Diagnosis and management of undifferentiated fever in children

Proteomic profiling of neonatal herpes simplex virus infection on dried blood spots

BACKGROUND

Neonatal herpes simplex virus (HSV) infection is life-threatening, with a mortality of up to 70-80% when disseminated, often due to vague symptoms and delayed treatment. Neonatal screening using dried blood spot (DBS) samples is among the most impactful preventative health measures ever implemented, but screening for HSV has not been investigated.

METHODS

We investigated high throughput multiplexed proteomics on DBS samples collected on days 2-3 of life from a nationwide cohort of neonates with HSV infection (n = 53) and matched controls. We measured 2941 proteins using the Olink Explore 3072 panels and proximity extension assays, followed by differential protein expression by Analysis of Variance with post-hoc correction and functional annotation.

RESULTS

Here, we show distinct protein profiles in neonates with disseminated HSV disease, with differences in 20 proteins compared to controls. These proteins are associated with innate and adaptive immune responses and cytokine activation.

CONCLUSIONS

Our findings indicate the potential of neonatal screening for disseminated HSV disease to ensure early treatment and reduce the high mortality.

Knowledge mapping of paediatric fever-a visual analysis based on CiteSpace

Objective

This study aimed to analyse the research hotspots and frontiers in the field of paediatric fever between 2013 and 2023.

Methods

The included articles were visually analysed using CiteSpace 6.1.R6 software.

Results

A total of 2,662 Chinese-language articles and 1,456 English-language articles were included in the study. Based on the Chinese literature, research groups were identified represented by Xinmin Li, Jinling Hong and Hongshuang Luo. Based on the English literature, research groups were formed represented by Henriette Moll, Santiago Mintegi and Elizabeth Alpern. Tianjin University of Traditional Chinese Medicine was the institution with the largest number of publications in the Chinese literature, and the Centers For Disease Control And Prevention was the institution with the largest number of publications in the English literature. The research on paediatric fever mainly focused on mechanism exploration, green treatment and clinical management.

Conclusion

Several relatively stable research groups have been formed. Future studies on the differential diagnosis, rational drug use, standardised management and clinical practice guidelines for paediatric fever are needed.

Procalcitonin and Presepsin as Markers of Infectious Respiratory Diseases in Children: A Scoping Review of the Literature

INTRODUCTION

Procalcitonin and presepsin have been suggested to be able to discriminate bacterial and viral infections, also in children. This scoping review aims to better explore the available evidence around the potential role of these biomarkers in the subgroup of children with respiratory infectious diseases.

METHODS

We performed a systematic scoping review of studies published until March 2023 in the following bibliographic databases: PubMed, EMBASE, Cochrane and SCOPUS.

RESULTS

In children with bacterial infection, procalcitonin values ranged from 0.5 ng/mL to 8.31 ng/dL, while in those hospitalized in an intensive care unit ranged from 0.6 ng/dL to 452.8 ng/dL with PCR from 2 ng/dL to 51.7 ng/dL. In children with viral infections, procalcitonin value values ranged from 0.2 ng/dL to 0.84 ng/dL, while in those hospitalized in an intensive care unit ranged from 0.61 ng/dL to 46.6 ng/dL. No studies on presepsin in children with respiratory infections were retrieved.

CONCLUSIONS

Although the available literature is highly heterogeneous, evidence does not suggest a role of procalcitonin in accurately differentiating bacterial and viral infections in children with respiratory infections. In future, new approaches based on multiple markers may better help determine which febrile children require antibiotics.

Outbreak investigation of acute febrile illness from the Himalayan foothills: Solving the puzzle of fever

In September 2022, Panchkula Civil Hospital reported an outbreak of acute febrile illness (AFI) in Pinjore, located in the Himalayan foothills, Haryana, North India. There was an upsurge of fever cases. Blood samples were taken from suspected patients (n = 58) with AFI and subjected to serology of dengue, chikungunya, Japanese encephalitis, leptospira and scrub typhus. The samples were also screened for West Nile & Zika virus RNA using real-time PCR. Viral strains were characterized by sequencing. Of the 58 cases of AFI, Dengue could be identified in 45 (77.58%) followed by JE and Chikungunya in 2 cases each (3.44%), respectively. Among Dengue positive cases, 44 had monoinfection (97.77%) and 1 patient had dengue and JE. None were positive for Zika, West Nile, Scrub typhus, and Leptospira with the testing protocol. Four patients developed dengue with warning signs, such as abdominal pain in one patient and recurrent vomiting in the remaining three. The dengue serotype could be determined in 17 samples and revealed serotype 2. Molecular evolution analysis based on the complete envelope gene revealed that all DENV-2 strains (n = 13) circulated in the outbreak area belonged to the DENV-2 cosmopoliton genotype. In the early stages of infection, relying only on clinical manifestations is ineffective, so both molecular and serological assays along with clinical diagnosis are noteworthy for determining the aetiology of AFI.

