Time to Pathogen Detection for Non-ill Versus Ill-Appearing Infants ≤60 Days Old With Bacteremia and Meningitis

Improving Guideline-Concordant Care for Febrile Infants Through a Quality Improvement Initiative

OBJECTIVES

We aimed to examine the impact of a quality improvement (QI) collaborative on adherence to specific recommendations within the American Academy of Pediatrics' Clinical Practice Guideline (CPG) for well-appearing febrile infants aged 8 to 60 days.

METHODS

Concurrent with CPG release in August 2021, we initiated a QI collaborative involving 103 general and children's hospitals across the United States and Canada. We developed a multifaceted intervention bundle to improve adherence to CPG recommendations for 4 primary measures and 4 secondary measures, while tracking 5 balancing measures. Primary measures focused on guideline recommendations where deimplementation strategies were indicated. We analyzed data using statistical process control (SPC) with baseline and project enrollment from November 2020 to October 2021 and the intervention from November 2021 to October 2022.

RESULTS

Within the final analysis, there were 17 708 infants included. SPC demonstrated improvement across primary and secondary measures. Specifically, the primary measures of appropriately not obtaining cerebrospinal fluid in qualifying infants and appropriately not administering antibiotics had the highest adherence at the end of the collaborative (92.4% and 90.0% respectively). Secondary measures on parent engagement for emergency department discharge of infants 22 to 28 days and oral antibiotics for infants 29 to 60 days with positive urinalyses demonstrated the greatest changes with collaborative-wide improvements of 16.0% and 20.4% respectively. Balancing measures showed no change in missed invasive bacterial infections.

CONCLUSIONS

A QI collaborative with a multifaceted intervention bundle was associated with improvements in adherence to several recommendations from the AAP CPG for febrile infants.

Predictors of Invasive Bacterial Infection in Febrile Infants Aged 2 to 6 Months in the Emergency Department

Our goal was to identify predictors of invasive bacterial infection (ie, bacteremia and bacterial meningitis) in febrile infants aged 2-6 months. In our multicenter retrospective cohort, older age and lower temperature identified infants at low risk for invasive bacterial infection who could safely avoid routine testing.

Finding significant pathogens in blood cultures in children: Should we set the timer to 36 hours?

Background

Knowledge of time to positivity (TTP) for blood cultures is useful to assess timing of discontinuation of empiric antimicrobials for suspected bacteremia with no focus.

Methods

An audit of positive blood cultures from the Children's Hospital of Eastern Ontario (CHEO) from November 1, 2019, to October 31, 2020, was performed to determine TTP, defined as the start of incubation to a positive signal from automated incubators.

Results

Three hundred seventy-six positive blood cultures were identified from 248 patients (average age: 6.27 [SD 6.24] years). Of these, 247 isolates were speciated; 90 (36.4%) were definitive/probable (DP) pathogens (median TTP 12.75 hours) and 157 (63.6%) possible/probable (PP) contaminants (median TTP 24.08 hours). At each time point, the adjusted rate of positive blood culture was significantly higher for DP pathogens compared to PP contaminants (hazard ratio [HR] 1.80 [95% CI 1.37, 2.36]) and for children ≤27 days old compared to the oldest age group (HR 1.94 [95% CI 1.19, 3.17]). By 36 hours, the proportion of positive cultures was significantly higher in the youngest age group (≤27 days) compared with the 3-11 years old age group (91.7% [95% CI 68.6%, 97.8%] versus 58.2% [95% CI 46.91%, 68.06%]).

Conclusion

Across all ages, the TTP was significantly shorter for blood cultures with DP pathogens compared to those with PP contaminants (HR 1.80 [95% CI 1.37, 2.36]). In newborns, 90% of blood cultures were positive by 36 hours supporting this re-assessment time for empiric antimicrobials. TTP was longer in children ≥12 months, possibly related to other factors such as blood culture volume.

La prise en charge des nourrissons de 90 jours ou moins, fiévreux mais dans un bon état général

On constate des pratiques très variées en matière d'évaluation et de prise en charge des jeunes nourrissons fiévreux. Bien que la plupart des jeunes nourrissons fiévreux mais dans un bon état général soient atteints d'une maladie virale, il est essentiel de détecter ceux qui sont à risque de présenter des infections bactériennes invasives, notamment une bactériémie et une méningite bactérienne. Le présent document de principes porte sur les nourrissons de 90 jours ou moins dont la température rectale est de 38,0 °C ou plus, mais qui semblent être dans un bon état général. Il est conseillé d'appliquer les récents critères de stratification du risque pour orienter la prise en charge, ainsi que d'intégrer la procalcitonine à l'évaluation diagnostique. Les décisions sur la prise en charge des nourrissons qui satisfont aux critères de faible risque devraient refléter la probabilité d'une maladie, tenir compte de l'équilibre entre les risques et les préjudices potentiels et faire participer les parents ou les proches aux décisions lorsque diverses options sont possibles. La prise en charge optimale peut également dépendre de considérations pragmatiques, telles que l'accès à des examens diagnostiques, à des unités d'observation, à des soins tertiaires et à un suivi. Des éléments particuliers, tels que la mesure de la température, le risque d'infection invasive à Herpes simplex et la fièvre postvaccinale, sont également abordés.

