, Hasbro Children's Hospital and Brown University, Providence, RI
| | - Jennifer Anders
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Dominic Borgialli
- Department of Emergency Medicine, Hurley Medical Center and University of Michigan, Flint, MI
| | - Melissa Vitale
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Peter S. Dayan
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, NY
| | | | - Octavio Ramilo
- Division of Pediatric Infectious Diseases and Center for Vaccines and Immunity, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine and UC Davis Health, Davis, CA
| | - Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN)PowellElizabeth C.MD, MPH14LevineDeborah A.MD15TunikMichael G.MD15NigrovicLise E.MD, MPH16RooseveltGenieMD17MahajanPrashantMD, MPH, MBA18AlpernElizabeth R.MD, MSCE19VitaleMelissaMD20BrowneLorinDO21SaundersMaryMD21AtabakiShireen M.MD, MPH22RuddyRichard M.MD23LinakisJames G.MD, PhD24HoyleJohn D.Jr.MD25BorgialliDominicDO, MPH26BlumbergStephenMD27CrainEllen F.MD, PhD27AndersJenniferMD28BonsuBemaMD29CohenDaniel M.MD29BennettJonathan E.MD30DayanPeter S.MD, MSc31GreenbergRichardMD32JaffeDavid M.MD33MuenzerJaredMD33CruzAndrea T.MD, MPH34MaciasCharlesMD34KuppermannNathanMD, MPH35TzimenatosLeahMD35GattuRajenderMD36RogersAlexander J.MD37BrayerAnneMD38LillisKathleenMD39Ann & Robert H. Lurie Children's HospitalBellevue Hospital CenterBoston Children's HospitalChildren's Hospital of ColoradoChildren's Hospital of MichiganChildren's Hospital of PhiladelphiaChildren's Hospital of PittsburghChildren's Hospital of WisconsinChildren's National Medical CenterCincinnati Children's Hospital Medical CenterHasbro Children's HospitalHelen DeVos Children's HospitalHurley Medical CenterJacobi Medical CenterJohns Hopkins Children's CenterNationwide Children's HospitalNemours/Alfred I. DuPont Hospital for ChildrenNew York Presbyterian-Morgan Stanley Children's HospitalPrimary Children's Medical CenterSt. Louis Children's HospitalTexas Children's HospitalUniversity of California Davis HealthUniversity of MarylandUniversity of MichiganUniversity of RochesterWomen and Children's Hospital of Buffalo
| |
Collapse
|
18
|
Woll C, Neuman MI, Pruitt CM, Wang ME, Shapiro ED, Shah SS, McCulloh RJ, Nigrovic LE, Desai S, DePorre AG, Leazer RC, Marble RD, Balamuth F, Feldman EA, Sartori L, Browning WL, Aronson PL. Epidemiology and Etiology of Invasive Bacterial Infection in Infants ≤60 Days Old Treated in Emergency Departments. J Pediatr 2018; 200:210-217.e1. [PMID: 29784512 PMCID: PMC6109608 DOI: 10.1016/j.jpeds.2018.04.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/07/2018] [Accepted: 04/17/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To help guide empiric treatment of infants ≤60 days old with suspected invasive bacterial infection by describing pathogens and their antimicrobial susceptibilities. STUDY DESIGN Cross-sectional study of infants ≤60 days old with invasive bacterial infection (bacteremia and/or bacterial meningitis) evaluated in the emergency departments of 11 children's hospitals between July 1, 2011 and June 30, 2016. Each site's microbiology laboratory database or electronic medical record system was queried to identify infants from whom a bacterial pathogen was isolated from either blood or cerebrospinal fluid. Medical records of these infants were reviewed to confirm the presence of a pathogen and to obtain demographic, clinical, and laboratory data. RESULTS Of the 442 infants with invasive bacterial infection, 353 (79.9%) had bacteremia without meningitis, 64 (14.5%) had bacterial meningitis with bacteremia, and 25 (5.7%) had bacterial meningitis without bacteremia. The peak number of cases of invasive bacterial infection occurred in the second week of life; 364 (82.4%) infants were febrile. Group B streptococcus was the most common pathogen identified (36.7%), followed by Escherichia coli (30.8%), Staphylococcus aureus (9.7%), and Enterococcus spp (6.6%). Overall, 96.8% of pathogens were susceptible to ampicillin plus a third-generation cephalosporin, 96.0% to ampicillin plus gentamicin, and 89.2% to third-generation cephalosporins alone. CONCLUSIONS For most infants ≤60 days old evaluated in a pediatric emergency department for suspected invasive bacterial infection, the combination of ampicillin plus either gentamicin or a third-generation cephalosporin is an appropriate empiric antimicrobial treatment regimen. Of the pathogens isolated from infants with invasive bacterial infection, 11% were resistant to third-generation cephalosporins alone.
