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Kaplan RL, Cruz AT, Freedman SB, Smith K, Freeman J, Lane RD, Michelson KA, Marble RD, Middelberg LK, Bergmann KR, McAneney C, Noorbakhsh KA, Pruitt C, Shah N, Badaki-Makun O, Schnadower D, Thompson AD, Blackstone MM, Abramo TJ, Srivastava G, Avva U, Samuels-Kalow M, Morientes O, Kannikeswaran N, Chaudhari PP, Strutt J, Vance C, Haines E, Khanna K, Gerard J, Bajaj L. Omphalitis and Concurrent Serious Bacterial Infection. Pediatrics 2022; 149:186812. [PMID: 35441224 DOI: 10.1542/peds.2021-054189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Describe the clinical presentation, prevalence of concurrent serious bacterial infection (SBI), and outcomes among infants with omphalitis. METHODS Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants ≤90 days of age with omphalitis seen in the emergency department from January 1, 2008, to December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized. RESULTS Among 566 infants (median age 16 days), 537 (95%) were well-appearing, 64 (11%) had fever at home or in the emergency department, and 143 (25%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 472 (83%), 326 (58%), and 222 (39%) infants, respectively. Pathogens grew in 1.1% (95% confidence interval [CI], 0.3%-2.5%) of blood, 0.9% (95% CI, 0.2%-2.7%) of urine, and 0.9% (95% CI, 0.1%-3.2%) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 320 (57%) infants, with 85% (95% CI, 80%-88%) growing a pathogen, most commonly methicillin-sensitive Staphylococcus aureus (62%), followed by methicillin-resistant Staphylococcus aureus (11%) and Escherichia coli (10%). Four hundred ninety-eight (88%) were hospitalized, 81 (16%) to an ICU. Twelve (2.1% [95% CI, 1.1%-3.7%]) had sepsis or shock, and 2 (0.4% [95% CI, 0.0%-1.3%]) had severe cellulitis or necrotizing soft tissue infection. There was 1 death. Serious complications occurred only in infants aged <28 days. CONCLUSIONS In this multicenter cohort, mild, localized disease was typical of omphalitis. SBI and adverse outcomes were uncommon. Depending on age, routine testing for SBI is likely unnecessary in most afebrile, well-appearing infants with omphalitis.
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Affiliation(s)
- Ron L Kaplan
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathleen Smith
- Department of Pediatrics, Rady Children's Hospital San Diego, San Diego, California
| | - Julia Freeman
- Department of Pediatrics, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, Colorado
| | - Roni D Lane
- Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Richard D Marble
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leah K Middelberg
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Constance McAneney
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kathleen A Noorbakhsh
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Pruitt
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nipam Shah
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - David Schnadower
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Amy D Thompson
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Mercedes M Blackstone
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas J Abramo
- Pediatric Emergency Medicine Associates, Children's Hospital of Atlanta, Atlanta, Georgia
| | | | - Usha Avva
- Department of Pediatrics, Joseph M Sanzari Children's Hospital, Hackensack Meridian Health, Hackensack, New Jersey
| | | | - Oihane Morientes
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain
| | - Nirupama Kannikeswaran
- Department of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, Michigan
| | - Pradip P Chaudhari
- Department of Pediatrics, University of Southern California, Children's Hospital Los Angeles, Los Angeles, California
| | - Jonathan Strutt
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, California
| | - Elizabeth Haines
- Ronald O. Perelman Department of Emergency Medicine/NYU Langone Health, New York, New York
| | - Kajal Khanna
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - James Gerard
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louise, Missouri
| | - Lalit Bajaj
- Department of Pediatrics, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, Colorado
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2
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Kaplan RL, Cruz AT, Michelson KA, McAneney C, Blackstone MM, Pruitt CM, Shah N, Noorbakhsh KA, Abramo TJ, Marble RD, Middelberg L, Smith K, Kannikeswaran N, Schnadower D, Srivastava G, Thompson AD, Lane RD, Freeman JF, Bergmann KR, Morientes O, Gerard J, Badaki-Makun O, Avva U, Chaudhari PP, Freedman SB, Samuels-Kalow M, Haines E, Strutt J, Khanna K, Vance C, Bajaj L. Neonatal Mastitis and Concurrent Serious Bacterial Infection. Pediatrics 2021; 148:peds.2021-051322. [PMID: 34187909 DOI: 10.1542/peds.2021-051322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Describe the clinical presentation, prevalence, and outcomes of concurrent serious bacterial infection (SBI) among infants with mastitis. METHODS Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants aged ≤90 days with mastitis who were seen in the emergency department between January 1, 2008, and December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized. RESULTS Among 657 infants (median age 21 days), 641 (98%) were well appearing, 138 (21%) had history of fever at home or in the emergency department, and 63 (10%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 581 (88%), 274 (42%), and 216 (33%) infants, respectively. Pathogens grew in 0.3% (95% confidence interval [CI] 0.04-1.2) of blood, 1.1% (95% CI 0.2-3.2) of urine, and 0.4% (95% CI 0.01-2.5) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 335 (51%) infants, with 77% (95% CI 72-81) growing a pathogen, most commonly methicillin-resistant Staphylococcus aureus (54%), followed by methicillin-susceptible S aureus (29%), and unspecified S aureus (8%). A total of 591 (90%) infants were admitted to the hospital, with 22 (3.7%) admitted to an ICU. Overall, 10 (1.5% [95% CI 0.7-2.8]) had sepsis or shock, and 2 (0.3% [95% CI 0.04-1.1]) had severe cellulitis or necrotizing soft tissue infection. None received vasopressors or endotracheal intubation. There were no deaths. CONCLUSIONS In this multicenter cohort, mild localized disease was typical of neonatal mastitis. SBI and adverse outcomes were rare. Evaluation for SBI is likely unnecessary in most afebrile, well-appearing infants with mastitis.
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Affiliation(s)
- Ron L Kaplan
- Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Constance McAneney
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mercedes M Blackstone
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher M Pruitt
- Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Nipam Shah
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, Alabama
| | - Kathleen A Noorbakhsh
- Department of Pediatrics, School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas J Abramo
- Pediatric Emergency Medicine Associates, Children's Hospital of Atlanta, Atlanta, Georgia
| | - Richard D Marble
- Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Leah Middelberg
- Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kathleen Smith
- Department of Pediatrics, School of Medicine, University of California, San Diego and Rady Children's Hospital San Diego, San Diego, California
| | - Nirupama Kannikeswaran
- Department of Pediatrics, College of Medicine, Central Michigan University and Children's Hospital of Michigan, Detroit, Michigan
| | - David Schnadower
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | - Amy D Thompson
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Roni D Lane
- Department of Pediatrics, School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Julia F Freeman
- Children's Hospital Colorado and Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Oihane Morientes
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain
| | - James Gerard
- Department of Pediatrics, School of Medicine, Saint Louis University and SSM Health Cardinal Glennon Children's Hospital, St Louis, Missouri
| | | | - Usha Avva
- Department of Pediatrics, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack Meridian Health, Hackensack, New Jersey
| | - Pradip P Chaudhari
- Department of Pediatrics, Kerk School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California
| | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary and Alberta Children's Hospital, Alberta, Canada
| | | | - Elizabeth Haines
- Ronald O. Perelman Department of Emergency Medicine, Grossman School of Medicine, New York University and New York University Langone Health, New York, New York
| | - Jonathan Strutt
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Kajal Khanna
- Department of Emergency Medicine, School of Medicine, Stanford University, Stanford, California
| | - Cheryl Vance
- Department of Pediatrics and Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, California
| | - Lalit Bajaj
- Children's Hospital Colorado and Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
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Michelson KA, Neuman MI, Pruitt CM, Desai S, Wang ME, DePorre AG, Leazer RC, Sartori LF, Marble RD, Rooholamini SN, Woll C, Balamuth F, Aronson PL. Height of fever and invasive bacterial infection. Arch Dis Child 2021; 106:594-596. [PMID: 32819913 PMCID: PMC7895851 DOI: 10.1136/archdischild-2019-318548] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 07/12/2020] [Accepted: 07/26/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE We aimed to evaluate the association of height of fever with invasive bacterial infection (IBI) among febrile infants <=60 days of age. METHODS In a secondary analysis of a multicentre case-control study of non-ill-appearing febrile infants <=60 days of age, we compared the maximum temperature (at home or in the emergency department) for infants with and without IBI. We then computed interval likelihood ratios (iLRs) for the diagnosis of IBI at each half-degree Celsius interval. RESULTS The median temperature was higher for infants with IBI (38.8°C; IQR 38.4-39.2) compared with those without IBI (38.4°C; IQR 38.2-38.9) (p<0.001). Temperatures 39°C-39.4°C and 39.5°C-39.9°C were associated with a higher likelihood of IBI (iLR 2.49 and 3.40, respectively), although 30.4% of febrile infants with IBI had maximum temperatures <38.5°C. CONCLUSIONS Although IBI is more likely with higher temperatures, height of fever alone should not be used for risk stratification of febrile infants.