Management of well-appearing febrile young infants aged ≤90 days

The evaluation and management of young infants presenting with fever remains an area of significant practice variation. While most well-appearing febrile young infants have a viral illness, identifying those at risk for invasive bacterial infections, specifically bacteremia and bacterial meningitis, is critical. This statement considers infants aged ≤90 days who present with a rectal temperature ≥38.0°C but appear well otherwise. Applying recent risk-stratification criteria to guide management and incorporating diagnostic testing with procalcitonin are advised. Management decisions for infants meeting low-risk criteria should reflect the probability of disease, consider the balance of risks and potential harm, and include parents/caregivers in shared decision-making when options exist. Optimal management may also be influenced by pragmatic considerations, such as access to diagnostic investigations, observation units, tertiary care, and follow-up. Special considerations such as temperature measurement, risk for invasive herpes simplex infection, and post-immunization fever are also discussed.

Time to Positive Blood and Cerebrospinal Fluid Cultures in Hypothermic Young Infants

BACKGROUND AND OBJECTIVE

Hypothermia in young infants may be secondary to an invasive bacterial infection. No studies have explored culture time-to-positivity (TTP) in hypothermic infants. Our objective was to compare TTP of blood and cerebrospinal fluid (CSF) cultures between pathogenic and contaminant bacteria in hypothermic infants ≤90 days of age.

METHODS

Secondary analysis of a retrospective cohort of 9 children's hospitals. Infants ≤90 days of age presenting to the emergency department or inpatient setting with hypothermia from September 1, 2017, to May 5, 2021, with positive blood or CSF cultures were included. Differences in continuous variables between pathogenic and contaminant organism groups were tested using a 2-sample t test and 95% confidence intervals for the mean differences reported.

RESULTS

Seventy-seven infants met inclusion criteria. Seventy-one blood cultures were positive, with 20 (28.2%) treated as pathogenic organisms. Five (50%) of 10 positive CSF cultures were treated as pathogenic. The median (interquartile range [IQR]) TTP for pathogenic blood cultures was 16.8 (IQR 12.7-19.2) hours compared with 26.11 (IQR 20.5-48.1) hours for contaminant organisms (P < .001). The median TTP for pathogenic organisms on CSF cultures was 34.3 (IQR 2.0-53.7) hours, compared with 58.1 (IQR 52-72) hours for contaminant CSF organisms (P < .186).

CONCLUSIONS

Our study is the first to compare the TTP of blood and CSF cultures between pathogenic and contaminant bacteria in hypothermic infants. All pathogenic bacteria in the blood grew within 36 hours. No difference in TTP of CSF cultures between pathogenic and contaminant bacteria was detected.

FeBRILe3: Safety Evaluation of Febrile Infant Guidelines Through Prospective Bayesian Monitoring

OBJECTIVES

Despite evidence supporting earlier discharge of well-appearing febrile infants at low risk of serious bacterial infection (SBI), admissions for ≥48 hours remain common. Prospective safety monitoring may support broader guideline implementation.

METHODS

A sequential Bayesian safety monitoring framework was used to evaluate a new hospital guideline recommending early discharge of low-risk infants. Hospital readmissions within 7 days of discharge were regularly assessed against safety thresholds, derived from historic rates and expert opinion, and specified a priori (8 per 100 infants). Infants aged under 3 months admitted to 2 Western Australian metropolitan hospitals for management of fever without source were enrolled (August 2019-December 2021), to a prespecified maximum 500 enrolments.

RESULTS

Readmission rates remained below the prespecified threshold at all scheduled analyses. Median corrected age was 34 days, and 14% met low-risk criteria (n = 71). SBI was diagnosed in 159 infants (32%), including urinary tract infection (n = 140) and bacteraemia (n = 18). Discharge occurred before 48 hours for 192 infants (38%), including 52% deemed low-risk. At study completion, 1 of 37 low-risk infants discharged before 48 hours had been readmitted (3%), for issues unrelated to SBI diagnosis. In total, 20 readmissions were identified (4 per 100 infants; 95% credible interval 3, 6), with >0.99 posterior probability of being below the prespecified noninferiority threshold, indicating acceptable safety.

