Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments

OBJECTIVES

The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs).

METHODS

Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use.

RESULTS

Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82).

CONCLUSIONS

BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

A Novel Risk Score to Guide the Evaluation of Acute Hematogenous Osteomyelitis in Children

OBJECTIVES

To identify independent predictors of and derive a risk score for acute hematogenous osteomyelitis (AHO) in children.

METHODS

We conducted a retrospective matched case-control study of children >90 days to <18 years of age undergoing evaluation for a suspected musculoskeletal (MSK) infection from 2017 to 2019 at 23 pediatric emergency departments (EDs) affiliated with the Pediatric Emergency Medicine Collaborative Research Committee. Cases were identified by diagnosis codes and confirmed by chart review to meet accepted diagnostic criteria for AHO. Controls included patients who underwent laboratory and imaging tests to evaluate for a suspected MSK infection and received an alternate final diagnosis.

RESULTS

We identified 1135 cases of AHO matched to 2270 controls. Multivariable logistic regression identified 10 clinical and laboratory factors independently associated with AHO. We derived a 4-point risk score for AHO using (1) duration of illness >3 days, (2) history of fever or highest ED temperature ≥38°C, (3) C-reactive protein >2.0 mg/dL, and (4) erythrocyte sedimentation rate >25 mm per hour (area under the curve: 0.892, 95% confidence interval [CI]: 0.881 to 0.901). Choosing to pursue definitive diagnostics for AHO when 3 or more factors are present maximizes diagnostic accuracy at 84% (95% CI: 82% to 85%), whereas children with 0 factors present are highly unlikely to have AHO (sensitivity: 0.99, 95% CI: 0.98 to 1.00).

CONCLUSIONS

We identified 10 predictors for AHO in children undergoing evaluation for a suspected MSK infection in the pediatric ED and derived a novel 4-point risk score to guide clinical decision-making.

Omphalitis: Clinical Presentation and Approach to Evaluation and Management

ABSTRACT

Omphalitis is an uncommon but potentially serious infection in neonates. Findings include erythema and induration around the umbilical stump, and purulent drainage may be present. Fever and signs of systemic illness may occur, or there may only be signs of localized soft tissue infection. Until recently, there have been very few cohort studies of omphalitis in high-income countries, and no literature was available regarding the incidence of concurrent serious bacterial infection such as meningitis or urinary tract infection. A recent large, multicenter study suggests that most omphalitis presents as localized soft tissue infection, with very low rates of concurrent serious bacterial infection or adverse outcomes. Underlying urachal abnormalities should be considered in the infant with umbilical drainage. Treatment of omphalitis consists primarily of antibiotic administration, with surgical intervention rarely needed. Although antibiotics are typically administered intravenously, there may be a role for oral antibiotics in some lower risk infants with omphalitis.

Diagnostic testing for evaluation of brief resolved unexplained events

BACKGROUND

Since the publication of the American Academy of Pediatrics (AAP) clinical practice guideline for brief resolved unexplained events (BRUEs), a few small, single-center studies have suggested low yield of diagnostic testing in infants presenting with such an event. We conducted this large retrospective multicenter study to determine the role of diagnostic testing in leading to a confirmatory diagnosis in BRUE patients.

METHODS

Secondary analysis from a large multicenter cohort derived from 15 hospitals participating in the BRUE Quality Improvement and Research Collaborative. The study subjects were infants < 1 year of age presenting with a BRUE to the emergency departments (EDs) of these hospitals between October 1, 2015, and September 30, 2018. Potential BRUE cases were identified using a validated algorithm that relies on administrative data. Chart review was conducted to confirm study inclusion/exclusion, AAP risk criteria, final diagnosis, and contribution of test results. Findings were stratified by ED or hospital discharge and AAP risk criteria. For each patient, we identified whether any diagnostic test contributed to the final diagnosis. We distinguished true (contributory) results from false-positive results.

RESULTS

Of 2036 patients meeting study criteria, 63.2% were hospitalized, 87.1% qualified as AAP higher risk, and 45.3% received an explanatory diagnosis. Overall, a laboratory test, imaging, or an ancillary test supported the final diagnosis in 3.2% (65/2036, 95% confidence interval [CI] 2.7%-4.4%) of patients. Out of 5163 diagnostic tests overall, 1.1% (33/2897, 95% CI 0.8%-1.5%) laboratory tests and 1.5% (33/2266, 95% CI 1.0%-1.9%) of imaging and ancillary studies contributed to a diagnosis. Although 861 electrocardiograms were performed, no new cardiac diagnoses were identified during the index visit.

CONCLUSIONS

Diagnostic testing to explain BRUE including for those with AAP higher risk criteria is low yield and rarely contributes to an explanation. Future research is needed to evaluate the role of testing in more specific, at-risk populations.

Omphalitis and Concurrent Serious Bacterial Infection

OBJECTIVE

Describe the clinical presentation, prevalence of concurrent serious bacterial infection (SBI), and outcomes among infants with omphalitis.

METHODS

Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants ≤90 days of age with omphalitis seen in the emergency department from January 1, 2008, to December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized.

