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Gatto A, Mantani L, Gola C, Pansini V, Di Sarno L, Capossela L, Ferretti S, Graglia B, Chiaretti A. Presepsin Levels in Pediatric Patients with Fever and Suspected Sepsis: A Pilot Study in an Emergency Department. CHILDREN (BASEL, SWITZERLAND) 2024; 11:594. [PMID: 38790589 PMCID: PMC11119862 DOI: 10.3390/children11050594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024]
Abstract
Sepsis is a life-threatening condition that affects 1.2 million children annually. Although there are several criteria for diagnosing this condition, signs are often nonspecific, and identifying sepsis is challenging. In this context, presepsin (P-SEP) seems to be a promising new biomarker since its plasma levels increase earlier than other sepsis-related proteins and its measurement is faster. We enrolled 157 minors who presented to the Pediatric Emergency Department of Agostino Gemelli Hospital with fever and suspected sepsis. Biochemical, anamnestic, and clinical data were collected. Viral agents were identified as the causative factor in 64 patients, who had an average P-SEP value of 309.04 pg/mL (SD ± 273.2), versus an average P-SEP value of 526.09 pg/mL (SD ± 657) found in 27 bacterial cases (p value: 0.0398). Four cases of overt sepsis had an average P-SEP value of 3328.5 pg/mL (SD ± 1586.6). The difference in P-SEP levels in viral versus bacterial infections was found to be statistically significant; therefore, P-SEP may have a central role in the evaluation of febrile children, helping clinicians distinguish between these two etiologies. Furthermore, amongst the cases of confirmed sepsis, P-SEP was always greater than 2000 pg/mL, while C-reactive protein and procalcitonin values appeared lower than what was considered significant.
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Affiliation(s)
- Antonio Gatto
- Department of Pediatrics, Fondazione Policlinico Universitario A. Gemelli—IRCCS, 00168 Rome, Italy;
| | - Lucia Mantani
- Department of Pediatrics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.M.); (C.G.); (L.D.S.); (L.C.); (S.F.); (B.G.)
| | - Caterina Gola
- Department of Pediatrics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.M.); (C.G.); (L.D.S.); (L.C.); (S.F.); (B.G.)
| | - Valeria Pansini
- Department of Pediatrics, Fondazione Policlinico Universitario A. Gemelli—IRCCS, 00168 Rome, Italy;
| | - Lorenzo Di Sarno
- Department of Pediatrics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.M.); (C.G.); (L.D.S.); (L.C.); (S.F.); (B.G.)
| | - Lavinia Capossela
- Department of Pediatrics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.M.); (C.G.); (L.D.S.); (L.C.); (S.F.); (B.G.)
| | - Serena Ferretti
- Department of Pediatrics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.M.); (C.G.); (L.D.S.); (L.C.); (S.F.); (B.G.)
| | - Benedetta Graglia
- Department of Pediatrics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.M.); (C.G.); (L.D.S.); (L.C.); (S.F.); (B.G.)
| | - Antonio Chiaretti
- Department of Women’s Health Sciences, Fondazione Policlinico Universitario A. Gemelli—IRCCS, 00168 Rome, Italy;
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San Geroteo J, Levy M, Bailhache M, De Jorna C, Privat E, Gasmi O, Fuentes-Lopez M, Laoudi Y, Mazeghrane M, Malterre A, Bories P, Abdel Aal K, Arjoca I, Gaschignard J, Tanchaleune D, Minodier P, Audren F, Mazetier T, Quagliaro P, Raimond F, Sieng S, Robert B, Wohrer D, De Suremain N, Dauger S. Assessment of adherence to the 2020 Surviving Sepsis Campaign guidelines for fluid resuscitation in children with suspected septic shock in paediatric emergency departments: a prospective multicentre study. Arch Dis Child 2024:archdischild-2023-325837. [PMID: 38499323 DOI: 10.1136/archdischild-2023-325837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Paediatric sepsis is the leading cause of death in children under 5 years. No studies have evaluated the application of the Surviving Sepsis Campaign 2020 (SSC-2020) guidelines in paediatric emergency departments (PEDs). OBJECTIVE To assess physician adherence to the SSC-2020 fluid resuscitation guidelines in children with suspected septic shock in PEDs. METHODS This was a prospective multicentre observational study conducted in 21 French hospitals over 5 sequential weeks, between November 2021 and March 2022. Children with suspected septic shock and who received antimicrobial therapy within 72 hours were included. Primary outcome was SSC-2020 fluid resuscitation guidelines adherence (low 0-24%; moderate 25-74%; high 75-100%) according to: bolus volume of 10-20 mL/kg each, exclusive administration of balanced crystalloids at 1 and 24 hours of management, and initiation of fluid resuscitation within 1 hour of septic shock recognition. RESULTS 63 children were included. 10 (16%) children had severe sepsis and 2 (3%) met the definition of septic shock. Compared with the SSC-2020 guidelines, 43 (68%) patients received boluses of 10-20 mL/kg; fluid resuscitation was initiated within 1 hour of septic shock recognition in 42 (76%) cases; balanced crystalloids were the only fluids administrated in 35 (56%) and 34 (55%) children at 1 and 24 hours of management, respectively. Main barriers reported by physicians were difficult intravenous access (43%), lack of team training (29%), workload constraints (28%), and absence or out-of-date protocols (24%). CONCLUSIONS This study found high adherence for fluid resuscitation initiation but moderate adherence for bolus volume and fluid choice. TRIAL REGISTRATION NUMBER NCT05066464.