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Affiliation(s)
- Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Christopher M. Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Sanyukta Desai
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Marie E. Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA
| | - Adrienne G. DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO
| | - Rianna C. Leazer
- Division of Hospital Medicine, Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA
| | - Laura F. Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Richard D. Marble
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sahar N. Rooholamini
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Christopher Woll
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Fran Balamuth
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Wang ME, Neuman MI, Nigrovic LE, Pruitt CM, Desai S, DePorre AG, Sartori LF, Marble RD, Woll C, Leazer RC, Balamuth F, Rooholamini SN, Aronson PL. Characteristics of Afebrile Infants ≤60 Days of Age With Invasive Bacterial Infections. Hosp Pediatr 2020; 11:100-105. [PMID: 33318052 DOI: 10.1542/hpeds.2020-002204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe the characteristics and outcomes of afebrile infants ≤60 days old with invasive bacterial infection (IBI). METHODS We conducted a secondary analysis of a cross-sectional study of infants ≤60 days old with IBI presenting to the emergency departments (EDs) of 11 children's hospitals from 2011 to 2016. We classified infants as afebrile if there was absence of a temperature ≥38°C at home, at the referring clinic, or in the ED. Bacteremia and bacterial meningitis were defined as pathogenic bacterial growth from a blood and/or cerebrospinal fluid culture. RESULTS Of 440 infants with IBI, 78 (18%) were afebrile. Among afebrile infants, 62 (79%) had bacteremia without meningitis and 16 (20%) had bacterial meningitis (10 with concomitant bacteremia). Five infants (6%) died, all with bacteremia. The most common pathogens were Streptococcus agalactiae (35%), Escherichia coli (16%), and Staphylococcus aureus (16%). Sixty infants (77%) had an abnormal triage vital sign (temperature <36°C, heart rate ≥181 beats per minute, or respiratory rate ≥66 breaths per minute) or a physical examination abnormality (ill appearance, full or depressed fontanelle, increased work of breathing, or signs of focal infection). Forty-three infants (55%) had ≥1 of the following laboratory abnormalities: white blood cell count <5000 or >15 000 cells per μL, absolute band count >1500 cells per μl, or positive urinalysis. Presence of an abnormal vital sign, examination finding, or laboratory test result had a sensitivity of 91% (95% confidence interval 82%-96%) for IBI. CONCLUSIONS Most afebrile young infants with an IBI had vital sign, examination, or laboratory abnormalities. Future studies should evaluate the predictive ability of these criteria in afebrile infants undergoing evaluation for IBI.
