Clinical and Cost-Effectiveness of Procalcitonin Test for Prodromal Meningococcal Disease-A Meta-Analysis

Procalcitonin use in febrile children attending European emergency departments: a prospective multicenter study

BACKGROUND

Studies on procalcitonin (PCT) for identifying sepsis were published as early as 1993 and since then, PCT has been the topic of over 8,500 studies. Several studies show PCT to be superior to CRP in differentiating invasive infections such as sepsis from viral infections, especially early in the disease course. However, its actual use in clinical practice is poorly documented. Our aim was to study the use of PCT in febrile children attending the ED across Europe and compare this to the use of CRP.

METHODS

The MOFICHE/PERFORM study, a prospective multicenter study, took place at 12 European EDs in eight countries and included febrile children < 18 years. In this secondary analysis of nine participating EDs that used PCT, descriptive analyses were performed, describing the use of PCT in all febrile children and for different age groups, foci of fever and fever duration.

RESULTS

In total, 31,612 pediatric febrile episodes were available for analyses. Blood tests were performed in 15,812 (50.0%, range 9.6-92.6%)) febrile episodes. CRP was included in 98.3% of blood tests (range between hospitals 80-100%), while PCT was included in only 3.9% (range 0.1-86%). PCT was most often performed in children below 3 months (12.0% versus 3.6% in older children, p < 0.001). PCT was used slightly more often in children with fever less than 24 h in comparison to children with a duration of fever ≥ 24 h (4.9% versus 3.4%, p < 0.001). Regarding clinical alarming signs, PCT was used most often in children with meningeal signs (7.0%) or a non-blanching rash (10.9%).

CONCLUSION

Actual PCT use in febrile children at European EDs is limited and varies largely between hospitals. Possible explanations include lack of guidelines, limited availability, higher costs and lack of readiness to adapt new clinical strategies.

European study confirms the combination of fever and petechial rash as an important warning sign for childhood sepsis and meningitis

AIM

This study investigated febrile children with petechial rashes who presented to European emergency departments (EDs) and investigated the role that mechanical causes played in diagnoses.

METHODS

Consecutive patients with fever presenting to EDs in 11 European emergency departments in 2017-2018 were enrolled. The cause and focus of infection were identified and a detailed analysis was performed on children with petechial rashes. The results are presented as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

We found that 453/34010 (1.3%) febrile children had petechial rashes. The focus of the infection included sepsis (10/453, 2.2%) and meningitis (14/453, 3.1%). Children with a petechial rash were more likely than other febrile children to have sepsis or meningitis (OR 8.5, 95% CI 5.3-13.1) and bacterial infections (OR 1.4, 95% CI 1.0-1.8) as well as need for immediate life-saving interventions (OR 6.6, 95% CI 4.4-9.5) and intensive care unit admissions (OR 6.5, 95% CI 3.0-12.5).

CONCLUSION

The combination of fever and petechial rash is still an important warning sign for childhood sepsis and meningitis. Ruling out coughing and/or vomiting was insufficient to safely identify low-risk patients.

Characteristics and management of adolescents attending the ED with fever: a prospective multicentre study

OBJECTIVE

Most studies on febrile children have focused on infants and young children with serious bacterial infection (SBI). Although population studies have described an increased risk of sepsis in adolescents, little is known about febrile adolescents attending the emergency department (ED). We aimed to describe patient characteristics and management of febrile adolescents attending the ED.

DESIGN AND SETTING

The MOFICHE/PERFORM study (Management and Outcome of Febrile Children in Europe/Personalised Risk assessment in Febrile illness to Optimise Real-life Management across the European Union), a prospective multicentre study, took place at 12 European EDs. Descriptive and multivariable regression analyses were performed, comparing febrile adolescents (12-18 years) with younger children in terms of patient characteristics, markers of disease severity (vital signs, clinical alarming signs), management (diagnostic tests, therapy, admission) and diagnosis (focus, viral/bacterial infection).

RESULTS

37 420 encounters were included, of which 2577 (6.9%) were adolescents. Adolescents were more often triaged as highly urgent (38.9% vs 34.5%) and described as ill appearing (23.1% vs 15.6%) than younger children. Increased work of breathing and a non-blanching rash were present less often in adolescents, while neurological signs were present more often (1% vs 0%). C reactive protein tests were performed more frequently in adolescents and were more often abnormal (adjusted OR (aOR) 1.7, 95% CI 1.5 to 1.9). Adolescents were more often diagnosed with SBI (OR 1.8, 95% CI 1.6 to 2.0) and sepsis/meningitis (OR 2.3, 95% CI 1.1 to 5.0) and were more frequently admitted (aOR 1.3, 95% CI 1.2 to 1.4) and treated with intravenous antibiotics (aOR 1.7, 95% CI 1.5 to 2.0).

CONCLUSIONS

Although younger children presented to the ED more frequently, adolescents were more often diagnosed with SBI and sepsis/meningitis. Our data emphasise the importance of awareness of severe infections in adolescents.