Collapse
Affiliation(s)
- Christopher Woll
- Departments of Pediatrics and of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Mark I. Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Christopher M. Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Marie E. Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA
| | - Eugene D. Shapiro
- Departments of Pediatrics, of Epidemiology, and of Investigative Medicine, Yale University, New Haven, CT
| | - Samir S. Shah
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Russell J. McCulloh
- Division of Infectious Diseases, Children’s Mercy Hospital, Kansas City, MO,Division of Hospital Medicine, Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO
| | - Lise. E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Sanyukta Desai
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Adrienne G. DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO
| | - Rianna C. Leazer
- Division of Hospital Medicine, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Richard D. Marble
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Frances Balamuth
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Laura Sartori
- Divisions of Pediatric Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Whitney L. Browning
- Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Paul L. Aronson
- Departments of Pediatrics and of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT,Address Correspondence to: Paul L. Aronson, MD, Section of Pediatric Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511. Phone: 203-785-3849, Fax: 203-737-7447,
| | | |
Collapse
|
19
|
Blaschke AJ, Holmberg KM, Daly JA, Leber AL, Dien Bard J, Korgenski EK, Bourzac KM, Kanack KJ. Retrospective Evaluation of Infants Aged 1 to 60 Days with Residual Cerebrospinal Fluid (CSF) Tested Using the FilmArray Meningitis/Encephalitis (ME) Panel. J Clin Microbiol 2018; 56:e00277-18. [PMID: 29669791 PMCID: PMC6018345 DOI: 10.1128/jcm.00277-18] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/14/2018] [Indexed: 01/02/2023] Open
Abstract
In pediatric practice it is common for infants under 2 months of age to undergo evaluation for sepsis when they are ill, often including lumbar puncture to assess for central nervous system (CNS) infection. The FilmArray Meningitis/Encephalitis (ME) panel is a newly approved test for rapid identification of CNS pathogens. Our objective was to study the epidemiology of CNS infection in young infants and the potential impact of rapid multiplex PCR on their care. A performance evaluation of the FilmArray ME panel was conducted from February 2014 to September 2014 at 11 sites. FilmArray ME panel results were compared to reference standards but not shared with providers. In our study, medical records for infants (aged 1 to 60 days) enrolled at three sites were reviewed for clinical, laboratory, and outcome data. A total of 145 infants were reviewed. The median age was 25 days. Most of the infants were hospitalized (134/145 [92%]) and received antibiotics (123/145 [85%]), and almost half (71/145 [49%]) received acyclovir. One infant had a bacterial pathogen, likely false positive, identified by the FilmArray ME panel. Thirty-six infants (25%) had a viral pathogen detected, including 21 enteroviruses. All infants with enteroviral meningitis detected by the FilmArray ME panel and conventional PCR were hospitalized, but 20% were discharged in less than 24 h when conventional PCR results became available. The FilmArray ME panel may play a role in the evaluation of young infants for CNS infection. Results may be used to guide management, possibly resulting in a decreased length of stay and less antimicrobial exposure for infants with low-risk viral infection detected.