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Affiliation(s)
- Marie E Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children's Hospital Stanford and School of Medicine, Stanford University, Palo Alto, California;
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sanyukta Desai
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Adrienne G DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Laura F Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt and School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Richard D Marble
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christopher Woll
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Rianna C Leazer
- Division of Hospital Medicine, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Fran Balamuth
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Sahar N Rooholamini
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and School of Medicine, University of Washington, Seattle, Washington
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5
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Yankova LC, Neuman MI, Wang ME, Woll C, DePorre AG, Desai S, Sartori LF, Nigrovic LE, Pruitt CM, Marble RD, Leazer RC, Rooholamini SN, Balamuth F, Aronson PL. Febrile Infants ≤60 Days Old With Positive Urinalysis Results and Invasive Bacterial Infections. Hosp Pediatr 2020; 10:1120-1125. [PMID: 33239319 DOI: 10.1542/hpeds.2020-000638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES We aimed to describe the clinical and laboratory characteristics of febrile infants ≤60 days old with positive urinalysis results and invasive bacterial infections (IBI). METHODS We performed a planned secondary analysis of a retrospective cohort study of febrile infants ≤60 days old with IBI who presented to 11 emergency departments from July 1, 2011, to June 30, 2016. For this subanalysis, we included infants with IBI and positive urinalysis results. We analyzed the sensitivity of high-risk past medical history (PMH) (prematurity, chronic medical condition, or recent antimicrobial receipt), ill appearance, and/or abnormal white blood cell (WBC) count (<5000 or >15 000 cells/μL) for identification of IBI. RESULTS Of 148 febrile infants with positive urinalysis results and IBI, 134 (90.5%) had bacteremia without meningitis and 14 (9.5%) had bacterial meningitis (11 with concomitant bacteremia). Thirty-five infants (23.6%) with positive urinalysis results and IBI did not have urinary tract infections. The presence of high-risk PMH, ill appearance, and/or abnormal WBC count had a sensitivity of 53.4% (95% confidence interval: 45.0-61.6) for identification of IBI. Of the 14 infants with positive urinalysis results and concomitant bacterial meningitis, 7 were 29 to 60 days old. Six of these 7 infants were ill-appearing or had an abnormal WBC count. The other infant had bacteremia with cerebrospinal fluid pleocytosis after antimicrobial pretreatment and was treated for meningitis. CONCLUSIONS The sensitivity of high-risk PMH, ill appearance, and/or abnormal WBC count is suboptimal for identifying febrile infants with positive urinalysis results at low risk for IBI. Most infants with positive urinalysis results and bacterial meningitis are ≤28 days old, ill-appearing, or have an abnormal WBC count.
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Affiliation(s)
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Marie E Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children's Hospital Stanford, School of Medicine, Stanford University, Palo Alto, California
| | | | - Adrienne G DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Sanyukta Desai
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Laura F Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard D Marble
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rianna C Leazer
- Division of Hospital Medicine, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Sahar N Rooholamini
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and School of Medicine, University of Washington, Seattle, Washington; and
| | - Fran Balamuth
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul L Aronson
- Departments of Pediatrics and .,Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
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Fleischer E, Neuman MI, Wang ME, Nigrovic LE, Desai S, DePorre AG, Leazer RC, Marble RD, Sartori LF, Aronson PL. Cerebrospinal Fluid Profiles of Infants ≤60 Days of Age With Bacterial Meningitis. Hosp Pediatr 2019; 9:979-982. [PMID: 31690569 DOI: 10.1542/hpeds.2019-0202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES We aimed to describe the cerebrospinal fluid (CSF) profiles of infants ≤60 days old with bacterial meningitis and the characteristics of infants with bacterial meningitis who did not have CSF abnormalities. METHODS We included infants ≤60 days old with culture-positive bacterial meningitis who were evaluated in the emergency departments of 11 children's hospitals between July 1, 2011, and June 30, 2016. From medical records, we abstracted clinical and laboratory data. For infants with traumatic lumbar punctures (CSF red blood cell count of ≥10 000 cells per mm3), we used a red blood cell count/white blood cell (WBC) count correction factor of 1000:1 to determine the corrected CSF WBC count. We calculated the sensitivity for bacterial meningitis of a CSF Gram-stain and corrected CSF pleocytosis (≥16 WBCs per mm3 for infants ≤28 days old and ≥10 WBCs per mm3 for infants 29-60 days old). RESULTS Among 66 infants with bacterial meningitis, the sensitivity of a CSF Gram-stain was 71.9% (95% confidence interval [CI]: 59.2-82.4), and the sensitivity of corrected CSF pleocytosis was 80.3% (95% CI: 68.7-89.1). The sensitivity of combining positive Gram-stain results with corrected CSF pleocytosis was 86.4% (95% CI: 75.7-93.6). Of 9 infants with meningitis who had a negative Gram-stain result and no corrected CSF pleocytosis, 8 (88.9%) had either an abnormal peripheral WBC count (>15 000 or <5000 cells per μL) or bandemia >10%. CONCLUSIONS Most infants ≤60 days old with bacterial meningitis have CSF pleocytosis or a positive Gram-stain result. Infants with no CSF pleocytosis and a negative Gram-stain result are unlikely to have bacterial meningitis in the absence of other laboratory abnormalities.