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Affiliation(s)
- Julian San Geroteo
- Pediatric Intensive Care Unit, Robert-Debré Mother-Child University Hospital, Paris, France
| | - Michael Levy
- Pediatric Intensive Care Unit, Robert-Debré Mother-Child University Hospital, Paris, France
| | - Marion Bailhache
- Pediatric Emergency Department, University Hospital Centre Bordeaux Pellegrin Hospital Group Children's Hospital, Bordeaux, France
| | - Claire De Jorna
- Pediatric Emergency Department, Lille University Hospital Center, Lille, France
| | - Elodie Privat
- Pediatric Emergency Department, Lille University Hospital Center, Lille, France
| | - Oussama Gasmi
- Pediatric Emergency Department, University Hospital Centre Nantes, Nantes, France
| | - Maria Fuentes-Lopez
- Pediatric Emergency Department, University Hospital Necker for Sick Children, Paris, France
| | - Yacine Laoudi
- Pediatric Emergency Department, Intermunicipal Hospital Centre Robert Ballanger, Aulnay sous Bois, France
| | - Mustapha Mazeghrane
- Pediatric Emergency Department, Centre Hospitalier Intercommunal André Grégoire, Montreuil, France
| | - Aline Malterre
- Pediatric Emergency Department, Centre Hospitalier Intercommunal de Créteil, Creteil, France
| | - Pauline Bories
- Pediatric Emergency Department, Hospital Louis-Mourier, Colombes, France
| | - Khaled Abdel Aal
- Pediatric Emergency Department, Hospital Centre Gonesse, Gonesse, France
| | - Iozefina Arjoca
- Pediatric Emergency Department, Centre Hospitalier François Quesnay, Mantes-la-Jolie, France
| | - Jean Gaschignard
- Pediatric Emergency Department, Groupement Hospitalier Nord Essonne, Longjumeau, France
| | - Davy Tanchaleune
- Pediatric Emergency Department, Hospital Bicetre, Le Kremlin-Bicetre, France
| | - Philippe Minodier
- Pediatric Emergency Department, Public Assistance-Hospitals of Marseille, Marseille, France
| | - Fabien Audren
- Pediatric Emergency Department, Intermunicipal Hospital Centre Villeneuve Saint Georges, Villeneuve Saint Georges, France
| | - Tifanny Mazetier
- Pediatric Emergency Department, Hospital Centre Victor Dupouy Argenteuil, Argenteuil, France
| | - Pauline Quagliaro
- Pediatric Emergency Department, Hospital Jean Verdier, Bondy, France
| | - Florence Raimond
- Pediatric Emergency Department, Hospital Antoine-Beclere, Clamart, France
| | - Soria Sieng
- Pediatric Emergency Department, Grand Hopital de l'Est Francilien, Jossigny, France
| | - Blandine Robert
- Pediatric Emergency Department, Centre Hospitalier de Pontoise, Pontoise, France
| | - Delphine Wohrer
- Pediatric Emergency Department, Robert-Debré Mother-Child University Hospital, Paris, France
| | - Nathalie De Suremain
- Pediatric Emergency Department, Armand-Trousseau Children's Hospital, Paris, France
| | - Stéphane Dauger
- Pediatric Intensive Care Unit, Robert-Debré Mother-Child University Hospital, Paris, France
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Nijman RG, Cadman E, Maconochie I. Emerging art of doing less. Arch Dis Child 2023:archdischild-2023-326437. [PMID: 38041657 DOI: 10.1136/archdischild-2023-326437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/16/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Ruud Gerard Nijman
- Section of Paediatric Infectious Diseases, Imperial College London, London, UK
- Department of Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Emily Cadman
- Department of Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ian Maconochie
- Department of Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
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Simon A, Lehrnbecher T, Baltaci Y, Dohna-Schwake C, Groll A, Laws HJ, Potratz J, Hufnagel M, Bochennek K. [Time to Antibiotics (TTA) - Reassessment from the German Working Group for Fever and Neutropenia in Children and Adolescents (DGPI/GPOH)]. KLINISCHE PADIATRIE 2023; 235:331-341. [PMID: 37751768 DOI: 10.1055/a-2135-4210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND The current German guidance from 2016 recommends a Time to Antibiotics (TTA) of<60 min in children and adolescents with febrile neutropenia (FN). METHODS Critical analysis of available studies and recent meta-analyses, and discussion of the practical consequences in the FN working group of the German Societies for Paediatric Oncology and Haematology and Paediatric Infectious Diseases. RESULTS The available evidence does not support