Collapse
Affiliation(s)
- Anne J Blaschke
- University of Utah School of Medicine, Department of Pediatrics, Division of Pediatric Infectious Diseases, Salt Lake City, Utah, USA
| | | | - Judy A Daly
- Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Amy L Leber
- Nationwide Children's Hospital, Columbus, Oklahoma, USA
| | | | - Ernest K Korgenski
- University of Utah School of Medicine, Department of Pediatrics, Division of Pediatric Infectious Diseases, Salt Lake City, Utah, USA
- Pediatric Clinical Program, Intermountain Healthcare, Salt Lake City, Utah, USA
| | | | | |
Collapse
|
20
|
Scarfone R, Murray A, Gala P, Balamuth F. Lumbar Puncture for All Febrile Infants 29-56 Days Old: A Retrospective Cohort Reassessment Study. J Pediatr 2017; 187:200-205.e1. [PMID: 28526220 DOI: 10.1016/j.jpeds.2017.04.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/20/2017] [Accepted: 04/05/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine the incidence of bacterial meningitis (BM) among all febrile infants 29-56 days old undergoing a lumbar puncture (LP) in the emergency department of a tertiary care children's hospital and the number of low-risk febrile infants with BM to reassess the need for routine LP in these infants. STUDY DESIGN Retrospective cohort study using a quality improvement registry from July 2007-April 2014. Infants included were 29-56 days old with fever and who had an LP in the emergency department. Low-risk criteria were adapted from the Philadelphia criteria. BM was defined as having a bacterial pathogen isolated from the cerebrospinal fluid. A medical record review of one-third of randomly selected patients in the cohort determined the proportion who met low-risk criteria. RESULTS One of 1188 febrile infants (0.08%) had BM; this patient did not meet low-risk criteria. An additional 40 (3.4%) had positive cerebrospinal fluid cultures; all were contaminants. Subanalysis of one-third of the study population revealed that 45.6% met low-risk criteria; the most common reasons for failing low-risk classification included abnormal white blood cell count or urinalysis. CONCLUSIONS In a cohort of febrile infants, BM is uncommon and no cases of BM would have been missed had LPs not been performed in those meeting low-risk criteria.
Collapse
|
21
|
Abstract
The use of empiric acyclovir for suspected neonatal herpes simplex virus (HSV) infection has been debated for years. To identify the gap in the decision to initiate empiric acyclovir, we performed a retrospective chart review and administered a survey to pediatricians to assess current practices regarding evaluation for possible HSV infection. Seventy infants received empiric acyclovir over a 1-year period; of these, 3 infants (4.3%) had positive HSV testing. Fourteen infants were identified as "high-risk" for HSV infection; of these, 13 infants had incomplete testing. Survey results revealed uncertainty in the decision to initiate acyclovir and in the composition of complete diagnostic testing. This study confirmed the clinical uncertainty in the decision to initiate empiric acyclovir. Using this chart review and survey as a baseline, future efforts will focus on a quality improvement project to reduce empiric acyclovir use in low-risk infants and to ensure complete diagnostic evaluation in high-risk infants.
Collapse
Affiliation(s)
- Peyton Wilson
- 1 University of North Carolina at Chapel Hill, NC, USA
| | | | | | | | - Ravi Jhaveri
- 1 University of North Carolina at Chapel Hill, NC, USA
| |
Collapse
|
22
|
Mischler M, Ryan MS, Leyenaar JK, Markowsky A, Seppa M, Wood K, Ren J, Asche C, Gigliotti F, Biondi E. Epidemiology of Bacteremia in Previously Healthy Febrile Infants: A Follow-up Study. Hosp Pediatr 2015; 5:293-300. [PMID: 26034160 DOI: 10.1542/hpeds.2014-0121] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Describe the etiology of bacteremia among a geographically diverse sample of previously well infants with fever admitted for general pediatric care and to characterize demographic and clinical characteristics of infants with bacteremia according to bacterial etiology. We hypothesized that the epidemiology of bacteremia in febrile infants from a geographically diverse cohort would show similar results to smaller or single-center cohorts previously reported. METHODS This was a retrospective review of positive, pathogenic blood cultures in previously healthy, febrile infants≤90 days old admitted to a general unit. In total, there were 17 participating sites from diverse geographic regions of the United States. Cultures were included if the results were positive for bacteria, obtained from an infant 90 days old or younger with a temperature≥38.0°C, analyzed using an automated detection system, and treated as pathogenic. RESULTS Escherichia coli was the most prevalent species, followed by group B Streptococcus, Streptococcus viridans, and Staphylococcus aureus. Among the most prevalent bacteria, there was no association between gender and species (Ps>.05). Age at presentation was associated only with Streptococcus pneumoniae. There were no cases of Listeria monocytogenes. CONCLUSIONS Our study confirms the data from smaller or single-center studies and suggests that the management of febrile well-appearing infants should change to reflect the current epidemiology of bacteremia. Further research is needed into the role of lumbar puncture, as well as the role of Listeria and Enterococcus species in infantile bacteremia.