Loop-mediated isothermal amplification for the early diagnosis of invasive meningococcal disease in children

BACKGROUND

Rapid molecular diagnostic testing has the potential to improve the early recognition of meningococcal disease (MD). The aim of this study was to report on the diagnostic test accuracy of point-of-care loop-mediated isothermal amplification (LAMP) in the diagnosis of MD.

DESIGN

Data were collected prospectively from three UK emergency departments (ED) between November 2017 and June 2019. Consecutive children under 18 years of age attending the ED with features of MD were eligible for inclusion. The meningococcal LAMP test (index test) was performed on a dry swab of the child's oropharynx. Reference standard testing was the confirmation of invasive MD defined as positive N. meningitidis culture or PCR result from a sterile body site (blood or cerebrospinal fluid).

RESULTS

There were 260 children included in the final analysis. The median age was 2 years 11 months and 169 (65%) children were aged 5 years or younger. The LAMP test was negative in 246 children and positive in 14 children. Of the 14 children with positive LAMP tests, there were five cases of invasive MD. Of the 246 children with negative LAMP tests, there were no cases of invasive MD. The sensitivity of LAMP testing was 1.00 and the specificity was 0.97. The negative and positive predictive values were 1.00 and 0.36, respectively. The positive likelihood ratio was 28.3.

DISCUSSION

Non-invasive LAMP testing using oropharyngeal swabs provided an accurate fast and minimally invasive mechanism for predicting invasive MD in this study.

TRIAL REGISTRATION NUMBER

NCT03378258.

Diagnostic test accuracy of point-of-care procalcitonin to diagnose serious bacterial infections in children

BACKGROUND

The National Institute for Health and Care Excellence (NICE) have called for research into the role of biomarkers, and specifically procalcitonin (PCT), for the early diagnosis of serious bacterial infections (SBI) in children. The aim of this study was to compare the diagnostic test accuracy of C-reactive protein (CRP) and PCT for the diagnosis of SBI in children.

METHODS

Data was collected prospectively from four UK emergency departments (ED) between November 2017 and June 2019. Consecutive children under 18 years of age with fever and features of possible sepsis and/or meningitis were eligible for inclusion. The index tests were PCT and CRP and the reference standard was the confirmation of SBI.

RESULTS

213 children were included in the final analysis. 116 participants (54.5%) were male, and the median age was 2 years, 9 months. Parenteral antibiotics were given to 100 (46.9%), three (1.4%) were admitted to a paediatric intensive care unit and there were no deaths. There were ten (4.7%) confirmed SBI. The area under the curve for PCT and CRP for the detection of SBI was identical at 0.70.

CONCLUSIONS

There was no difference in the performance of PCT and CRP for the recognition of SBI in this cohort.

TRIAL REGISTRATION

Registered at https://www.clinicaltrials.gov (trial registration: NCT03378258 ) on the 19th of December 2017.

Antimicrobial stewardship in children: more shadows than lights?

Introduction: The aim of this review is to evaluate the effectiveness of antimicrobial stewardship (AMS) programmes in the pediatric population in improving clinical outcomes, altering prescribing behavior, controlling antimicrobial resistance and measuring the cost-effectiveness.Areas covered: Medline Ovid MEDLINE(R), Embase, and Cochrane Library were searched on 30 September 2018 combining MeSH and free terms for 'antimicrobial stewardship', 'clinical outcomes', 'antimicrobial resistance', 'cost-effectiveness' and 'prescribing behavior'. Several studies have been conducted on the impact of antimicrobial stewardship programmes (ASPs) in children, which showed a positive impact on length of hospital stay and days of therapy. Together with ASP bundles, the introduction of fast microbiology and point-of-care tests showed a positive impact in terms of rapid identification of the pathogen, time to optimal antimicrobial therapy and reduction of antibiotic use, without worsening clinical outcomes. These improvements turned out to be limited over time. Conflicting results were observed regarding the impact of ASPs on antimicrobial resistance and on cost-effectiveness and cost-benefits, due to the lack of homogeneity between studies.Expert opinion: Evidence regarding the impact of ASPs in children is limited to single center studies, with different study designs, making it impossible to draw unequivocal conclusions. High quality studies are needed. More feasable approaches should be designed both for inpatients and outpatients and for critical patients.

The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department

BACKGROUND

Paediatric fever is a common cause of emergency department (ED) attendance. A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes.

METHODS

We studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children's Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing.

RESULTS

Infants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39-£2993.37] per child, (p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0-5.1-fold] higher resource use than consultants (p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5-13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate 'red flag', treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations.

CONCLUSION

The economic impact of diagnostic uncertainty when managing paediatric febrile illness is significant, and the precautionary use of antibiotics is strongly associated with increased costs. The use of ED resources is highest among infants (aged less than 3 months) and those infants managed by lesser experienced doctors, independent of clinical severity. Diagnostic advances which could increase confidence to withhold antibiotics may yield considerable efficiency gains in these groups, where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest.