a clinically significant outcome benefit of a TTA<60 min in all paediatric patients with FN. Studies suggesting such a benefit are biased (mainly triage bias), use different TTA definitions and display further methodical limitations. In any case, a TTA<60 min remains an essential component of the 1st hour-bundle in paediatric cancer patients with septic shock or sepsis with organ dysfunction. CONCLUSION Provided that all paediatric FN patients receive a structured medical history and physical examination (including vital signs) by experienced and trained medical personnel in a timely fashion, and provided that a sepsis triage and management bundle is established and implemented, a TTA lower than 3 hours is sufficient and reasonable in stable paediatric cancer patients with FN.
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Affiliation(s)
- Arne Simon
- Pädiatrische Onkologie und Hämatologie, Universitätskinderklinik Homburg, Homburg, Germany
| | - Thomas Lehrnbecher
- Klinik für Kinder- und Jugendheilkunde, Klinikum der Johann-Wolfgang-Goethe-Universität, Frankfurt, Germany
| | - Yeliz Baltaci
- Pädiatrische Onkologie und Hämatologie, TeleKasper Projekt, Universitätskinderklinik Homburg, Homburg, Germany
| | | | - Andreas Groll
- Päd. Hämatologie und Onkologie, Univ.-Klinikum Münster, Klinik für Kinder- und Jugendmedizin, Münster, Germany
| | - Hans-Jürgen Laws
- Klinik für Kinder-Onkologie, - Hämatologie und - Klinische Immunologie, Universerstitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Jenny Potratz
- Pädiatrische Onkologie und Hämatologie, Universitätskinderklinik Münster, Muenster, Germany
| | - Markus Hufnagel
- Klinik für Kinderheilkunde und Jugendmedizin, Universitätskinderklinik Freiburg, Freiburg, Germany
| | - Konrad Bochennek
- Pädiatrische Hämatologie und Onkologie, Universitätsklinik Frankfurt, Frankfurt, Germany
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Nygaard U, Dungu KHS, von Linstow ML, Lundstrøm K, Zhang H, Vissing NH. Lactate as a Screening Tool for Critical Illness in a Pediatric Emergency Department. Pediatr Emerg Care 2023; 39:735-738. [PMID: 36190394 DOI: 10.1097/pec.0000000000002860] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Lactate has in some pediatric emergency departments (PEDs) gained acceptance as a screening tool for critical illness, with cut-off values of 2.0 to 2.5 mmol/L. We aimed to investigate if lactate could predict the need of acute resuscitation in patients in a PED. PATIENTS AND METHODS This retrospective observational cohort study included patients aged 0 to 17 years admitted to the PED at Copenhagen University Hospital in Denmark from January 1, 2019 to January 1, 2021. Patients were included if they had lactate measured as part of their routine blood sampling because of acute PED evaluation. Area under the receiver operating characteristic (ROC) curve (AUC) was calculated to assess the ability of lactate to predict the need of acute resuscitation. In patients without need of acute resuscitation, we calculated the lactate upper limit as the 95th percentile, and significant predictors were included in a multiple linear regression model. RESULTS A total of 1355 children were included. Fourteen (1%) children with a need of acute resuscitation had a median lactate of 1.7 mmol/L (interquartile range, 1.4-2.3) versus 1.6 mmol/L (interquartile range, 1.3-2.1) in children without need of resuscitation ( P > 0.05). The AUC for lactate to predict acute resuscitation was 0.56 (95% confidence interval, 0.54-0.59). In children without need of acute resuscitation, the 95th percentile of lactate was 3.2 mmol/L, and 392 (29.8%) had lactate greater than 2.0 mmol/L. Increasing age and venous sampling were associated with lower lactate. Lactate was not associated with sex, pediatric early warning score, or duration of hospital admission. The 95th percentile of lactate after inhaled beta-2-agonists was 5.0 mmol/L. CONCLUSIONS In children evaluated in a PED, lactate achieved a low AUC, suggesting a poor ability of predicting acute resuscitation. In children without need of acute resuscitation, the 95th percentile for lactate was 3.2 mmol/L, higher than the generally accepted cut-off values. This is important to recognize to avoid concern in otherwise clinically stable children. Our data did not support the use of lactate as a screening tool for early recognition of critical illness in a PED.