RESULTS

Among 566 infants (median age 16 days), 537 (95%) were well-appearing, 64 (11%) had fever at home or in the emergency department, and 143 (25%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 472 (83%), 326 (58%), and 222 (39%) infants, respectively. Pathogens grew in 1.1% (95% confidence interval [CI], 0.3%-2.5%) of blood, 0.9% (95% CI, 0.2%-2.7%) of urine, and 0.9% (95% CI, 0.1%-3.2%) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 320 (57%) infants, with 85% (95% CI, 80%-88%) growing a pathogen, most commonly methicillin-sensitive Staphylococcus aureus (62%), followed by methicillin-resistant Staphylococcus aureus (11%) and Escherichia coli (10%). Four hundred ninety-eight (88%) were hospitalized, 81 (16%) to an ICU. Twelve (2.1% [95% CI, 1.1%-3.7%]) had sepsis or shock, and 2 (0.4% [95% CI, 0.0%-1.3%]) had severe cellulitis or necrotizing soft tissue infection. There was 1 death. Serious complications occurred only in infants aged <28 days.

CONCLUSIONS

In this multicenter cohort, mild, localized disease was typical of omphalitis. SBI and adverse outcomes were uncommon. Depending on age, routine testing for SBI is likely unnecessary in most afebrile, well-appearing infants with omphalitis.

Neonatal Mastitis and Concurrent Serious Bacterial Infection

OBJECTIVES

Describe the clinical presentation, prevalence, and outcomes of concurrent serious bacterial infection (SBI) among infants with mastitis.

METHODS

Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants aged ≤90 days with mastitis who were seen in the emergency department between January 1, 2008, and December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized.

RESULTS

Among 657 infants (median age 21 days), 641 (98%) were well appearing, 138 (21%) had history of fever at home or in the emergency department, and 63 (10%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 581 (88%), 274 (42%), and 216 (33%) infants, respectively. Pathogens grew in 0.3% (95% confidence interval [CI] 0.04-1.2) of blood, 1.1% (95% CI 0.2-3.2) of urine, and 0.4% (95% CI 0.01-2.5) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 335 (51%) infants, with 77% (95% CI 72-81) growing a pathogen, most commonly methicillin-resistant Staphylococcus aureus (54%), followed by methicillin-susceptible S aureus (29%), and unspecified S aureus (8%). A total of 591 (90%) infants were admitted to the hospital, with 22 (3.7%) admitted to an ICU. Overall, 10 (1.5% [95% CI 0.7-2.8]) had sepsis or shock, and 2 (0.3% [95% CI 0.04-1.1]) had severe cellulitis or necrotizing soft tissue infection. None received vasopressors or endotracheal intubation. There were no deaths.

CONCLUSIONS

In this multicenter cohort, mild localized disease was typical of neonatal mastitis. SBI and adverse outcomes were rare. Evaluation for SBI is likely unnecessary in most afebrile, well-appearing infants with mastitis.

Research environment and resources to support pediatric emergency medicine fellow research

BACKGROUND

There is a need for pediatric emergency medicine (PEM) researchers, but the current state of PEM fellow research training is not well described. We sought to (1) describe resources and gaps in PEM fellowship research training and (2) assess agreement between fellow and program director (PD) perceptions of these in fellow research experience.

METHODS

Surveys were distributed electronically to U.S. PEM fellows and PDs from March to April 2020. Fellows and PDs were queried on program research infrastructure and current gaps in fellow research experience. For programs that had at least one fellow and PD response, each fellow response was compared to their PD's corresponding response (reference standard). For each binary survey item, we determined the percent of responses with agreement between the fellow and PD.

RESULTS

Of 79 fellowship programs, 70 (89%) were represented with at least one response, including responses from 59 PDs (75%) and 218 fellows (39% of all fellows, representing 80% of programs). Fellows and PDs identified mentorship and faculty engagement as the most important needs for successful fellowship research; for every one fellow there was a median of 0.8 potential faculty mentors in the division. Twenty percent of fellows were not satisfied with mentorship opportunities. There was no association between fellow career research intent (high, defined as ≥20% dedicated time, or low) with current year of training (p = 0.88), program size (p = 0.67), and area of research focus (p = 0.40). Fellows were often unaware of research being performed by division faculty.

CONCLUSION

PEM fellows were not consistently aware of resources available to support research training. To better support PEM fellows' research training, many programs may need to expand mentorship and increase fellows' awareness of local and external resources and opportunities.

Accuracy of Diagnostic Codes for Identifying Brief Resolved Unexplained Events

OBJECTIVES

To evaluate International Classification of Diseases, 10th Revision (ICD-10) coding strategies for the identification of patients with a brief resolved unexplained event (BRUE).

METHODS

Multicenter retrospective cohort study, including patients aged <1 year with an emergency department (ED) visit between October 1, 2015, and September 30, 2018, and an ICD-10 code for the following: (1) BRUE; (2) characteristics of BRUE; (3) serious underlying diagnoses presenting as a BRUE; and (4) nonserious diagnoses presenting as a BRUE. Sixteen algorithms were developed by using various combinations of these 4 groups of ICD-10 codes. Manual chart review was used to assess the performance of these ICD-10 algorithms for the identification of (1) patients presenting to an ED who met the American Academy of Pediatrics clinical definition for a BRUE and (2) the subset of these patients discharged from the ED or hospital without an explanation for the BRUE.