CONCLUSIONS

A Bayesian monitoring approach supported safe early discharge for many infants, without increased risk of readmission. This framework may be used to embed safety evaluations within future guideline implementation programs to further reduce low-value care.

Implementation of a 24-hour infection diagnosis protocol in the pediatric cardiac intensive care unit (CICU)

OBJECTIVES

To reduce unnecessary antibiotic exposure in a pediatric cardiac intensive care unit (CICU).

DESIGN

Single-center, quality improvement initiative. Monthly antibiotic utilization rates were compared between 12-month baseline and 18-month intervention periods.

SETTING

A 25-bed pediatric CICU.

PATIENTS

Clinically stable patients undergoing infection diagnosis were included. Patients with immunodeficiency, mechanical circulatory support, open sternum, and recent culture-positive infection were excluded.

INTERVENTIONS

The key drivers for improvement were standardizing the infection diagnosis process, order-set creation, limitation of initial antibiotic prescription to 24 hours, discouraging indiscriminate vancomycin use, and improving bedside communication and situational awareness regarding the infection diagnosis protocol.

RESULTS

In total, 109 patients received the protocol; antibiotics were discontinued in 24 hours in 72 cases (66%). The most common reasons for continuing antibiotics beyond 24 hours were positive culture (n = 13) and provider preference (n = 13). A statistical process control analysis showed only a trend in monthly mean antibiotic utilization rate in the intervention period compared to the baseline period: 32.6% (SD, 6.1%) antibiotic utilization rate during the intervention period versus 36.6% (SD, 5.4%) during the baseline period (mean difference, 4%; 95% CI, -0.5% to -8.5%; P = .07). However, a special-cause variation represented a 26% reduction in mean monthly vancomycin use during the intervention period. In the patients who had antibiotics discontinued at 24 hours, delayed culture positivity was rare.

CONCLUSIONS

Implementation of a protocol limiting empiric antibiotic courses to 24 hours in clinically stable, standard-risk, pediatric CICU patients with negative cultures is feasible. This practice appears safe and may reduce harm by decreasing unnecessary antibiotic exposure.

Cost modelling incorporating procalcitonin for the risk stratification of febrile infants ≤60 days old

Objectives

Procalcitonin testing is recommended to discriminate febrile young infants at risk of serious bacterial infections (SBI). However, this test is not available in many clinical settings, limited largely by cost. This study sought to evaluate contemporary real-world costs associated with the usual care of febrile young infants, and estimate impact on clinical trajectory and costs when incorporating procalcitonin testing.

Methods

We assessed hospital-level door-to-discharge costs of all well-appearing febrile infants aged ≤60 days, evaluated at a tertiary paediatric hospital between April/2016 and March/2019. Emergency Department and inpatient expense data for usual care were obtained from the institutional general ledger, validated by the provincial Ministry of Health. These costs were then incorporated into a probabilistic model of risk stratification for an equivalent simulated cohort, with the addition of procalcitonin.

Results

During the 3-year study period, 1168 index visits were included for analysis. Real-world median costs-per-infant were the following: $3266 (IQR $2468 to $4317, n=93) for hospitalized infants with SBIs; $2476 (IQR $1974 to $3236, n=530) for hospitalized infants without SBIs; $323 (IQR $286 to $393, n=538) for discharged infants without SBIs; and, $3879 (IQR $3263 to $5297, n=7) for discharged infants subsequently hospitalized for missed SBIs. Overall median cost-per-infant of usual care was $1555 (IQR $1244 to $2025), compared to a modelled cost of $1389 (IQR $1118 to $1797) with the addition of procalcitonin (10.7% overall cost savings; $1,816,733 versus $1,622,483). Under pessimistic and optimistic model assumptions, savings were 5.9% and 14.9%, respectively.

Conclusions

Usual care of febrile young infants is variable and resource intensive. Increased access to procalcitonin testing could improve risk stratification at lower overall costs.

Equity in Receipt of a Lumbar Puncture for Febrile Infants at an Academic Center

BACKGROUND

The evaluation of febrile infants ≤60 days of age is often guided by established protocols. However, structural racism and physicians' implicit bias may affect how such clinical guidelines are applied.

OBJECTIVE

To determine the association between self-identified race, insurance type, ZIP code-based median household income (MHI) and receiving a guideline-concordant lumbar puncture (GCLP) in febrile infants.