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Affiliation(s)
| | - Kia Hee Schultz Dungu
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marie-Louise von Linstow
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kaare Lundstrøm
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - He Zhang
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nadja Hawwa Vissing
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Ladhani SN. Rapid molecular diagnostic tests fail to PERFORM in febrile children. THE LANCET REGIONAL HEALTH. EUROPE 2023; 32:100707. [PMID: 37593132 PMCID: PMC10430139 DOI: 10.1016/j.lanepe.2023.100707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023]
Affiliation(s)
- Shamez N. Ladhani
- St. George’s University of London, Cranmer Terrace, London SW17 0RE, UK
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Affiliation(s)
- Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
| | - Alasdair Munro
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
- NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Wittmann S, Jorgensen R, Oostenbrink R, Moll H, Herberg J, Levin M, Maconochie I, Nijman R. Heart rate and respiratory rate in predicting risk of serious bacterial infection in febrile children given antipyretics: prospective observational study. Eur J Pediatr 2023; 182:2205-2214. [PMID: 36867236 PMCID: PMC10175419 DOI: 10.1007/s00431-023-04884-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/09/2023] [Accepted: 02/16/2023] [Indexed: 03/04/2023]
Abstract
Clinical algorithms used in the assessment of febrile children in the Paediatric Emergency Departments are commonly based on threshold values for vital signs, which in children with fever are often outside the normal range. Our aim was to assess the diagnostic value of heart and respiratory rate for serious bacterial infection (SBI) in children after temperature lowering following administration of antipyretics. A prospective cohort of children presenting with fever between June 2014 and March 2015 at the Paediatric Emergency Department of a large teaching hospital in London, UK, was performed. Seven hundred forty children aged 1 month-16 years presenting with a fever and ≥ 1 warning signs of SBI given antipyretics were included. Tachycardia or tachypnoea were defined by different threshold values: (a) APLS threshold values, (b) age-specific and temperature-adjusted centiles charts and (c) relative difference in z-score. SBI was defined by a composite reference standard (cultures from a sterile site, microbiology and virology results, radiological abnormalities, expert panel). Persistent tachypnoea after body temperature lowering was an important predictor of SBI (OR 1.92, 95% CI 1.15, 3.30). This effect was only observed for pneumonia but not other SBIs. Threshold values for tachypnoea > 97th centile at repeat measurement achieved high specificity (0.95 (0.93, 0.96)) and positive likelihood ratios (LR + 3.25 (1.73, 6.11)) and may be useful for ruling in SBI, specifically pneumonia. Persistent tachycardia was not an independent predictor of SBI and had limited value as a diagnostic test. Conclusion: Among children given antipyretics, tachypnoea at repeat measurement had some value in predicting SBI and was useful to rule in pneumonia. The diagnostic value of tachycardia was poor. Overreliance on heart rate as a diagnostic feature following body temperature lowering may not be justified to facilitate safe discharge. What is Known: • Abnormal vital signs at triage have limited value as a diagnostic test to identify children with SBI, and fever alters the specificity of commonly used threshold values for vital signs. • The observed temperature response after antipyretics is not a clinically useful indicator to differentiate the cause of febrile illness. What is New: • Persistent tachycardia following reduction in body temperature was not associated with an increased risk of SBI and of poor value as a diagnostic test, whilst persistent tachypnoea may indicate the presence of pneumonia.