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Affiliation(s)
- Eduardo Fleischer
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marie E Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sanyukta Desai
- Division of Hospital Medicine, Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adrienne G DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Rianna C Leazer
- Division of Hospital Medicine, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Richard D Marble
- Division of Emergency Medicine, Feinberg School of Medicine, Northwestern University and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
| | - Laura F Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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7
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Desai S, Aronson PL, Shabanova V, Neuman MI, Balamuth F, Pruitt CM, DePorre AG, Nigrovic LE, Rooholamini SN, Wang ME, Marble RD, Williams DJ, Sartori L, Leazer RC, Mitchell C, Shah SS. Parenteral Antibiotic Therapy Duration in Young Infants With Bacteremic Urinary Tract Infections. Pediatrics 2019; 144:peds.2018-3844. [PMID: 31431480 PMCID: PMC6855812 DOI: 10.1542/peds.2018-3844] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | - Paul L. Aronson
- Sections of Pediatric Emergency Medicine and,Departments of Pediatrics and,Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | | | - Mark I. Neuman
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Harvard University and Boston Children’s Hospital, Boston, Massachusetts
| | - Frances Balamuth
- Division of Emergency Medicine and,Center for Pediatric Clinical Effectiveness, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher M. Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Adrienne G. DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Harvard University and Boston Children’s Hospital, Boston, Massachusetts
| | - Sahar N. Rooholamini
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Washington and Seattle Children’s Hospital, Seattle, Washington
| | - Marie E. Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| | - Richard D. Marble
- Division of Emergency Medicine, Feinberg School of Medicine, Northwestern University and Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | | - Laura Sartori
- Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University and Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, Tennessee; and
| | - Rianna C. Leazer
- Division of Hospital Medicine, Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, Virginia
| | | | - Samir S. Shah
- Divisions of Hospital Medicine and,Infectious Diseases, Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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8
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Aronson PL, Shabanova V, Shapiro ED, Wang ME, Nigrovic LE, Pruitt CM, DePorre AG, Leazer RC, Desai S, Sartori LF, Marble RD, Rooholamini SN, McCulloh RJ, Woll C, Balamuth F, Alpern ER, Shah SS, Williams DJ, Browning WL, Shah N, Neuman MI. A Prediction Model to Identify Febrile Infants ≤60 Days at Low Risk of Invasive Bacterial Infection. Pediatrics 2019; 144:peds.2018-3604. [PMID: 31167938 PMCID: PMC6615531 DOI: 10.1542/peds.2018-3604] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To derive and internally validate a prediction model for the identification of febrile infants ≤60 days old at low probability of invasive bacterial infection (IBI). METHODS We conducted a case-control study of febrile infants ≤60 days old who presented to the emergency departments of 11 hospitals between July 1, 2011 and June 30, 2016. Infants with IBI, defined by growth of a pathogen in blood (bacteremia) and/or cerebrospinal fluid (bacterial meningitis), were matched by hospital and date of visit to 2 control patients without IBI. Ill-appearing infants and those with complex chronic conditions were excluded. Predictors of IBI were identified with multiple logistic regression and internally validated with 10-fold cross-validation, and an IBI score was calculated. RESULTS We included 181 infants with IBI (155 [85.6%] with bacteremia without meningitis and 26 [14.4%] with bacterial meningitis) and 362 control patients. Twenty-three infants with IBI (12.7%) and 138 control patients (38.1%) had fever by history only. Four predictors of IBI were identified (area under the curve 0.83 [95% confidence interval (CI): 0.79-0.86]) and incorporated into an IBI score: age <21 days (1 point), highest temperature recorded in the emergency department 38.0-38.4°C (2 points) or ≥38.5°C (4 points), absolute neutrophil count ≥5185 cells per μL (2 points), and abnormal urinalysis results (3 points). The sensitivity and specificity of a score ≥2 were 98.8% (95% CI: 95.7%-99.9%) and 31.3% (95% CI: 26.3%-36.6%), respectively. All 26 infants with meningitis had scores ≥2. CONCLUSIONS Infants ≤60 days old with fever by history only, a normal urinalysis result, and an absolute neutrophil count <5185 cells per μL have a low probability of IBI.