METHODS

This was a 3-year retrospective cross-sectional study of all febrile infants ≤60 days old presenting to a children's hospital from 2015 to 2017. GCLP was defined as obtaining or appropriately not obtaining a lumbar puncture as defined by the hospital's clinical practice guideline, which recommended performing a lumbar puncture for all febrile infants ≤60 days of age unless an infant was >28 days of age and had respiratory syncytial virus-positive bronchiolitis. Univariate analyses were used to identify variables associated with receiving a GCLP. Variables with a P < .1 were included in a multivariate logistic regression with race, MHI, and insurance type.

RESULTS

We included 965 infants. Age (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97) and temperature on arrival (adjusted odds ratio, 1.36; 95% confidence interval, 1.04-1.78) were significantly associated with receipt of a GCLP. Self-identified race, insurance type, and MHI were not associated with receiving a GCLP.

CONCLUSION

Receipt of a GCLP was not associated with race, MHI, or insurance type. As recent national guidelines change to increase shared decision-making, physician awareness and ongoing assessment of the role of factors such as race and socioeconomic status in the clinical evaluation and outcomes of febrile infants will be critical.

Performance of AAP Clinical Practice Guideline for Febrile Infants at One Pediatric Hospital

BACKGROUND

In the absence of procalcitonin, the American Academy of Pediatrics' clinical practice guideline (CPG) for evaluating and managing febrile infants recommends using previously untested combinations of inflammatory marker thresholds. Thus, CPG performance in detecting invasive bacterial infections (IBIs; bacteremia, bacterial meningitis) is poorly understood.

OBJECTIVE

To evaluate CPG performance without procalcitonin in detecting IBIs in well-appearing febrile infants 8 to 60 days old.

METHODS

For this cross-sectional, single-site study, we manually abstracted data for febrile infants using electronic health records from 2011 to 2018. We used CPG inclusion/exclusion criteria to identify eligible infants and stratified IBI risk with CPG inflammatory marker thresholds for temperature, absolute neutrophil count, and C-reactive protein. Because the CPG permits a wide array of interpretations, we performed 3 sensitivity analyses, modifying age and inflammatory marker thresholds. For each approach, we calculated area-under-the-receiver operating characteristic curve, sensitivity, and specificity in detecting IBIs.

RESULTS

For this study, 507 infants met the inclusion criteria. For the main analysis, we observed an area-under-the-receiver operating characteristic curve of 0.673 (95% confidence interval 0.652-0.694), sensitivity of 100% (66.4%-100%), and specificity of 34.5% (30.4%-38.9%). For the sensitivity analyses, sensitivities were all 100% and specificities ranged from 9% to 38%.

CONCLUSION

Findings suggest that the CPG is highly sensitive, minimizing missed IBIs, but specificity may be lower than previously reported. Future studies should prospectively investigate CPG performance in larger, multisite samples.

Derivation of a clinical-based model to detect invasive bacterial infections in febrile infants

BACKGROUND

Febrile infants are at risk for invasive bacterial infections (IBIs) (i.e., bacteremia and bacterial meningitis), which, when undiagnosed, may have devastating consequences. Current IBI predictive models rely on serum biomarkers, which may not provide timely results and may be difficult to obtain in low-resource settings.

OBJECTIVE

The aim of this study was to derive a clinical-based IBI predictive model for febrile infants.

DESIGNS, SETTING, AND PARTICIPANTS

This is a cross-sectional study of infants brought to two pediatric emergency departments from January 2011 to December 2018. Inclusion criteria were age 0-90 days, temperature ≥38°C, and documented gestational age, fever duration, and illness duration.

MAIN OUTCOME AND MEASURES

To detect IBIs, we used regression and ensemble machine learning models and evidence-based predictors (i.e., sex, age, chronic medical condition, gestational age, appearance, maximum temperature, fever duration, illness duration, cough status, and urinary tract inflammation). We up-weighted infants with IBIs 8-fold and used 10-fold cross-validation to avoid overfitting. We calculated the area under the receiver operating characteristic curve (AUC), prioritizing a high sensitivity to identify the optimal cut-point to estimate sensitivity and specificity.

RESULTS

Of 2311 febrile infants, 39 had an IBI (1.7%); the median age was 54 days (interquartile range: 35-71). The AUC was 0.819 (95% confidence interval: 0.762, 0.868). The predictive model achieved a sensitivity of 0.974 (0.800, 1.00) and a specificity of 0.530 (0.484, 0.575). Findings suggest that a clinical-based model can detect IBIs in febrile infants, performing similarly to serum biomarker-based models. This model may improve health equity by enabling clinicians to estimate IBI risk in any setting. Future studies should prospectively validate findings across multiple sites and investigate performance by age.