Model-based economic evaluations of diagnostic point of care tests were rarely fit for purpose

OBJECTIVES

Linked evidence models are recommended to predict health benefits and cost-effectiveness of diagnostic tests. We considered how published models accounted for changes in patient pathways that occur with point of care tests (POCTs) and their impact on patient health and costs.

STUDY DESIGN AND SETTING

Model-based evaluations of diagnostic POCTs published from 2004 to 2017 were identified from searching six databases. For each model, we assessed the outcomes considered, and whether reduced time to diagnosis and increased access to testing affected patient health and costs.

RESULTS

Seventy-four model-based evaluations were included: 95% incorporated evidence on test accuracy, but 34% only assessed intermediate outcomes such as rates of correct diagnosis. Of 54 models where POCTs reduced testing time, 39% addressed the economic and 37% addressed the health benefits of faster diagnosis. No model considered differences in access to tests.

CONCLUSION

Many models fail to capture the effects of POCTs in increasing access, advancing speed of diagnosis and treatment, and reducing anxiety and the associated costs. Many only consider the impact of testing from changes in accuracy. Ensuring models incorporate changes in patient pathways from faster and more accessible testing will lead to economic evaluations that better reflect the impact of POCTs.

Validation of two algorithms for managing children with a non-blanching rash

BACKGROUND

Paediatricians are concerned that children who present with a non-blanching rash (NBR) may have meningococcal disease (MCD). Two algorithms have been devised to help identify which children with an NBR have MCD.

AIM

To evaluate the NBR algorithms' ability to identify children with MCD.

METHODS

The Newcastle-Birmingham-Liverpool (NBL) algorithm was applied retrospectively to three cohorts of children who had presented with NBRs. This algorithm was also piloted in four hospitals, and then used prospectively for 12 months in one hospital. The National Institute for Health and Care Excellence (NICE) algorithm was validated retrospectively using data from all cohorts.

RESULTS

The cohorts included 625 children, 145 (23%) of whom had confirmed or probable MCD. Paediatricians empirically treated 324 (52%) children with antibiotics. The NBL algorithm identified all children with MCD and suggested treatment for a further 86 children (sensitivity 100%, specificity 82%). One child with MCD did not receive immediate antibiotic treatment, despite this being suggested by the algorithm. The NICE algorithm suggested 382 children (61%) who should be treated with antibiotics. This included 141 of the 145 children with MCD (sensitivity 97%, specificity 50%).

CONCLUSIONS

These algorithms may help paediatricians identify children with MCD who present with NBRs. The NBL algorithm may be more specific than the NICE algorithm as it includes fewer features suggesting MCD. The only significant delay in treatment of MCD occurred when the algorithms were not followed.

Procalcitonin: Is This the Promised Biomarker for Critically Ill Patients?

Objective Procalcitonin (PCT) has been increasingly used in the critical care setting to determine the presence of bacterial infection and also to guide antibiotic therapy. We reviewed PCT's physiologic role, as well as its clinical utility for the management of pediatric critically ill patients. Findings PCT is a precursor of the hormone calcitonin. Its production is induced by inflammatory conditions, especially bacterial infections. Literature shows that PCT is a moderately reliable diagnostic test for severe bacterial infection in children. Synthesis of available adult studies suggests that the use of PCT-based algorithms to support medical decision making reduces antibiotic exposure without compromising safety in critically ill patients. However, no study has addressed the usefulness and safety of PCT to guide antibiotic therapy in severely ill children. In pediatric patients with acute lower respiratory tract infections, the use of PCT-based algorithms also led to a safe decrease in antibiotic treatment duration. Conclusion PCT has demonstrated clinical utility in the pediatric critical care setting when used for the diagnosis of bacterial infections and to guide antibiotic use in children with acute lower respiratory tract infections. However, more research is needed in critically ill children to determine the utility of PCT-driven antibiotic therapy in this population.

The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults

Bacterial meningitis and meningococcal sepsis are rare conditions with high case fatality rates. Early recognition and prompt treatment saves lives. In 1999 the British Infection Society produced a consensus statement for the management of immunocompetent adults with meningitis and meningococcal sepsis. Since 1999 there have been many changes. We therefore set out to produce revised guidelines which provide a standardised evidence-based approach to the management of acute community acquired meningitis and meningococcal sepsis in adults. A working party consisting of infectious diseases physicians, neurologists, acute physicians, intensivists, microbiologists, public health experts and patient group representatives was formed. Key questions were identified and the literature reviewed. All recommendations were graded and agreed upon by the working party. The guidelines, which for the first time include viral meningitis, are written in accordance with the AGREE 2 tool and recommendations graded according to the GRADE system. Main changes from the original statement include the indications for pre-hospital antibiotics, timing of the lumbar puncture and the indications for neuroimaging. The list of investigations has been updated and more emphasis is placed on molecular diagnosis. Approaches to both antibiotic and steroid therapy have been revised. Several recommendations have been given regarding the follow-up of patients.