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Affiliation(s)
- Paul L. Aronson
- Departments of Pediatrics and,Emergency Medicine, Yale School of Medicine and
| | | | - Eugene D. Shapiro
- Departments of Pediatrics and,Department of Epidemiology of Microbial Diseases,
Yale University, New Haven, Connecticut
| | - Marie E. Wang
- Division of Pediatric Hospital Medicine, Department
of Pediatrics, Lucile Packard Children’s Hospital Stanford and School of
Medicine, Stanford University, Palo Alto, California
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of
Pediatrics, Boston Children’s Hospital and Harvard Medical School,
Harvard University, Boston, Massachusetts
| | - Christopher M. Pruitt
- Division of Pediatric Emergency Medicine, Department
of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Adrienne G. DePorre
- Division of Hospital Medicine, Department of
Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Rianna C. Leazer
- Division of Hospital Medicine, Department of
Pediatrics, Children’s Hospital of the King’s Daughters, Norfolk,
Virginia
| | | | | | - Richard D. Marble
- Division of Emergency Medicine, Ann and Robert H.
Lurie Children’s Hospital of Chicago and Feinberg School of Medicine,
Northwestern University, Chicago, Illinois
| | - Sahar N. Rooholamini
- Division of Hospital Medicine, Department of
Pediatrics, Seattle Children’s Hospital and School of Medicine,
University of Washington, Seattle, Washington; and
| | - Russell J. McCulloh
- Division of Hospital Medicine, Department of
Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Christopher Woll
- Departments of Pediatrics and,Emergency Medicine, Yale School of Medicine and
| | - Fran Balamuth
- Division of Emergency Medicine and,Department of Pediatrics, Center for Pediatric
Clinical Effectiveness, Children’s Hospital of Philadelphia and Perelman
School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H.
Lurie Children’s Hospital of Chicago and Feinberg School of Medicine,
Northwestern University, Chicago, Illinois
| | - Samir S. Shah
- Divisions of Hospital Medicine and,Infectious Diseases, Department of Pediatrics,
Cincinnati Children’s Hospital Medical Center and University of
Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek J. Williams
- Hospital Medicine, Department of Pediatrics, Monroe
Carell Jr. Children’s Hospital at Vanderbilt and School of Medicine,
Vanderbilt University, Nashville, Tennessee
| | - Whitney L. Browning
- Hospital Medicine, Department of Pediatrics, Monroe
Carell Jr. Children’s Hospital at Vanderbilt and School of Medicine,
Vanderbilt University, Nashville, Tennessee
| | - Nipam Shah
- Division of Pediatric Emergency Medicine, Department
of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark I. Neuman
- Division of Emergency Medicine, Department of
Pediatrics, Boston Children’s Hospital and Harvard Medical School,
Harvard University, Boston, Massachusetts
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9
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Pruitt CM, Neuman MI, Shah SS, Shabanova V, Woll C, Wang ME, Alpern ER, Williams DJ, Sartori L, Desai S, Leazer RC, Marble RD, McCulloh RJ, DePorre AG, Rooholamini SN, Lumb CE, Balamuth F, Shin S, Aronson PL. Factors Associated with Adverse Outcomes among Febrile Young Infants with Invasive Bacterial Infections. J Pediatr 2019; 204:177-182.e1. [PMID: 30297292 PMCID: PMC6309646 DOI: 10.1016/j.jpeds.2018.08.066] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/21/2018] [Accepted: 08/24/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine factors associated with adverse outcomes among febrile young infants with invasive bacterial infections (IBIs) (ie, bacteremia and/or bacterial meningitis). STUDY DESIGN Multicenter, retrospective cohort study (July 2011-June 2016) of febrile infants ≤60 days of age with pathogenic bacterial growth in blood and/or cerebrospinal fluid. Subjects were identified by query of local microbiology laboratory and/or electronic medical record systems, and clinical data were extracted by medical record review. Mixed-effect logistic regression was employed to determine clinical factors associated with 30-day adverse outcomes, which were defined as death, neurologic sequelae, mechanical ventilation, or vasoactive medication receipt. RESULTS Three hundred fifty infants met inclusion criteria; 279 (79.7%) with bacteremia without meningitis and 71 (20.3%) with bacterial meningitis. Forty-two (12.0%) infants had a 30-day adverse outcome: 29 of 71 (40.8%) with bacterial meningitis vs 13 of 279 (4.7%) with bacteremia without meningitis (36.2% difference, 95% CI 25.1%-48.0%; P < .001). On adjusted analysis, bacterial meningitis (aOR 16.3, 95% CI 6.5-41.0; P < .001), prematurity (aOR 7.1, 95% CI 2.6-19.7; P < .001), and ill appearance (aOR 3.8, 95% CI 1.6-9.1; P = .002) were associated with adverse outcomes. Among infants who were born at term, not ill appearing, and had bacteremia without meningitis, only 2 of 184 (1.1%) had adverse outcomes, and there were no deaths. CONCLUSIONS Among febrile infants ≤60 days old with IBI, prematurity, ill appearance, and bacterial meningitis (vs bacteremia without meningitis) were associated with adverse outcomes. These factors can inform clinical decision-making for febrile young infants with IBI.