Refinement and Validation of a Clinical-Based Approach to Evaluate Young Febrile Infants

BACKGROUND AND OBJECTIVE

For febrile infants, predictive models to detect bacterial infections are available, but clinical adoption remains limited by implementation barriers. There is a need for predictive models using widely available predictors. Thus, we previously derived 2 novel predictive models (machine learning and regression) by using demographic and clinical factors, plus urine studies. The objective of this study is to refine and externally validate the predictive models.

METHODS

This is a cross-sectional study of infants initially evaluated at one pediatric emergency department from January 2011 to December 2018. Inclusion criteria were age 0 to 90 days, temperature ≥38°C, documented gestational age, and insurance type. To reduce potential biases, we derived models again by using derivation data without insurance status and tested the ability of the refined models to detect bacterial infections (ie, urinary tract infection, bacteremia, and meningitis) in the separate validation sample, calculating areas-under-the-receiver operating characteristic curve, sensitivities, and specificities.

RESULTS

Of 1419 febrile infants (median age 53 days, interquartile range = 32-69), 99 (7%) had a bacterial infection. Areas-under-the-receiver operating characteristic curve of machine learning and regression models were 0.92 (95% confidence interval [CI] 0.89-0.94) and 0.90 (0.86-0.93) compared with 0.95 (0.91-0.98) and 0.96 (0.94-0.98) in the derivation study. Sensitivities and specificities of machine learning and regression models were 98.0% (94.7%-100%) and 54.2% (51.5%-56.9%) and 96.0% (91.5%-99.1%) and 50.0% (47.4%-52.7%).

CONCLUSIONS

Compared with the derivation study, the machine learning and regression models performed similarly. Findings suggest a clinical-based model can estimate bacterial infection risk. Future studies should prospectively test the models and investigate strategies to optimize clinical adoption.

Clinical utility of correction factors for febrile young infants with traumatic lumbar punctures

Objectives

Correction factors have been proposed for traumatic lumbar punctures (LPs) in febrile young infants. However, no studies have assessed their diagnostic utility. We sought to determine the proportion of traumatic LPs safely reclassified as low risk for bacterial meningitis using recently derived white blood cell (WBC) and protein correction factors.

Methods

We retrospectively analyzed traumatic LPs among all febrile infants ≤60 days old at two tertiary paediatric hospitals from 2006 through 2018. Traumatic LPs were defined as ≥10,000 RBCs/mm³. Abnormal cerebrospinal fluid (CSF) WBCs and protein were adjusted downward using a newly derived correction factor (877 red blood cells [RBCs]: 1 WBC), three commonly used correction factors (500 WBCs: 1 RBC; 1,000 WBCs: 1 WBC; peripheral RBCs: WBCs), and a newly derived protein correction factor (1,000 RBCs: 0.011 g/L protein).

Results

There were 437 traumatic LPs including 357 (82%) with pleocytosis and 4 (0.9%) with bacterial meningitis. Overall, fewer infants were classified as having CSF pleocytosis using 877:1 and 1,000:1 ratios (38% and 43%, respectively), with 100% sensitivity and negative predictive value, and improved specificity (63% for 877:1, 58% for 1,000:1 ratios versus 19% for uncorrected counts). Among infants with pleocytosis, 877:1 and 1,000:1 ratios reclassified 191 (54%) and 171 (48%) as normal with no misclassified bacterial meningitis cases. Ratios of 500:1 and peripheral RBC:WBC misclassified 1 infant that had bacterial meningitis. Corrected CSF protein outperformed uncorrected protein in specificity but did not add diagnostic value following WBC-based correction.

Conclusions

Correction ratios of 877:1 and 1,000:1 safely reclassified half of all febrile infants ≤60 days. These corrections should be considered when interpreting CSF results of traumatic LPs.

Time to Blood Culture Positivity by Pathogen and Primary Service

OBJECTIVES

Initiation and continuation of empirical antimicrobial agents for a 48-72-hour observation period is routine practice in the diagnosis and treatment of infants and children with concern for bacteremia. We examined blood cultures at a freestanding pediatric hospital over a 6-year period to determine the time to positivity.

METHODS

Data were extracted for all patients who were hospitalized and had blood cultures drawn between January 2013 and December 2018. Time to positivity was calculated on the basis of date and time culture was collected compared with date and time growth was first reported.

RESULTS

Over a 6-year period, 89 663 blood cultures were obtained, of which 6184 had positive results. After exclusions, a total of 2121 positive blood culture results remained, including 1454 (69%) pathogens and 667 contaminants (31%). For all positive blood culture results, the number and percentage positive at 24, 36, and 48 hours were 1441 of 2121 (68%), 1845 of 2121 (87%) and 1970 of 2121 (93%), respectively. One hundred twenty-five (66 pathogens, 59 contaminants) of the 89 663 cultures (0.14%) yielded positive results between 36 and 48 hours, indicating that 719 patients would need to be treated for 48 hours rather than 36 hours to prevent 1 case of antibiotic termination before positive result. Median times to positive result by pathogen and service line are presented.