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Affiliation(s)
- Stefanie Wittmann
- Department of Paediatric Emergency Medicine, Division of Medicine, St. Mary's Hospital-Imperial College NHS Healthcare Trust, London, UK
| | - Rikke Jorgensen
- Department of Paediatric Emergency Medicine, Division of Medicine, St. Mary's Hospital-Imperial College NHS Healthcare Trust, London, UK
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Henriette Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jethro Herberg
- Faculty of Medicine, Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College London, London, UK.,Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Mike Levin
- Faculty of Medicine, Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College London, London, UK.,Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Ian Maconochie
- Department of Paediatric Emergency Medicine, Division of Medicine, St. Mary's Hospital-Imperial College NHS Healthcare Trust, London, UK
| | - Ruud Nijman
- Department of Paediatric Emergency Medicine, Division of Medicine, St. Mary's Hospital-Imperial College NHS Healthcare Trust, London, UK. .,Faculty of Medicine, Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College London, London, UK. .,Centre for Paediatrics and Child Health, Imperial College London, London, UK.
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Mid-Regional Pro-Adrenomedullin in Combination With Pediatric Early Warning Scores for Risk Stratification of Febrile Children Presenting to the Emergency Department: Secondary Analysis of a Nonprespecified United Kingdom Cohort Study. Pediatr Crit Care Med 2022; 23:980-989. [PMID: 36239515 PMCID: PMC9708078 DOI: 10.1097/pcc.0000000000003075] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Current sepsis guidelines do not provide good risk stratification of subgroups in whom prompt IV antibiotics and fluid resuscitation might of benefit. We evaluated the utility of mid-regional pro-adrenomedullin (MR-proADM) in identification of patient subgroups at risk of requiring PICU or high-dependency unit (HDU) admission or fluid resuscitation. DESIGN Secondary, nonprespecified analysis of prospectively collected dataset. SETTING Pediatric Emergency Department in a United Kingdom tertiary center. PATIENTS Children less than 16 years old presenting with fever and clinical indication for venous blood sampling ( n = 1,183). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcome measures were PICU/HDU admission or administration of fluid resuscitation, with a secondary outcome of definite or probable bacterial infection. Biomarkers were measured on stored plasma samples and children phenotyped into bacterial and viral groups using a previously published algorithm. Of the 1,183 cases, 146 children (12.3%) required fluids, 48 (4.1%) were admitted to the PICU/HDU, and 244 (20.6%) had definite or probable bacterial infection. Area under the receiver operating characteristic (AUC) was used to assess performance. MR-proADM better predicted fluid resuscitation (AUC, 0.73; 95% CI, 0.67-0.78), than both procalcitonin (AUC, 0.65; 95% CI, 0.59-0.71) and Pediatric Early Warning Score (PEWS: AUC, 0.62; 95% CI, 0.56-0.67). PEWS alone showed good accuracy for PICU/HDU admission 0.83 (0.78-0.89). Patient subgroups with high MR-proADM (≥ 0.7 nmol/L) and high procalcitonin (≥ 0.5 ng/mL) had increased association with PICU/HDU admission, fluid resuscitation, and bacterial infection compared with subgroups with low MR-proADM (< 0.7 nmol/L). For children with procalcitonin less than 0.5 ng/mL, high MR-proADM improved stratification for fluid resuscitation only. CONCLUSIONS High MR-proADM and high procalcitonin were associated with increased likelihood of subsequent disease progression. Incorporating MR-proADM into clinical risk stratification may be useful in clinician decision-making regarding initiation of IV antibiotics, fluid resuscitation, and escalation to PICU/HDU admission.