RESULTS

Of 4512 records reviewed, 1646 (36.5%) of these patients met the American Academy of Pediatrics criteria for BRUE on ED presentation, 1016 (61.7%) were hospitalized, and 959 (58.3%) had no explanation on discharge. Among ED discharges, the BRUE ICD-10 code alone was optimal for case ascertainment (sensitivity: 89.8% to 92.8%; positive predictive value: 51.7% to 72.0%). For hospitalized patients, ICD-10 codes related to the clinical characteristics of BRUE are preferred (specificity 93.2%, positive predictive value 32.7% to 46.3%).

CONCLUSIONS

The BRUE ICD-10 code and/or the diagnostic codes for the characteristics of BRUE are recommended, but the choice between approaches depends on the investigative purpose and the specific BRUE population and setting of interest.

Predicting Adverse Outcomes for Shiga Toxin-Producing Escherichia coli Infections in Emergency Departments

OBJECTIVE

To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting.

STUDY DESIGN

We reviewed medical records of children <18 years old infected with STEC and treated in 1 of 38 participating emergency departments in North America between 2011 and 2015. The HUS severity score (hemoglobin [g/dL] plus 2-times serum creatinine [mg/dL]) was calculated using first available laboratory results. Children with scores >13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure, and death) using discrimination and net benefit (ie, threshold probability), with subgroup analyses by age and day-of-illness.

RESULTS

A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (area under the curve 0.71, 95% CI 0.63-0.79) and better among children <5 years old (area under the curve 0.77, 95% CI 0.68-0.87). For children <5 years, greatest net benefit was achieved for a threshold probability >26%.

CONCLUSIONS

The HUS severity score was able to discriminate between high- and low-risk children <5 years old with STEC-associated HUS at a statistically acceptable level; however, it did not appear to provide clinical benefit at a meaningful risk threshold.

Predicting Hemolytic Uremic Syndrome and Renal Replacement Therapy in Shiga Toxin-producing Escherichia coli-infected Children

BACKGROUND

Shiga toxin-producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care.

METHODS

We conducted a multicenter, historical cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children aged <18 years who submitted STEC-positive specimens between January 2011 and December 2015 at a participating study institution were eligible.

RESULTS

Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69-.85] per year), leukocyte count ≥13.0 × 103/μL (2.54 [1.42-4.54]), higher hematocrit (1.83 [1.21-2.77] per 5% increase) and serum creatinine (10.82 [1.49-78.69] per 1 mg/dL increase), platelet count <250 × 103/μL (1.92 [1.02-3.60]), lower serum sodium (1.12 [1.02-1.23 per 1 mmol/L decrease), and intravenous fluid administration initiated ≥4 days following diarrhea onset (2.50 [1.14-5.46]). A longer interval from diarrhea onset to index visit was associated with reduced HUS risk (OR, 0.70 [95% CI, .54-.90]). RRT predictors (all shown as OR [95% CI]) included female sex (2.27 [1.14-4.50]), younger age (0.83 [.74-.92] per year), lower serum sodium (1.15 [1.04-1.27] per mmol/L decrease), higher leukocyte count ≥13.0 × 103/μL (2.35 [1.17-4.72]) and creatinine (7.75 [1.20-50.16] per 1 mg/dL increase) concentrations, and initial intravenous fluid administration ≥4 days following diarrhea onset (2.71 [1.18-6.21]).

CONCLUSIONS

The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.

Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media

OBJECTIVES

To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM).

METHODS

We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect.

RESULTS

Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%-1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%-3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%-1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained.

CONCLUSION

Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

Clinical Practice Guideline: Maintenance Intravenous Fluids in Children

Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong).

Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis

OBJECTIVE

The goal of this study was to evaluate the effect of antibiotic administration before lumbar puncture on cerebrospinal fluid profiles in children with bacterial meningitis.

METHODS

We reviewed the medical records of all children (1 month to 18 years of age) with bacterial meningitis who presented to 20 pediatric emergency departments between 2001 and 2004. Bacterial meningitis was defined by positive cerebrospinal fluid culture results for a bacterial pathogen or cerebrospinal fluid pleocytosis with positive blood culture and/or cerebrospinal fluid latex agglutination results. Probable bacterial meningitis was defined as positive cerebrospinal fluid Gram stain results with negative results of bacterial cultures of blood and cerebrospinal fluid. Antibiotic pretreatment was defined as any antibiotic administered within 72 hours before the lumbar puncture.

RESULTS

We identified 231 patients with bacterial meningitis and another 14 with probable bacterial meningitis. Of those 245 patients, 85 (35%) had received antibiotic pretreatment. After adjustment for patient age, duration and severity of illness at presentation, and bacterial pathogen, longer duration of antibiotic pretreatment was not significantly associated with cerebrospinal fluid white blood cell count, cerebrospinal fluid absolute neutrophil count. However, antibiotic pretreatment was significantly associated with higher cerebrospinal fluid glucose and lower cerebrospinal fluid protein levels. Although these effects became apparent earlier, patients with >or=12 hours of pretreatment, compared with patients who either were not pretreated or were pretreated for <12 hours, had significantly higher median cerebrospinal fluid glucose levels (48 mg/dL vs 29 mg/dL) and lower median cerebrospinal fluid protein levels (121 vs 178 mg/dL).

CONCLUSIONS

In patients with bacterial meningitis, antibiotic pretreatment is associated with higher cerebrospinal fluid glucose levels and lower cerebrospinal fluid protein levels, although pretreatment does not modify cerebrospinal fluid white blood cell count or absolute neutrophil count results.

Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis

CONTEXT

Children with cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital and treated with parenteral antibiotics, although few have bacterial meningitis. We previously developed a clinical prediction rule, the Bacterial Meningitis Score, that classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria: positive CSF Gram stain, CSF absolute neutrophil count (ANC) of at least 1000 cells/microL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10,000 cells/microL, and a history of seizure before or at the time of presentation.

OBJECTIVE

To validate the Bacterial Meningitis Score in the era of widespread pneumococcal conjugate vaccination.

DESIGN, SETTING, AND PATIENTS

A multicenter, retrospective cohort study conducted in emergency departments of 20 US academic medical centers through the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. All children aged 29 days to 19 years who presented at participating emergency departments between January 1, 2001, and June 30, 2004, with CSF pleocytosis (CSF white blood cells > or =10 cells/microL) and who had not received antibiotic treatment before lumbar puncture.

MAIN OUTCOME MEASURE

The sensitivity and negative predictive value of the Bacterial Meningitis Score.

RESULTS

Among 3295 patients with CSF pleocytosis, 121 (3.7%; 95% confidence interval [CI], 3.1%-4.4%) had bacterial meningitis and 3174 (96.3%; 95% CI, 95.5%-96.9%) had aseptic meningitis. Of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old. A total of 2518 patients (80%) with aseptic meningitis were hospitalized.

CONCLUSIONS

This large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to emergency departments with CSF pleocytosis.

Nalmefene for elective reversal of procedural sedation in children

Nalmefene is a newer, long-acting opioid antagonist. Its use in children for the elective reversal of emergency department procedures has not been investigated. The objective was to evaluate the safety of nalmefene in children. An open-label pediatric clinical trial was performed. The study was conducted at the emergency department of an urban, university-affiliated children's hospital and consisted of children aged 6 months to 12 years who required procedural sedation where an opioid agent was administered. Patients were excluded if there was altered mental status, history of head trauma, history of opioid allergy, or the anticipated need for opioid agents for pain relief after the procedure. At the completion of the procedure, nalmefene was administered in a dose of 0.25 microg/kg increments (max 10 microg) until sedation was resolved, or to a maximum of 1.0 microg/kg (max 40 microg). Serial ECGs, vital signs, and oxygen saturation were recorded. Sedation was assessed using the Clinical Global Impression Scale (CGIS) at baseline, 2, 4, 6, 8, and 10 minutes after the initial nalmefene dose. The observer's assessment of alertness and sedation (OAA/S) was measured at baseline, 10, 30, 60, 90, and 120 minutes after the first dose of nalmefene. Episodes of resedation were recorded. All patients received follow-up by telephone at 4 and 24 hours after the initial dose of nalmefene to identify any potential late adverse effects. Over the study interval 15 patients were enrolled. Mean age was 59.1 +/- 41.5 months. Procedures involved fracture reduction (n=8), laceration repair (n = 4), abscess drainage (n = 2), and arthrocentesis (n = 1). All patients received IV fentanyl and midazolam. The mean dosage of fentanyl and midazolam was 3.21 +/- 1.03 microg/kg and 0.07 +/- 0.03 mg/kg, respectively. The mean dose of nalmefene at the time of complete response (CGIS = 1 or 2) was 0.55 +/- 0.29 microg/kg. The median number of nalmefene doses was 2. All but one patient (93%) had a complete response based on CGIS at 10 minutes after the initial dose of nalmefene was given. Nalmefene resulted in a significant improvement in CGIS (1.60 +/- 0.82 v 3.26 +/- 0.88, P =.001) and OAA/S (median score 5 v 4) when compared at baseline with 10 minutes after the initial dose of nalmefene. Nalmefene also resulted in increased diastolic blood pressure (62.6 +/- 10.5 v 55.8 +/- 10.7, P =.04) as well as improved oxygen saturation when compared at 120 minutes to baseline (99.5 +/- 0.74% v 98.5 +/- 0.4%, P =.03). There were no significant changes in pulse, systolic blood pressure, respiratory rate, and ECG. None of the patients became resedated after nalmefene was given. One patient developed nausea and vomiting within the first 2 hours after nalmefene; this resolved without intervention before discharge. No adverse events occurred in any of the patients at 4 and 24 hours postadministration. The results of this study showed that nalmefene is effective and safe for reversal of procedural sedation by opioids in children.

Time to detection of positive cultures in 28- to 90-day-old febrile infants

OBJECTIVE

To determine the time to detection of positive blood, urine, and cerebrospinal fluid (CSF) cultures among febrile 28- to 90-day-old infants.

STUDY DESIGN

Retrospective cohort of consecutive 28- to 90-day-old infants presenting with a temperature of >/=38 degrees C to an urban pediatric emergency department. Positive cultures and times to detection were noted. Patients were categorized as being at high risk for serious bacterial illness (SBI) based on clinical and laboratory criteria.

RESULTS

Of the 3166 febrile infants seen in the emergency department during the study, 2733 had blood (86%), 2517 had urine (80%), and 2361 had CSF (75%) specimens obtained for culture, and 2190 had all 3 cultures (69%) sent. There were 224 positive cultures in 214 patients; of these, 191 had all 3 cultures (89%) sent. Subsequent analyses were confined to those who had all 3 cultures sent. The detected rate of SBI was 8.7% (191/2190). There were 28 positive blood cultures (1. 3%), 165 positive urine cultures (7.5%), and 8 positive CSF cultures (.4%). Median time to detection of positive cultures was 16 hours for blood, 16 hours for urine, and 18 hours for CSF. Four blood cultures (.1%), 20 urine cultures (.9%), and 0 CSF cultures were noted to have growth of a pathogen >24 hours after the specimen was obtained. All 4 blood cultures and 17 of 20 urine cultures with growth noted after 24 hours occurred among high-risk patients.