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Affiliation(s)
- Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL.
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Samir S Shah
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH; Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Veronika Shabanova
- Department of Pediatrics and Yale Center for Analytical Sciences, Yale School of Medicine, New Haven, CT
| | - Christopher Woll
- Section of Pediatric Emergency Medicine, Department of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Marie E Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Derek J Williams
- Division of Hospital Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Laura Sartori
- Pediatric Emergency Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Sanyukta Desai
- Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Rianna C Leazer
- Division of Hospital Medicine, Children's Hospital of The King's Daughters, Norfolk, VA
| | - Richard D Marble
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Adrienne G DePorre
- Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | | | - Catherine E Lumb
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Fran Balamuth
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sarah Shin
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Department of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
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10
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Aronson PL, Wang ME, Shapiro ED, Shah SS, DePorre AG, McCulloh RJ, Pruitt CM, Desai S, Nigrovic LE, Marble RD, Leazer RC, Rooholamini SN, Sartori LF, Balamuth F, Woll C, Neuman MI. Risk Stratification of Febrile Infants ≤60 Days Old Without Routine Lumbar Puncture. Pediatrics 2018; 142:peds.2018-1879. [PMID: 30425130 PMCID: PMC6317769 DOI: 10.1542/peds.2018-1879] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2018] [Indexed: 12/18/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5840460609001PEDS-VA_2018-1879Video Abstract OBJECTIVES: To evaluate the Rochester and modified Philadelphia criteria for the risk stratification of febrile infants with invasive bacterial infection (IBI) who do not appear ill without routine cerebrospinal fluid (CSF) testing. METHODS We performed a case-control study of febrile infants ≤60 days old presenting to 1 of 9 emergency departments from 2011 to 2016. For each infant with IBI (defined as a blood [bacteremia] and/or CSF [bacterial meningitis] culture with growth of a pathogen), controls without IBI were matched by site and date of visit. Infants were excluded if they appeared ill or had a complex chronic condition or if data for any component of the Rochester or modified Philadelphia criteria were missing. RESULTS Overall, 135 infants with IBI (118 [87.4%] with bacteremia without meningitis and 17 [12.6%] with bacterial meningitis) and 249 controls were included. The sensitivity of the modified Philadelphia criteria was higher than that of the Rochester criteria (91.9% vs 81.5%; P = .01), but the specificity was lower (34.5% vs 59.8%; P < .001). Among 67 infants >28 days old with IBI, the sensitivity of both criteria was 83.6%; none of the 11 low-risk infants had bacterial meningitis. Of 68 infants ≤28 days old with IBI, 14 (20.6%) were low risk per the Rochester criteria, and 2 had meningitis. CONCLUSIONS The modified Philadelphia criteria had high sensitivity for IBI without routine CSF testing, and all infants >28 days old with bacterial meningitis were classified as high risk. Because some infants with bacteremia were classified as low risk, infants discharged from the emergency department without CSF testing require close follow-up.