CONCLUSIONS

This study reveals that ≤36 hours may be a sufficient period of observation for infants and children started on empirical antimicrobial agents for concern for bacteremia. These findings highlight opportunities for antimicrobial stewardship to limit antimicrobial .

Time to Positive Blood and Cerebrospinal Fluid Cultures in Febrile Infants ≤60 Days of Age

OBJECTIVES

To determine the time to positivity for bacterial pathogens and contaminants in blood and cerebrospinal fluid (CSF) cultures in a cohort of febrile infants ≤60 days of age.

METHODS

This was a secondary analysis of prospective observational multicenter study of noncritically ill infants ≤60 days of age with temperatures ≥38°C and blood cultures (December 2008 to May 2013). The main outcome was time to positivity for bacterial pathogens and contaminants.

RESULTS

A total of 256 of 303 (84.49%) patients with positive blood cultures, and 73 of 88 (82.95%) with positive CSF cultures met inclusion criteria. Median time (interquartile range [IQR]) to positivity for blood cultures was 16.6 hours (IQR 12.6-21.9) for bacterial pathogens (n = 74) and 25.1 hours (IQR 19.8-33.0) for contaminants (n = 182); P < .001. Time to bacterial pathogen positivity was similar in infants 0 to 28 days of age (15.8 hours [IQR 12.6-21.0]) and 29 to 60 days of age (17.2 [IQR 12.9-24.3]; P = .328). Median time to positivity for CSF was 14.0 hours (IQR 1.5-21.0) for bacterial pathogens (n = 22) and 40.5 hours (IQR 21.2-62.6) for contaminants (n = 51); P < .001. A total of 82.4% (95% confidence interval, 71.8-90.3) and 81.8% (95% confidence interval, 59.7%-94.8%) of blood and CSF cultures showed bacterial pathogen positivity within 24 hours.

CONCLUSIONS

Among febrile infants ≤60 days of age, time to blood and CSF positivity was significantly shorter for bacterial pathogens than contaminants. Most blood and CSF cultures for bacterial pathogens were positive within 24 hours. With our findings, there is potential to reduce duration of hospitalization and avoid unnecessary antibiotics.

Trends and Variation in Length of Stay Among Hospitalized Febrile Infants ≤60 Days Old

OBJECTIVES

Researchers in recent studies suggest that hospitalized febrile infants aged ≤60 days may be safely discharged if bacterial cultures are negative after 24-36 hours of incubation. We aimed to describe trends and variation in length of stay (LOS) for hospitalized febrile infants across children's hospitals.

METHODS

We conducted a multicenter retrospective cohort study of febrile infants aged ≤60 days hospitalized from 2016 to 2019 at 39 hospitals in the Pediatric Health Information System database. We excluded infants with complex chronic conditions, bacterial infections, lower respiratory tract viral infections, and those who required ICU admission. The primary outcomes were trends in LOS overall and for individual hospitals, adjusted for patient demographics and clinical characteristics. We also evaluated the hospital-level association between LOS and 30-day readmissions.

RESULTS

We identified 11 868 eligible febrile infant encounters. The adjusted mean LOS for the study cohort decreased from 44.0 hours in 2016 to 41.9 hours in 2019 (P < .001). There was substantial variation in adjusted mean LOS across children's hospitals, range 33.5-77.9 hours in 2016 and 30.4-100.0 hours in 2019. The change from 2016 to 2019 in adjusted mean LOS across individual hospitals also varied widely (-23.9 to +26.7 hours; median change -1.8 hours, interquartile range: -5.4 to 0.3). There was no association between hospital-level LOS and readmission rates (P = .70).

CONCLUSIONS

The LOS for hospitalized febrile infants decreased marginally between 2016 and 2019, although overall LOS and change in LOS varied substantially across children's hospitals. Continued quality improvement efforts are needed to reduce LOS for hospitalized febrile infants.

Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old

This guideline addresses the evaluation and management of well-appearing, term infants, 8 to 60 days of age, with fever ≥38.0°C. Exclusions are noted. After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active investigators, 21 key action statements were derived. For each key action statement, the quality of evidence and benefit-harm relationship were assessed and graded to determine the strength of recommendations. When appropriate, parents' values and preferences should be incorporated as part of shared decision-making. For diagnostic testing, the committee has attempted to develop numbers needed to test, and for antimicrobial administration, the committee provided numbers needed to treat. Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Decreasing Hospital Observation Time for Febrile Infants

BACKGROUND

Febrile infants aged 0 to 60 days are often hospitalized for a 36-to-48 hour observation period to rule out invasive bacterial infections (IBI). Evidence suggests that monitoring blood and cerebrospinal fluid (CSF) cultures for 24 hours may be appropriate for most infants. We aimed to decrease the average culture observation time (COT) from 38 to 30 hours among hospitalized infants 0 to 60 days old over 12 months.