CONCLUSIONS

The risk of identifying SBI after 24 hours is 1.1% among all 28- to 90-day-old febrile infants and.3% in low-risk infants.

Evaluation of a combination rapid immunoassay for detection of Giardia and Cryptosporidium antigens

A combination cassette format nonenzymatic rapid immunoassay for detection of Giardia and Cryptosporidium antigens was evaluated by using 556 patient stool specimens from three clinical laboratories. This assay (Genzyme Diagnostics Contrast Giardia/Cryptosporidium), which can be used with fresh or formalin-fixed specimens, had unadjusted sensitivities and specificities of 96.1 and 98.5% for Giardia and 100 and 98.7% for Cryptosporidium, respectively, in this study.

A 5-year surveillance study of 44,691 isolates of Haemophilus influenzae project Beta-Alert 1993-1997

Beta-Alert is a surveillance program developed in 1993 to monitor the percentage of beta-lactamase-producing Haemophilus influenzae isolates obtained from specimens submitted to regional commercial laboratories. The results of this study demonstrate that levels of beta-lactamase producers have remained between 31 and 38% in the United States over the past 5 years.

A survey of beta-lactamase-producing Haemophilus influenzae. An evaluation of 5750 isolates

Previous studies have reported that 15%-34% of Haemophilus influenzae produce beta-lactamase. A surveillance program was developed by SmithKline Beecham Clinical Laboratories to determine the current percentage of beta-lactamase-producing H. influenzae from five selected geographic locations in the United States. In 1993, results of 5750 isolates from specimens submitted to five reference clinical laboratories were evaluated. Data were collected from 29 states and the District of Columbia. The percentages of beta-lactamase-producing H. influenzae was 33% and ranged from 22%-40% for the individual states.

Comparison of the PREMIER cryptococcal antigen enzyme immunoassay and the latex agglutination assay for detection of cryptococcal antigens

A new enzyme immunoassay (EIA), PREMIER Cryptococcal Antigen, was compared with latex agglutination (LA) for the detection and quantitation of circulating capsular polysaccharide antigen from Cryptococcus neoformans. The clinical evaluation of PREMIER EIA as a screening assay, including 475 specimens with 120 LA and EIA positives, resulted in 99% sensitivity and 97% specificity. The clinical specimens included sera and cerebrospinal fluids as well as 10 rheumatoid factor-positive and 20 anti-nuclear antibody-positive serum samples. This monoclonal antibody-based assay detects serotypes A to D at 0.63, 0.63, 7.8, and 62 ng/ml, respectively. With three different known positive specimens, the assay was found to yield coefficients of variation of 2 to 12% for intra- and interassay comparisons of precision and reproducibility. The primary use for semiquantitative values derived with the LA or EIA is to follow the course of disease and monitor drug therapies. The present data suggest that the PREMIER EIA will be a valuable method for this purpose. We conclude that the PREMIER Cryptococcal Antigen EIA provides a rapid, convenient, and reliable antigen detection method for screening and semiquantitative determination of antigen levels.

Empiric antimicrobial therapy of domestically acquired acute diarrhea in urban adults

From June 1985 to September 1987, 202 adults were enrolled in a randomized, double-blinded study comparing ciprofloxacin (500 mg) with sulfamethoxazole and trimethoprim (160 mg/800 mg) or placebo for adults with acute diarrhea. All patients were treated on the day of presentation and received medication on a twice-daily schedule (every 12 hours) for 5 days. Bacterial isolates from these patients included 35 Campylobacter, 18 Shigella, and 15 Salmonella. Treatment at the time of presentation with ciprofloxacin compared with placebo shortened the duration of diarrhea (2.4 vs 3.4 days), and increased the percentage of patients cured or improved by treatment days 1, 3, 4, and 5. Similar significant differences for sulfamethoxazole and trimethoprim compared with placebo were not seen.

Contact neodynium-yttrium-aluminum garnet laser acts as a sterilizing scalpel

As a cold knife cuts through contaminated or infected wounds, bacteria are dragged along with the blade of the knife through the entire wound. Herein, the effect of incisions made with a cold knife is compared with that of incisions made by a contact neodynium-yttrium-aluminum garnet (Nd:YAG) laser. Agar plates were inoculated with multiple strains of exogenous, endogenous, hospital-acquired and multiple antibiotic resistant strains of bacteria. While the cold knife dragged bacteria to sterile areas, incisions made with the contact laser were always sterile. In addition to not dragging bacteria, the tip of the contact laser sterilized itself and provided a bacteria-free zone on either side of the cut, depending on the power density applied. It appears that the contact Nd:YAG laser acts as a sterilizing wand while providing much needed tactile feedback, precision and hemostasis during surgical treatment with the laser.