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Heal C, Harvey A, Brown S, Rowland AG, Roland D. The association between temperature, heart rate, and respiratory rate in children aged under 16 years attending urgent and emergency care settings. Eur J Emerg Med 2022; 29:413-416. [PMID: 35679531 PMCID: PMC9605188 DOI: 10.1097/mej.0000000000000951] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND IMPORTANCE Body temperature is considered an independent determinant of respiratory rate and heart rate; however, there is limited scientific evidence regarding the association. This study aimed to assess the association between temperature, and heart rate and respiratory rate in children. OBJECTIVE The objective of this study was to validate earlier findings that body temperature causes an increase of approximately 10 bpm rise in heart rate per 1 °C rise in temperature, in children aged under 16 years old. DESIGN A prospective study using anonymised prospectively collected patient data of 188 635 attendances, retrospectively extracted from electronic patient records. SETTINGS AND PARTICIPANTS Four Emergency or Urgent Care Departments in the North West of England. Participants were children and young people aged 0-16 years old who attended one of the four sites over a period of 3 years. OUTCOME MEASURES AND ANALYSIS Multiple linear regression models, adjusted for prespecified confounders (including oxygen saturation, heart rate, respiratory rate, site of attendance, age), were used to examine the influence of various variables on heart rate and respiratory rate. MAIN RESULTS Among the 235 909 patient visits (median age 5) included, the mean temperature was 37.0 (SD, 0.8). Mean heart rate and respiratory rate were 115.6 (SD, 29.0) and 26.9 (SD, 8.3), respectively. For every 1 °C increase in temperature, heart rate will on average be 12.3 bpm higher (95% CI, 12.2-12.4), after accounting for oxygen saturation, location of attendance, and age. For every 1 °C increase in temperature, there is on average a 0.3% decrease (95% CI, 0.2-0.4%) in respiratory rate. CONCLUSION In this study on children attending urgent and emergency care settings, there was an independent association between temperature and heart rate but not between temperature and respiratory rate.
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Affiliation(s)
- Calvin Heal
- Centre for Biostatistics, The University of Manchester
| | - Anna Harvey
- North Manchester General Hospital, Manchester University NHS Foundation Trust, Manchester
| | | | - Andrew Graeme Rowland
- North Manchester General Hospital, Manchester University NHS Foundation Trust, Manchester
- School of Health and Society, The University of Salford, Salford
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children’s Emergency Department, Leicester Royal Infirmary
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
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11
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Urbane UN, Petrosina E, Zavadska D, Pavare J. Integrating Clinical Signs at Presentation and Clinician's Non-analytical Reasoning in Prediction Models for Serious Bacterial Infection in Febrile Children Presenting to Emergency Department. Front Pediatr 2022; 10:786795. [PMID: 35547543 PMCID: PMC9082163 DOI: 10.3389/fped.2022.786795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Development and validation of clinical prediction model (CPM) for serious bacterial infections (SBIs) in children presenting to the emergency department (ED) with febrile illness, based on clinical variables, clinician's "gut feeling," and "sense of reassurance. MATERIALS AND METHODS Febrile children presenting to the ED of Children's Clinical University Hospital (CCUH) between April 1, 2017 and December 31, 2018 were enrolled in a prospective observational study. Data on clinical signs and symptoms at presentation, together with clinician's "gut feeling" of something wrong and "sense of reassurance" were collected as candidate variables for CPM. Variable selection for the CPM was performed using stepwise logistic regression (forward, backward, and bidirectional); Akaike information criterion was used to limit the number of parameters and simplify the model. Bootstrapping was applied for internal validation. For external validation, the model was tested in a separate dataset of patients presenting to six regional hospitals between January 1 and March 31, 2019. RESULTS The derivation cohort consisted of 517; 54% (n = 279) were boys, and the median age was 58 months. SBI was diagnosed in 26.7% (n = 138). Validation cohort included 188 patients; the median age was 28 months, and 26.6% (n = 50) developed SBI. Two CPMs were created, namely, CPM1 consisting of six clinical variables and CPM2 with four clinical variables plus "gut feeling" and "sense of reassurance." The area under the curve (AUC) for receiver operating characteristics (ROC) curve of CPM1 was 0.744 (95% CI, 0.683-0.805) in the derivation cohort and 0.692 (95% CI, 0.604-0.780) in the validation cohort. AUC for CPM2 was 0.783 (0.727-0.839) and 0.752 (0.674-0.830) in derivation and validation cohorts, respectively. AUC of CPM2 in validation population was significantly higher than that of CPM1 [p = 0.037, 95% CI (-0.129; -0.004)]. A clinical evaluation score was derived from CPM2 to stratify patients in "low risk," "gray area," and "high risk" for SBI. CONCLUSION Both CPMs had moderate ability to predict SBI and acceptable performance in the validation cohort. Adding variables "gut feeling" and "sense of reassurance" in CPM2 improved its ability to predict SBI. More validation studies are needed for the assessment of applicability to all febrile patients presenting to ED.