METHODS

This quality improvement initiative occurred at a large children's hospital, in conjunction with development of a multidisciplinary evidence-based guideline for the management of febrile infants. We included infants aged 0 to 60 days admitted with fever without a clear infectious source. We excluded infants who had positive blood, urine, or CSF cultures within 24 hours of incubation and infants who were hospitalized for other indications (eg, bronchiolitis). Interventions included guideline dissemination, education regarding laboratory monitoring practices, standardized order sets, and near-time identification of failures. Our primary outcome was COT, defined as time between initiation of culture incubation and hospital discharge in hours. Interventions were tracked on an annotated statistical process control chart. Our balancing measure was identification of IBI after hospital discharge.

RESULTS

In our cohort of 184 infants aged 0 to 60 days, average COT decreased from 38 hours to 32 hours after structured guideline dissemination and order-set standardization; this decrease was sustained over 17 months. IBI was not identified in any patients after discharge.

CONCLUSIONS

Implementation of an evidence-based guideline through education, transparency of laboratory procedures, creation of standardized order sets, and near-time feedback was associated with shorter COT for febrile infants aged 0 to 60 days.

Using Clinical History Factors to Identify Bacterial Infections in Young Febrile Infants

OBJECTIVE

To develop a novel predictive model using primarily clinical history factors and compare performance to the widely used Rochester Low Risk (RLR) model.

STUDY DESIGN

In this cross-sectional study, we identified infants brought to one pediatric emergency department from January 2014 to December 2016. We included infants age 0-90 days, with temperature ≥38°C, and documented gestational age and illness duration. The primary outcome was bacterial infection. We used 10 predictors to develop regression and ensemble machine learning models, which we trained and tested using 10-fold cross-validation. We compared areas under the curve (AUCs), sensitivities, and specificities of the RLR, regression, and ensemble models.

RESULTS

Of 877 infants, 67 had a bacterial infection (7.6%). The AUCs of the RLR, regression, and ensemble models were 0.776 (95% CI 0.746, 0.807), 0.945 (0.913, 0.977), and 0.956 (0.935, 0.975), respectively. Using a bacterial infection risk threshold of .01, the sensitivity and specificity of the regression model was 94.6% (87.4%, 100%) and 74.5% (62.4%, 85.4%), compared with 95.5% (87.5%, 99.1%) and 59.6% (56.2%, 63.0%) using the RLR model.

CONCLUSIONS

Compared with the RLR model, sensitivities of the novel predictive models were similar whereas AUCs and specificities were significantly greater. If externally validated, these models, by producing an individualized bacterial infection risk estimate, may offer a targeted approach to young febrile infants that is noninvasive and inexpensive.

Comparison of a commercial real-time PCR panel to routine laboratory methods for the diagnosis of meningitis-encephalitis

Meningitis-encephalitis can range from a mild, self limiting illness to a life threatening disease. Rapid microbial diagnosis allows for early targeted management. This study aimed to compare the BioFire FilmArray Meningitis/Encephalitis multiplex PCR panel (ME panel) to traditional testing algorithms for accuracy and turnaround time in the diagnosis of meningitis-encephalitis. From April to November 2018, cerebrospinal fluid (CSF) samples meeting existing laboratory testing criteria for suspected community acquired meningitis-encephalitis were tested on the ME panel and by routine laboratory methods. The methods were compared for accuracy of diagnosis and turnaround time. Where an organism was not identified, the study investigators came to a consensus on whether an infective aetiology was likely based on CSF parameters, clinical features, management and final discharge diagnosis. A total of 147 CSF samples met criteria for testing. Results were concordant in 143 (97%) of cases, including 27 samples where the same organism was identified by both methods. Of the four discordant samples, three organisms identified by the ME panel alone were considered clinically insignificant. One sample, which was culture and antigen positive for Cryptococcus neoformans, was not detected on the ME panel. The ME panel and routine methods identified an organism in 55% and 58% of clinically compatible cases of infection, respectively. The median turnaround time for the ME panel was 2.9 hours, compared to 21.1 hours for routine testing. The ME panel showed high concordance with traditional testing, simplified laboratory workflow, and significantly reduced turnaround time. The failure of the ME panel to detect Cryptococcus spp. is concerning. When cryptococcal meningitis is suspected, we would recommend using culture and cryptococcal antigen testing as the investigations of choice. Despite the availability of molecular assays targeting the common causes of CNS infection, the diagnostic yield remains suboptimal.