In vitro activities of lomefloxacin and temafloxacin against pathogens causing diarrhea

The in vitro activities of temafloxacin (A63004) and lomefloxacin (SC-47111; NY-198) were compared with those of seven other antibiotics against 146 isolates of bacterial enteric pathogens, including Campylobacter jejuni and Campylobacter coli. Ciprofloxacin was the most active drug against the Salmonella, Shigella, Yersinia, and Vibrio spp. tested. Lomefloxacin, temafloxacin, and difloxacin were the most active drugs tested against Campylobacter spp. (MIC for 90% of strains, 0.125 to 0.25 micrograms/ml).

Clinical impact of rapid identification and susceptibility testing of bacterial blood culture isolates

Two hundred twenty-six patients with bacteremia were prospectively enrolled in a randomized trial that was performed to determine the clinical impact of the receipt of in vitro microbiological data by the physician soon after organism detection as opposed to having the physicians wait until similar data were available by routine methods. Identification and antibiotic susceptibility patterns of 110 isolates were determined by direct inoculation of the Vitek AutoMicrobic system (Vitek Systems, Inc., Hazelwood, Mo.) with a sample from a positive blood culture vial. One hundred sixteen isolates were processed by routine methods. Microbiological results were available within an average of 8.8 h by the direct method versus an average of 48 h by the routine method. In both groups an infectious disease fellow used the information to make therapeutic recommendations to the responsible physician. When compared with that provided by the routine method, the information provided by the direct method was significantly more likely to result in an initiation of antibiotic therapy, a change to more effective therapy, or a change to less expensive therapy. Recommendations were significantly more likely to be followed in patients whose isolates were processed by the direct method versus the routine method. A projected savings of $158 per patient was estimated for the patients who were changed to less expensive therapy or in whom antibiotics were discontinued because results were available sooner. These cost savings, coupled with changes in therapy made for reasons of efficacy, support the usefulness of the earlier reporting of the identity and antibiotic susceptibility patterns of bacterial blood culture isolates.

Disseminated penicilliosis in a patient with acquired immunodeficiency syndrome

We describe a case of disseminated penicilliosis in a patient with the acquired immunodeficiency syndrome. Penicillium marneffei was cultured from the blood, bone marrow, sputum, stool, and skin; the yeast forms were demonstrated in skin and bone marrow biopsy specimens. To our knowledge, this is the first reported case of disseminated penicilliosis described in a patient with the acquired immunodeficiency syndrome. The differential diagnosis with Histoplasma capsulatum is reviewed.

Disseminated Fusarium solani infection with cutaneous nodules in a bone marrow transplant patient

Fusarium is a ubiquitous fungus that commonly colonizes ulcerated, burned, or traumatized skin and may cause keratitis and onychomycosis in healthy hosts. Serious disseminated infection due to Fusarium has been reported with increasing frequency in immunocompromised patients. We describe a bone marrow transplant patient who developed fungal septicemia and disseminated skin nodules due to Fusarium solani. Fusarium should be recognized as a potential cause of deep fungal infection in immunocompromised patients.

A pseudoepidemic due to atypical mycobacteria in a hospital water supply

We describe a pseudoepidemic due to atypical mycobacteria contaminating the water used by a pathology laboratory and bronchoscopy suite on two floors of the same hospital building. Inspection of laboratory procedures revealed that contamination occurred during specimen processing in pathology and while obtaining the bronchoscopic specimens. Mycobacterium gordonae, Mycobacterium avium complex, and Mycobacterium scrofulaceum were identified. During an eight-month period, a total of 22 (31%) of 70 patients with positive acid-fast smears had either an illness inconsistent with tuberculosis or a known alternate diagnosis. Control was easily obtained by insertion of a 0.2-micron polymer filter into the outflow tubing of our pathology tap water-deionizing unit and the tap water source in the bronchoscopy suite. The pseudoepidemic led to additional diagnostic-therapeutic intervention, but no patient experienced delay in appropriate diagnosis. Pseudoepidemics due to atypical mycobacteria will likely be of increased importance in institutions providing care to patients with acquired immunodeficiency syndrome.

In vitro activity of A-56268 (TE-031), a new macrolide, compared with that of erythromycin and clindamycin against selected gram-positive and gram-negative organisms

The in vitro activity of A-56268 was determined and compared with that of erythromycin and clindamycin against a limited spectrum of 401 gram-positive and gram-negative organisms. A-56268 was quite active against erythromycin-susceptible Staphylococcus aureus, Neisseria gonorrhoeae, Listeria monocytogenes, Streptococcus pneumoniae, Streptococcus pyogenes, and group B streptococci and was moderately active against Campylobacter fetus subsp. fetus. A-56268 was consistently bactericidal only for S. pneumoniae. The activity of A-56268 was comparable to that of erythromycin against most organisms tested.

Effects of erythromycin and ciprofloxacin on chronic fecal excretion of Campylobacter species in marmosets

Ciprofloxacin was compared with erythromycin for the eradication of Campylobacter species that were chronically excreted in the stools of marmosets (Saguinus labiatus labiatus, Saguinus fuscicollis nigrifrons, and Saguinus fuscicollis illigeri). Stool cultures were negative within 48 h of the beginning of treatment with either agent. Within 10 days after the end of therapy, however, Campylobacter species were again isolated from the stools of six animals that had received erythromycin. During an 8-week follow-up period, no animal that had received ciprofloxacin relapsed. High levels of ciprofloxacin in the stool (mean, 49.2 micrograms/g) possibly contributed to the efficacy of this agent.