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Affiliation(s)
- Urzula Nora Urbane
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Eva Petrosina
- Statistics Unit, Riga Stradins University, Riga, Latvia
| | - Dace Zavadska
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Jana Pavare
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
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Nijman RG, Oostenbrink R, Moll HA, Casals-Pascual C, von Both U, Cunnington A, De T, Eleftheriou I, Emonts M, Fink C, van der Flier M, de Groot R, Kaforou M, Kohlmaier B, Kuijpers TW, Lim E, Maconochie IK, Paulus S, Martinon-Torres F, Pokorn M, Romaine ST, Calle IR, Schlapbach LJ, Smit FJ, Tsolia M, Usuf E, Wright VJ, Yeung S, Zavadska D, Zenz W, Levin M, Herberg JA, Carrol ED. A Novel Framework for Phenotyping Children With Suspected or Confirmed Infection for Future Biomarker Studies. Front Pediatr 2021; 9:688272. [PMID: 34395340 PMCID: PMC8356564 DOI: 10.3389/fped.2021.688272] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/28/2021] [Indexed: 12/11/2022] Open
Abstract
Background: The limited diagnostic accuracy of biomarkers in children at risk of a serious bacterial infection (SBI) might be due to the imperfect reference standard of SBI. We aimed to evaluate the diagnostic performance of a new classification algorithm for biomarker discovery in children at risk of SBI. Methods: We used data from five previously published, prospective observational biomarker discovery studies, which included patients aged 0- <16 years: the Alder Hey emergency department (n = 1,120), Alder Hey pediatric intensive care unit (n = 355), Erasmus emergency department (n = 1,993), Maasstad emergency department (n = 714) and St. Mary's hospital (n = 200) cohorts. Biomarkers including procalcitonin (PCT) (4 cohorts), neutrophil gelatinase-associated lipocalin-2 (NGAL) (3 cohorts) and resistin (2 cohorts) were compared for their ability to classify patients according to current standards (dichotomous classification of SBI vs. non-SBI), vs. a proposed PERFORM classification algorithm that assign patients to one of eleven categories. These categories were based on clinical phenotype, test outcomes and C-reactive protein level and accounted for the uncertainty of final diagnosis in many febrile children. The success of the biomarkers was measured by the Area under the receiver operating Curves (AUCs) when they were used individually or in combination. Results: Using the new PERFORM classification system, patients with clinically confident bacterial diagnosis ("definite bacterial" category) had significantly higher levels of PCT, NGAL and resistin compared with those with a clinically confident viral diagnosis ("definite viral" category). Patients with diagnostic uncertainty had biomarker concentrations that varied across the spectrum. AUCs were higher for classification of "definite bacterial" vs. "definite viral" following the PERFORM algorithm than using the "SBI" vs. "non-SBI" classification; summary AUC for PCT was 0.77 (95% CI 0.72-0.82) vs. 0.70 (95% CI 0.65-0.75); for NGAL this was 0.80 (95% CI 0.69-0.91) vs. 0.70 (95% CI 0.58-0.81); for resistin this was 0.68 (95% CI 0.61-0.75) vs. 0.64 (0.58-0.69) The three biomarkers combined had summary AUC of 0.83 (0.77-0.89) for "definite bacterial" vs. "definite viral" infections and 0.71 (0.67-0.74) for "SBI" vs. "non-SBI." Conclusion: Biomarkers of bacterial infection were strongly associated with the diagnostic categories using the PERFORM classification system in five independent cohorts. Our proposed algorithm provides a novel framework for phenotyping children with suspected or confirmed infection for future biomarker studies.