Collapse
Affiliation(s)
- Matthew Mischler
- University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Michael S Ryan
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | | | - Allison Markowsky
- The George Washington University School of Medicine, Washington, District of Columbia
| | | | - Kelly Wood
- University of Iowa Children's Hospital, Iowa City, Iowa
| | - Jinma Ren
- University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Carl Asche
- University of Illinois College of Medicine at Peoria, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | | | - Eric Biondi
- University of Rochester Medical Center, Rochester, New York
| |
Collapse
|
23
|
Mahajan P, Kuppermann N, Suarez N, Mejias A, Casper C, Dean JM, Ramilo O; Febrile Infant Working Group for the Pediatric Emergency Care Applied Research Network (PECARN). RNA transcriptional biosignature analysis for identifying febrile infants with serious bacterial infections in the emergency department: a feasibility study. Pediatr Emerg Care 2015; 31:1-5. [PMID: 25526020 DOI: 10.1097/PEC.0000000000000324] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To develop the infrastructure and demonstrate the feasibility of conducting microarray-based RNA transcriptional profile analyses for the diagnosis of serious bacterial infections in febrile infants 60 days and younger in a multicenter pediatric emergency research network. METHODS We designed a prospective multicenter cohort study with the aim of enrolling more than 4000 febrile infants 60 days and younger. To ensure success of conducting complex genomic studies in emergency department (ED) settings, we established an infrastructure within the Pediatric Emergency Care Applied Research Network, including 21 sites, to evaluate RNA transcriptional profiles in young febrile infants. We developed a comprehensive manual of operations and trained site investigators to obtain and process blood samples for RNA extraction and genomic analyses. We created standard operating procedures for blood sample collection, processing, storage, shipping, and analyses. We planned to prospectively identify, enroll, and collect 1 mL blood samples for genomic analyses from eligible patients to identify logistical issues with study procedures. Finally, we planned to batch blood samples and determined RNA quantity and quality at the central microarray laboratory and organized data analysis with the Pediatric Emergency Care Applied Research Network data coordinating center. Below we report on establishment of the infrastructure and the feasibility success in the first year based on the enrollment of a limited number of patients. RESULTS We successfully established the infrastructure at 21 EDs. Over the first 5 months we enrolled 79% (74 of 94) of eligible febrile infants. We were able to obtain and ship 1 mL of blood from 74% (55 of 74) of enrolled participants, with at least 1 sample per participating ED. The 55 samples were shipped and evaluated at the microarray laboratory, and 95% (52 of 55) of blood samples were of adequate quality and contained sufficient RNA for expression analysis. CONCLUSIONS It is possible to create a robust infrastructure to conduct genomic studies in young febrile infants in the context of a multicenter pediatric ED research setting. The sufficient quantity and high quality of RNA obtained suggests that whole blood transcriptional profile analysis for the diagnostic evaluation of young febrile infants can be successfully performed in this setting.