Parenteral Antibiotic Therapy Duration in Young Infants With Bacteremic Urinary Tract Infections

OBJECTIVES

To determine the association between parenteral antibiotic duration and outcomes in infants ≤60 days old with bacteremic urinary tract infection (UTI).

METHODS

This multicenter retrospective cohort study included infants ≤60 days old who had concomitant growth of a pathogen in blood and urine cultures at 11 children's hospitals between 2011 and 2016. Short-course parenteral antibiotic duration was defined as ≤7 days, and long-course parenteral antibiotic duration was defined as >7 days. Propensity scores, calculated using patient characteristics, were used to determine the likelihood of receiving long-course parenteral antibiotics. We conducted inverse probability weighting to achieve covariate balance and applied marginal structural models to the weighted population to examine the association between parenteral antibiotic duration and outcomes (30-day UTI recurrence, 30-day all-cause reutilization, and length of stay).

RESULTS

Among 115 infants with bacteremic UTI, 58 (50%) infants received short-course parenteral antibiotics. Infants who received long-course parenteral antibiotics were more likely to be ill appearing and have growth of a non-Escherichia coli organism. There was no difference in adjusted 30-day UTI recurrence between the long- and short-course groups (adjusted risk difference: 3%; 95% confidence interval: -5.8 to 12.7) or 30-day all-cause reutilization (risk difference: 3%; 95% confidence interval: -14.5 to 20.6).

CONCLUSIONS

Young infants with bacteremic UTI who received ≤7 days of parenteral antibiotics did not have more frequent recurrent UTIs or hospital reutilization compared with infants who received long-course therapy. Short-course parenteral therapy with early conversion to oral antibiotics may be considered in this population.

Serious Bacterial Infections in Neonates Presenting Afebrile With History of Fever

BACKGROUND

Infants ≤28 days of age with fever are frequently hospitalized while undergoing infectious evaluation. We assessed differences in rates of serious bacterial infection (SBI; bacteremia, bacterial meningitis, urinary tract infection) and invasive bacterial infection (IBI; bacteremia, bacterial meningitis) among the following neonates: (1) febrile at presentation (FP), (2) afebrile with history of fever without subsequent fever during hospitalization, and (3) afebrile with history of fever with subsequent fever during hospitalization.

METHODS

We performed a single-center retrospective study of neonates evaluated for SBI during emergency department evaluation between January 1, 2006, and December 31, 2017. Patients were categorized into FP, afebrile with no subsequent fever (ANF), and afebrile with subsequent fever (ASF) groups. We compared rates of SBI and IBI between groups using logistic regression and assessed time to fever development using time-to-event analysis.

RESULTS

Of 931 neonates, 278 (29.9%) were in the ANF group, 93 (10.0%) were in the ASF group, and 560 (60.2%) were in the FP group. Odds of SBI in neonates ANF were 0.42 (95% confidence interval [CI] 0.23-0.79) compared with infants FP, although differences in IBI were not statistically significant (0.52, 95% CI 0.19-1.51). In infants ASF, median time to fever was 5.6 hours (interquartile range, 3.1-11.4). Infants ASF had higher odds of SBI compared to infants FP (odds ratio 1.93, 95% CI 1.07-3.50).

CONCLUSIONS

Neonates with history of fever who remain afebrile during hospitalization may have lower odds for SBI and be candidates for early discharge after an observation period.

Early onset sepsis calculator-based management of newborns exposed to maternal intrapartum fever: a cost benefit analysis

OBJECTIVE

To determine potential net monetary benefit of an early onset sepsis calculator-based approach for management of neonates exposed to maternal intrapartum fever, compared to existing guidelines.

STUDY DESIGN

We performed a cost-benefit analysis comparing two management approaches for newborns >34 weeks gestational age exposed to maternal intrapartum fever. Probabilities of sepsis and meningitis, consequences of infection and antibiotic use, direct medical costs, and indirect costs for long-term disability and mortality were considered.

RESULTS

A calculator-based approach resulted in a net monetary benefit of $3998 per infant with a 60% likelihood of net benefit in probabilistic sensitivity analysis. Our model predicted a 67% decrease in antibiotic use in the calculator arm. The absolute difference for all adverse clinical outcomes between approaches was ≤0.6%.

CONCLUSIONS

Compared to existing guidelines, a calculator-based approach for newborns exposed to maternal intrapartum fever yields a robust net monetary benefit, largely by preventing unnecessary antibiotic treatment.