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Affiliation(s)
- Ruud G. Nijman
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College of Science, Technology and Medicine, London, United Kingdom
- Department of Pediatric Accident and Emergency, Imperial College NHS Healthcare Trust, London, United Kingdom
| | - Rianne Oostenbrink
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Henriette A. Moll
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Climent Casals-Pascual
- Nuffield Department of Medicine, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
- Department of Clinical Microbiology, Hospital Clínic de Barcelona, Biomedical Diagnostic Centre, Barcelona, Spain
- ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain
| | - Ulrich von Both
- Division of Pediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University, Munich, Germany
- German Centre for Infection Research, DZIF, Partner Site Munich, Munich, Germany
| | - Aubrey Cunnington
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Tisham De
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Irini Eleftheriou
- Second Department of Pediatrics, P. and A. Kyriakou Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marieke Emonts
- Pediatric Immunology, Infectious Diseases and Allergy Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, United Kingdom
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- National Institute for Health Research Newcastle Biomedical Research Centre Based at Newcastle upon Tyne Hospitals NHS Trust, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Colin Fink
- Micropathology Ltd., Warwick, United Kingdom
| | - Michiel van der Flier
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Pediatric Infectious Diseases and Immunology, Radboud Centre for Infectious Diseases, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Ronald de Groot
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Pediatric Infectious Diseases and Immunology, Radboud Centre for Infectious Diseases, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Myrsini Kaforou
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Benno Kohlmaier
- Department of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Taco W. Kuijpers
- Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Amsterdam University Medical Center, Location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Landsteiner Laboratory at the Amsterdam Medical Centre, Sanquin Research Institute, University of Amsterdam, Amsterdam, Netherlands
| | - Emma Lim
- Pediatric Immunology, Infectious Diseases and Allergy Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, United Kingdom
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ian K. Maconochie
- Department of Pediatric Accident and Emergency, Imperial College NHS Healthcare Trust, London, United Kingdom
| | - Stephane Paulus
- Department of Pediatrics, Children's Hospital, John Radcliffe, University of Oxford, Level 2, Oxford, United Kingdom
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Federico Martinon-Torres
- Genetics, Vaccines, Infections and Pediatrics Research Group, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Marko Pokorn
- Department of Infectious Diseases, University Medical Centre Ljubljana, Univerzitetni Klinični Centre, Ljubljana, Slovenia
- Department of Infectious Diseases and Epidemiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sam T. Romaine
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Irene Rivero Calle
- Genetics, Vaccines, Infections and Pediatrics Research Group, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Frank J. Smit
- Department of Pediatrics, Maasstad Hospital, Rotterdam, Netherlands
| | - Maria Tsolia
- German Centre for Infection Research, DZIF, Partner Site Munich, Munich, Germany
| | - Effua Usuf
- Child Survival, Medical Research Council: The Gambia Unit, Fajara, Gambia
| | - Victoria J. Wright
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Shunmay Yeung
- Faculty of Tropical and Infectious Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dace Zavadska
- Department of Pediatrics, Children Clinical University Hospital, Rigas Stradina Universitāte, Riga, Latvia
| | - Werner Zenz
- Department of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Michael Levin
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Jethro A. Herberg
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Enitan D. Carrol
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
- Liverpool Health Partners, Liverpool, United Kingdom
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Gangoiti I, Fernandez CL, Gallego M, Gomez B, Benito J, Mintegi S. Markers for invasive bacterial infections in previously healthy children. Am J Emerg Med 2021; 48:83-86. [PMID: 33862390 DOI: 10.1016/j.ajem.2021.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/06/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Iker Gangoiti
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Catarina-Livana Fernandez
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Mikel Gallego
- Microbiology Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Borja Gomez
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain.
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14
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Long E, Schlapbach LJ, Babl FE. The challenge of infrequency. Acta Paediatr 2021; 110:1075. [PMID: 33128236 DOI: 10.1111/apa.15647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Elliot Long
- Department of Emergency Medicine The Royal Children's Hospital Parkville Vic. Australia
- Murdoch Children's Research Institute Parkville Vic. Australia
- Department of Paediatrics Faculty of Medicine, Dentistry, and Health Sciences University of Melbourne Melbourne Vic. Australia
- Department of Medicine and Radiology Centre for Integrated Critical CareMelbourne Medical School Melbourne Vic. Australia
| | - Luregn J. Schlapbach
- Paediatric Critical Care Research Group Child Health Research CentreThe University of Queensland Brisbane QLD Australia
- Paediatric and Neonatal Intensive Care Unit University Children's Hospital Zurich Switzerland
| | - Franz E. Babl
- Department of Emergency Medicine The Royal Children's Hospital Parkville Vic. Australia
- Murdoch Children's Research Institute Parkville Vic. Australia
- Department of Paediatrics Faculty of Medicine, Dentistry, and Health Sciences University of Melbourne Melbourne Vic. Australia
- Department of Medicine and Radiology Centre for Integrated Critical CareMelbourne Medical School Melbourne Vic. Australia
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