Results of a screening method used in a 12-month stool survey for Escherichia coli O157:H7

Escherichia coli serotype O157:H7 has been epidemiologically linked to outbreaks of hemorrhagic colitis associated with fast-food restaurants and nursing homes. Sporadic cases now exceed those associated with outbreaks. The incidence of the organism in patients with common diarrhea syndromes and in asymptomatic persons is unknown. Routine serotyping of E. coli isolates is impractical for most clinical microbiology laboratories. We developed a screening plate by utilizing sorbitol fermentation as a biochemical marker to identify organisms for serotyping. A total of 2,552 stool samples were screened. In 106 (4.1%), sorbitol-negative E. coli were identified. Of these, two were serotype O157:H7, and both produced a Vero cell toxin. One patient had hemorrhagic colitis and the other a mild, febrile, self-limited diarrhea with no other bacterial pathogen identified. This plate provides an easy, effective method of screening for sorbitol-negative E. coli, a process facilitating the selection of organisms for serotyping and one that may help clarify this organism's role in human disease.

Evaluation of the Spot-CAMP test for the rapid presumptive identification of group B streptococci

A rapid Spot-CAMP test was evaluated for its ability to accurately identify colonies of Streptococcus agalactiae (Lancefield Group B) growing on primary sheep blood agar plates. The test uses a beta-lysin-containing filtrate, which is prepared from a broth culture of Staphylococcus aureus. A drop of beta-lysin filtrate is applied adjacent to a suspected group B Streptococcus (GBS) colony and the plate is incubated and then examined for a zone of synergistic hemolysis. The Spot-CAMP test demonstrated 100% correlation with both a Standard CAMP procedure and Lancefield serogrouping. The rapid Spot-CAMP test was easy to perform and inexpensive, and could presumptively identify within 30 minutes colonies of GBS growing on primary isolation plates.

A urine preservative system to maintain bacterial counts. A laboratory and clinical evaluation

The urinary tract is a common site of infection in the hospitalized, institutionalized, or ambulatory patient population. Ideally, urine should be cultured immediately or refrigerated up to 24 hours for quantitative examination for microorganisms. In the evaluation of patients at their homes or in long-term care facilities, rapid plating or refrigeration may not be practical. This is also true when evaluating small children in whom external collection devices are required to obtain a specimen. Because of these limitations, we evaluated a urine preservative and transport system, the Sage Products Urine Culture Tube, in a study of 1469 clinical specimens. This tube utilizes boric acid (1.1% final concentration) as a preservative. The Urine Culture Tube was easy to use and was as effective as refrigeration in maintaining bacterial counts. This system may be particularly useful where rapid transport or refrigeration is limited.

Comparative in vitro activities of twelve antimicrobial agents against Campylobacter species

The in vitro susceptibility of 27 Campylobacter jejuni, 31 Campylobacter coli, and 30 Campylobacter fetus subsp. fetus strains to 12 antimicrobial agents was determined. Ciprofloxacin, a new quinoline derivative, was the most active agent tested. Antimicrobial susceptibility differed among the three species tested.

Comparative in vitro activity of ciprofloxacin against Campylobacter spp. and other bacterial enteric pathogens

A comparison was made of the in vitro activity of ciprofloxacin (Bay o 9867) with nine other antibiotics against isolates of Campylobacter jejuni, Salmonella spp., Shigella spp., Yersinia enterocolitica, Clostridium difficile, Vibrio spp., and Escherichia coli. Minimum inhibitory concentrations of ciprofloxacin were the lowest of any compound tested for all organisms except C. difficile.

A pseudoepidemic due to Salmonella typhimurium

A pseudoepidemic due to Salmonella typhimurium occurred in the clinical microbiology laboratory of a university hospital and involved 10 patients. One patient received "unnecessary" antibiotics. Investigation of the events implicated a contaminated rubber pipette bulb. Such bulbs should be considered as a possible source of false-positive cultures.

Binding of human C-reactive protein to bacteria

The binding of C-reactive protein to a variety of species of bacteria with potential clinical significance was studied to assess the potential function of C-reactive protein in nonimmune defense against infection. Purified, radioiodinated human C-reactive protein bound to all Streptococcus pneumoniae tested and to some viridans streptococci, but not to group A or group B streptococci or to any of eight different gram-negative rods and cocci.

Speciation and antibiotic susceptibility patterns of coagulase-negative staphylococci

During a six month period, 191 isolates of coagulase-negative staphylococci from blood, urine, cerebrospinal fluid and heart valves were identified to species level and tested for antimicrobial susceptibility. Seventy-one percent of isolates were Staphylococcus epidermidis, 8% Staphylococcus warneri, 7% Staphylococcus hominis, 7% Staphylococcus haemolyticus, 4% Staphylococcus capitis, 2% Staphylococcus saprophyticus and 1% Staphylococcus cohnii. Approximately 4% of isolates were felt to be associated with infection. Overall, 18% of isolates were susceptible to penicillin G, 61% oxacillin, 98% cephalothin, 98% cefamandole, 72% cefotaxime, 95% cefsulodin, 76% gentamicin, 64% clindamycin and 98% rifampicin. All isolates were susceptible to vancomycin. Vancomycin, rifampicin, cephalothin and cefamandole showed excellent activity against oxacillin-resistant isolates. With one exception, speciation was not helpful in determining whether or not an isolate was associated with infection.