Levels and correlates of knowledge of teething among Saudi Arabian families

Background

Parental knowledge of teething has been repeatedly investigated; however, little emphasis has been made on the associated sociodemographic factors with good knowledge of the parents and whether or not good knowledge is translated into adopting proper pain-relieving practices. The present study aims to firstly assess the knowledge level and practices of Saudi parents regarding teething and then explore associated sociodemographic variables with good knowledge of teething to determine the relation between parents' knowledge of teething and their adoption of pain-relieving practices.

Methods

This cross-sectional study recruited parents from the social networking sites Facebook, Twitter, Instagram, and WhatsApp, and they were asked to answer a pretested three-part internationally accepted questionnaire. Data were examined using descriptive statistics, chi-square analysis, multivariate logistic regression analysis, and Spearman rank-order correlation coefficient analysis.

Results

One thousand four hundred ninety-nine parents responded and returned completed questionnaires. Of those, only 11.2% had good knowledge of teething. The majority of parents did not have basic knowledge of the teething period as well as believed that teething was associated with a runny nose (87.5%), diarrhea (77.9%), and sleep disturbance (72%). The results of multivariate logistic regression analysis indicated that parents with no primary school education (Odds Ratio: 0.29), or those who had an intermediate or secondary education level (OR: 0.55 and 0.78) were less likely to have good knowledge compared with parents who had a university degree. However, parents who earned intermediate monthly income (OR: 6.63) were more likely to have good knowledge of teething. With regards to practices used to relieve teething pain, inappropriate practices were observed regarding bottle feeding at night to soothe the child's pain (72%) and applying topical analgesics to rub the gum (72.4%). A significant positive correlation was found between the knowledge score and the practice score of both fathers and mothers (r = 0.22 and 0.13, p < 0.0001).

Conclusion

A very low percentage of Saudi parents, mainly those with the highest education level and intermediate monthly income, had good knowledge of teething, which translated into appropriate practices to soothe the child's pain regardless of the parent's gender. Saudi parents should receive anticipatory guidance related to teething from all health professionals to ensure an uneventful teething period for their children.

Etiology of acute febrile illnesses in Southern China: Findings from a two-year sentinel surveillance project, 2017-2019

BACKGROUND

Southern China is at risk for arborvirus disease transmission, including Zika virus and dengue. Patients often present to clinical care with non-specific acute febrile illnesses (AFI). To better describe the etiology of AFI, we implemented a two-year AFI surveillance project at five sentinel hospitals in Yunnan and Guangdong Provinces.

METHODS

Between June 2017 and August 2019, we enrolled patients between 2 and 65 years of age presenting at one sentinel hospital in Mengla County, Yunnan, and four in Jiangmen City, Guangdong, with symptoms of AFI (acute onset of fever ≥ 37.5°C within the past 7 days) without respiratory symptoms or diarrhea. Demographic, epidemiologic, and clinical information was obtained and entered into a web-based AFI surveillance database. A custom TaqMan Array card (TAC) was used to test patients' whole blood specimens for 27 different pathogens using real-time polymerase chain reaction assays.

RESULTS

During the two-year project period, 836 patients were enrolled; 443 patients from Mengla County and 393 patients from Jiangmen City. The median age was 33 years [range: 2-65], and most were hospitalized [641, 77%]. Of 796 patients with valid TAC results, 341 (43%) were positive for at least one of the 10 unique pathogens detected. This included 205 (26%) patients positive for dengue virus, 60 (8%) for Orientia tsutsugamushi, and 42 (5%) for Coxiella burnetii. Ten patients (1%) in Jiangmen City tested positive for malaria, 8 of whom reported recent travel outside of China. TAC results were negative for 455 (57%) patients. None of the patients had a positive TAC detection for Zika virus.

CONCLUSIONS

The project detected variability in the etiology of AFI in Southern China and highlighted the importance of differential diagnosis. Dengue, O. tsutsugamushi, and C. burnetii were the most frequently identified pathogens among enrolled AFI patients. As a non-notifiable disease, the frequent detection of C. burnetii is noteworthy and warrants additional investigation. The project provided a framework for routine surveillance for persons presenting with AFI.