Collapse
|
24
|
Bender JM, Taylor CS, Cumpio J, Novak SM, She RC, Steinberg EA, Marlowe EM. Infants 1-90 days old hospitalized with human rhinovirus infection. J Clin Lab Anal 2014; 28:349-52. [PMID: 24648198 DOI: 10.1002/jcla.21692] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 09/12/2013] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Human rhinovirus (HRV) is a common cause of respiratory illness in children. The impact of HRV infection on 1- to 90-day-old infants is unclear. We hypothesized that HRV infection would be clinically similar to respiratory syncytial virus (RSV) infection in the hospitalized infants. METHODS We conducted a retrospective study of hospitalized infants, who were 1-90 days old, with HRV or RSV within the Southern California Kaiser Permanente network over a 1-year period (August 2010 to October 2011). RESULTS We identified 245 hospitalized infants who underwent respiratory virus testing. HRV was found in 52 infants (21%) compared to 79 infants (32%) with RSV (P = 0.008). Infants with HRV infection experienced longer hospital stays compared to those with RSV (median length of stay 4 days vs. 3 days, P = 0.009) and had fewer short hospital stays ≤3 days (P = 0.029). There was a trend in infants with HRV infection to be younger (P = 0.071) and have more fevers (P = 0.052). CONCLUSIONS Recent advances in diagnostics allow for identification of a broad range of viral pathogens in infants. Compared to RSV, HRV was associated with longer hospital stays. Additional studies and improved, more specific testing, methods are needed to further define the effects of HRV infection in infants 1-90 days old.
Collapse
Affiliation(s)
- Jeffrey M Bender
- Department of Pediatrics, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California; Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | | | | | | | | | | | | |
Collapse
|
25
|
Biondi E, Evans R, Mischler M, Bendel-Stenzel M, Horstmann S, Lee V, Aldag J, Gigliotti F. Epidemiology of bacteremia in febrile infants in the United States. Pediatrics 2013; 132:990-6. [PMID: 24218461 DOI: 10.1542/peds.2013-1759] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Fever in infants is a common clinical dilemma. The objective of this study was to present data from hospital systems across the northeast, southeast, mid-west, and western United States to identify the pathogens causing bacteremia in febrile infants admitted to general care units. METHODS This was a retrospective review of positive blood culture results in febrile infants aged ≤90 days admitted to a general care unit across 6 hospital systems. Data were collected from January 1, 2006 through December 31, 2012 from emergency departments and general inpatient units. Cultures from ICUs, central lines, or infants who had complex comorbidities were excluded, as were repeat cultures positive for the same bacteria. Common contaminants were considered pathogens if they were treated as such. RESULTS We identified 181 cases of bacteremia in 177 infants. The most common pathogen was Escherichia coli (42%), followed by group B Streptococcus (23%). Streptococcus pneumoniae was more likely in older infants (P = .01). Non-low-risk bacteremic infants were more likely to have E. coli or group B Streptococcus than low-risk bacteremic infants. We identified no cases of Listeria monocytogenes. Variation between sites was minimal. CONCLUSIONS This is the largest and most geographically diverse study to date examining the epidemiology of bacteremia in infants. We suggest E. coli is the most common cause of bacteremia in previously healthy febrile infants admitted to a general inpatient unit. We identified no cases of L monocytogenes and question whether empirical therapy remains necessary for this pathogen.
Collapse
Affiliation(s)
- Eric Biondi
- Department of Pediatrics, University of Rochester Medical Center, 601 Elmwood Ave, Box 667, Rochester, NY 14620.
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Doby EH, Stockmann C, Korgenski EK, Blaschke AJ, Byington CL. Cerebrospinal fluid pleocytosis in febrile infants 1-90 days with urinary tract infection. Pediatr Infect Dis J 2013; 32:1024-6. [PMID: 23584580 DOI: 10.1097/INF.0b013e31829063cd] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sterile cerebrospinal fluid pleocytosis occurs in febrile infants with urinary tract infection. Coinfection with enterovirus is a possible cause. We evaluated 57 infants with urinary tract infection and cerebrospinal fluid pleocytosis. All had enterovirus testing by polymerase chain reaction. An explanation for pleocytosis was determined for 24 infants (42%). Enterovirus infection was detected in 4 and is an uncommon cause of cerebrospinal fluid pleocytosis in infants with urinary tract infection.
Collapse
|