Comparison of rectal swabs and stool cultures in detecting Campylobacter fetus subsp. jejuni

Rectal swabs and stool specimens were compared for the detection of Campylobacter fetus subsp. jejuni in marmosets. Rectal swabs were superior to stool specimens for detection of Campylobacter fetus subsp. jejuni (P = 0.016). Preliminary human data are also presented.

Campylobacter fetus subsp. jejuni: experience in a large Chicago medical center

From January 1979 through December 1979, 2069 stool specimens received by our laboratory for enteric culturing were additionally examined for the presence of Campylobacter fetus subsp. jejuni. The study population included inpatients, outpatients and hospital food handlers. Patients were included regardless of symptoms. Enteric pathogens were identified as follows: Salmonella, 27 isolates; Campylobacter fetus subsp. jejuni, 26 isolates; and Shigella, 11 isolates. Twenty-five of 26 patients with stool cultures positive for Campylobacter fetus subsp. jejuni had an acute diarrheal illness. Diarrhea, fever and chills were the most common symptoms. In most patients the disease was self-limited, requiring only supportive therapy. A seasonal variation was noted, with 14 of the 26 patients presenting between July and September.

Rheumatoid pleurisy. observations on the development of low pleural fluid pH and glucose level

A patient with rheumatoid pleurisy provided the opportunity to observe the time course of development of the low glucose level and low pH characteristic of these pleural effusions. During six days, the effusion evolved from one with a normal glucose value and pH to one with a glucose value of 20 mg/dL and a pH of 6.78. The mechanisms responsible for these phenomena probably are (1) a selective block to glucose transport from blood to pleural fluid, (2) enhanced glucose use by rheumatoid pleura, and (3) an efflux block to the end products of pleural space glucose metabolism. Once the low glucose value-low pH rheumatoid effusion develops, it seems not to revert to an effusion with a normal glucose level and pH.

Radiometric detection of mycobacteria in routine blood cultures

Mycobacterium chelonei subsp. abscessus was detected radiometrically in routine blood cultures. The organism was detected in two patients without the use of special mycobacteriological media.

The diagnostic value of pleural fluid pH

One hundred eighty-three patients had simultaneous blood and pleural fluid pH determinations. Thirty-six effusions were transudates, and 147 were exudates. In 46 effusions, the pleural fluid pH was less than 7.30; all 46 were exudates. A pleural fluid pH less than 7.30 was associated with the following six diagnoses: (1) empyema; (2) malignancy; (3) collagen vascular disease; (4) tuberculosis; (5) esophageal rupture; and (6) hemothorax. The results of pleural fluid pH determination are immediately available, narrow the differential diagnosis of the exudate, and may expedite patient management. The pH of pleural fluid should be measured whenever a diagnostic thoracocentesis is performed.

A model of immune complex-mediated pleuropulmonary injury; evidence of deposition of circulating immune complexes in the lung

Severe acute, diffuse lung inflammation was induced in rabbits immunized to bovine serum albumin (BSA) and subsequently challenged with BSA intrapleurally. Evidence suggesting involvement of circulating immune complexes in the pathogenesis of lung injury in these rabbits include 1) positive lung immunofluorescence, 2) a fall in serum hemolytic complement, 3) diffuse bilateral involvement despite unilateral antigen challenge, and 4) absence of these findings in control rabbits. Further investigation with this model may provide insight into the processes involved in the deposition of immune complexes in the lung and the mechanisms of lung injury provoked by immune complex deposition.

Cellular mechanisms of insulin release. Effects of retinol on insulin release and islet ultrastructure

In previous studies using perifused collagenase-isolated rat islets, retinol (vit A) inhibited glucose-induced Diphasic insulin release and glucose oxidation. To further evaluate vit A action and elucidate cellular mechanisms of insulin release, we tested the effects of vit A on glucose uptake by islets, on other stimuli of insulin release, and oh islet ultrastructure and the effects of calcium on vit A inhibition of insulin release. Vit A did hot inhibit 2-deoxy-D-glucose uptake into islets. Vit A inhibited second phase 9.7 and 13.9 mM glucoseinduced insulin release to 50%, 10 mM glyceraldehydeinduced release to 64%, and 20 mM leucine-induced release to 66% of control. First phase, release was unaffected. Kinetic analysis of the effects of vit A on glucose-induced release indicated a change in the Vmax but not in the Km, suggesting inhibition of a potentiator of insulin release by vit A. Calcium (4 mM) opposed vit A inhibition of glucose-induced release.

Ultrastructurally, vit A decreased the volume fraction of secretory granules to 90% of control, increased the volume fraction of material within the rough endoplasmic reticulum to 147% of control, and increased the outer and decreased the inner mitochondrial compartment volume fractions by 14%.

Our functional and ultrastructural findings, in all, suggest that vit A inhibitioh of second phase insulin release is not specific for glucose and may be mediated in part through impairment of mitochondrial function and intracellular glucose oxidation.

Incidence and outcome of the respiratory distress syndrome in gram-negative sepsis

Twenty cases of the adult respiratory distress syndrome (ARDS) in 86 cases of Gram-negative bacteremia were identified. Features of Gram-negative bacteremia associated with the development of ARDS included a history of cardiac disease, hypotension, and thrombocytopenia. The mortality of patients with and without ARDS was 90% and 55%, respectively. The association of hypotension and thrombocytopenia with the subsequent development of ARDS suggests the possible role of endotoxin-induced coagulopathy in this complication.