A Prospective Cohort Study of the Clinical Predictors of Bacteremia in Under-Five Children With Acute Undifferentiated Fever Attending a Secondary Health Facility in Northwestern Nigeria

BACKGROUND

Children with acute febrile illness with no localizing signs often receive antibiotics empirically in most resource-poor settings. However, little is known about the burden of bacteremia in this category of patients, and an appraisal is thus warranted. This will guide clinical practice and promote rational antibiotics use.

METHODS

We prospectively followed up 140 under-five children who presented with acute undifferentiated fever at the emergency/outpatient pediatric unit of a secondary healthcare facility. Baseline clinical and laboratory information was obtained and documented in a structured questionnaire. We compared baseline characteristics between participants with bacteremia and those without bacteremia. We further fitted a multivariable logistic regression model to identify factors predictive of bacteremia among the cohort.

RESULT

The prevalence of bacteremia was 17.1%, and Salmonella Typhi was the most frequently (40.9%) isolated pathogen. The majority (78.6%) of the study participants were managed as outpatients. The participants who required admission were four times more likely to have bacteremia when compared to those managed as outpatients (AOR 4.08, 95% CI 1.19 to 14.00). There is a four times likelihood of bacteremia (AOR 4.75, 95% CI 1.48 to 15.29) with a fever duration of beyond 7 days. Similarly, participants who were admitted with lethargy were six times more likely to have bacteremia (AOR 6.20, 95% CI 1.15 to 33.44). Other significant predictors were tachypnea and lymphopenia.

CONCLUSION

Among under-five children with acute undifferentiated fever, longer duration of fever, lethargy, inpatient care, tachypnea, and lymphopenia were the significant predictors of bacteremia.

Management of febrile infants aged 1 month and less than 3 months in a French university hospital: Clinical practice evaluation

BACKGROUND

Management of febrile infants is challenging due to the increased risk of serious bacterial infections and it varies among physicians and hospitals. The goals of this study were to describe and compare the management of febrile infants aged 1-2 months in a hospital in 2011 and 2016.

METHODS

We conducted a retrospective study in the Bordeaux Pellegrin University Hospital, France, in 2011 and 2016. All infants aged 1-2 months with diagnosis codes referring to fever were included. Data on infant characteristics, fever episodes, clinical symptoms, and management were collected from medical charts. Univariate analyses and multivariate logistic models were used.

RESULTS

A total of 530 infants were included; 89.2% had blood testing and 81.1% urine testing; 79.6% of the infants were hospitalized, three of them in the pediatric intensive care unit. The median hospitalization duration was 3 days. In the sample investigated, 59.8% of the infants received antibiotic therapy and 128 (24.1%) had bacterial infections with no difference between 2011 and 2016. The main bacterial infection was pyelonephritis (86.7%). Urethral catheterization was implemented in 2016, whereas a urine bag was utilized for 174 out of 177 infants in 2011. The percentage of contaminated urine cultures was higher in 2011 (35.9%) than in 2016 (19.6%, P<0.001). The hospitalization rate was higher in 2016.

CONCLUSIONS

Management of febrile infants changed between 2011 and 2016. The hospitalization rate and antibiotic therapy use remained high regarding the rate of bacterial infection. Use of urethral catheterization decreased the level of contamination.

Guidelines for the symptomatic management of fever in children: systematic review of the literature and quality appraisal with AGREE II

INTRODUCTION

Several societies have produced and disseminated clinical practice guidelines (CPGs) for the symptomatic management of fever in children. However, to date, the quality of such guidelines has not been appraised.

OBJECTIVE

To identify and evaluate guidelines for the symptomatic management of fever in children.

METHODS

The research was conducted using PubMed, guideline websites, and Google (January 2010 to July 2016). The quality of the CPGs was independently assessed by two assessors using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument, and specific recommendations in guidelines were summarised and evaluated. Domain scores were considered of sufficient quality when >60% and of good quality when >80%.

RESULTS

Seven guidelines were retrieved. The median score for the scope and purpose domain was 85.3% (range 66.6-100%). The median score for the stakeholder involvement domain was 57.5% (range 33.3-83.3%) and four guidelines scored >60%. The median score for the rigour of development domain was 52.0% (range 14.6-98.9%), and only three guidelines scored >60%. The median score for the clarity of presentation domain was 80.9% (range 50.0-94.4%). The median score for the applicability domain was 39.3% (8.3-100%). Only one guideline scored >60%. The median score for the editorial independence domain was 48.84% (0-91.6%); only three guidelines scored >60%.

CONCLUSION

Most guidelines were recommended for use even if with modification, especially in the methodology, the applicability and the editorial independence domains. Our results could help improve reporting of future guidelines, and affect the selection and use of guidelines in clinical practice.