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Affiliation(s)
- Paul L. Aronson
- Departments of Pediatrics and,Emergency Medicine, Yale School of Medicine,
and
| | - Marie E. Wang
- Division of Pediatric Hospital Medicine, Lucile
Packard Children’s Hospital Stanford and Department of Pediatrics, School
of Medicine, Stanford University, Palo Alto, California
| | - Eugene D. Shapiro
- Departments of Pediatrics and,Department of Epidemiology of Microbial Diseases,
Yale University, New Haven, Connecticut
| | - Samir S. Shah
- Divisions of Infectious Diseases and,Hospital Medicine, Cincinnati Children’s
Hospital Medical Center and Department of Pediatrics, College of Medicine,
University of Cincinnati, Cincinnati, Ohio
| | | | - Russell J. McCulloh
- Divisions of Hospital Medicine and,Infectious Diseases, Department of Pediatrics,
Children’s Mercy Hospital, Kansas City, Missouri
| | - Christopher M. Pruitt
- Division of Pediatric Emergency Medicine, Department
of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sanyukta Desai
- Hospital Medicine, Cincinnati Children’s
Hospital Medical Center and Department of Pediatrics, College of Medicine,
University of Cincinnati, Cincinnati, Ohio
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston
Children’s Hospital and Department of Pediatrics, Harvard Medical School,
Harvard University, Boston, Massachusetts
| | - Richard D. Marble
- Division of Emergency Medicine, Ann and Robert H.
Lurie Children’s Hospital of Chicago and Feinberg School of Medicine,
Northwestern University, Chicago, Illinois
| | - Rianna C. Leazer
- Division of Hospital Medicine, Department of
Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk,
Virginia
| | - Sahar N. Rooholamini
- Division of Hospital Medicine, Seattle
Children’s Hospital and Department of Pediatrics, School of Medicine,
University of Washington, Seattle, Washington
| | - Laura F. Sartori
- Division of Pediatric Emergency Medicine, Monroe
Carell Jr Children’s Hospital at Vanderbilt and Department of Pediatrics,
School of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Fran Balamuth
- Division of Emergency Medicine, and,Center for Pediatric Clinical Effectiveness,
Children’s Hospital of Philadelphia and Department of Pediatrics,
Perelman School of Medicine, University of Pennsylvania, Philadelphia,
Pennsylvania
| | - Christopher Woll
- Departments of Pediatrics and,Emergency Medicine, Yale School of Medicine,
and
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston
Children’s Hospital and Department of Pediatrics, Harvard Medical School,
Harvard University, Boston, Massachusetts
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11
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Woll C, Neuman MI, Pruitt CM, Wang ME, Shapiro ED, Shah SS, McCulloh RJ, Nigrovic LE, Desai S, DePorre AG, Leazer RC, Marble RD, Balamuth F, Feldman EA, Sartori L, Browning WL, Aronson PL. Epidemiology and Etiology of Invasive Bacterial Infection in Infants ≤60 Days Old Treated in Emergency Departments. J Pediatr 2018; 200:210-217.e1. [PMID: 29784512 PMCID: PMC6109608 DOI: 10.1016/j.jpeds.2018.04.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/07/2018] [Accepted: 04/17/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To help guide empiric treatment of infants ≤60 days old with suspected invasive bacterial infection by describing pathogens and their antimicrobial susceptibilities. STUDY DESIGN Cross-sectional study of infants ≤60 days old with invasive bacterial infection (bacteremia and/or bacterial meningitis) evaluated in the emergency departments of 11 children's hospitals between July 1, 2011 and June 30, 2016. Each site's microbiology laboratory database or electronic medical record system was queried to identify infants from whom a bacterial pathogen was isolated from either blood or cerebrospinal fluid. Medical records of these infants were reviewed to confirm the presence of a pathogen and to obtain demographic, clinical, and laboratory data. RESULTS Of the 442 infants with invasive bacterial infection, 353 (79.9%) had bacteremia without meningitis, 64 (14.5%) had bacterial meningitis with bacteremia, and 25 (5.7%) had bacterial meningitis without bacteremia. The peak number of cases of invasive bacterial infection occurred in the second week of life; 364 (82.4%) infants were febrile. Group B streptococcus was the most common pathogen identified (36.7%), followed by Escherichia coli (30.8%), Staphylococcus aureus (9.7%), and Enterococcus spp (6.6%). Overall, 96.8% of pathogens were susceptible to ampicillin plus a third-generation cephalosporin, 96.0% to ampicillin plus gentamicin, and 89.2% to third-generation cephalosporins alone. CONCLUSIONS For most infants ≤60 days old evaluated in a pediatric emergency department for suspected invasive bacterial infection, the combination of ampicillin plus either gentamicin or a third-generation cephalosporin is an appropriate empiric antimicrobial treatment regimen. Of the pathogens isolated from infants with invasive bacterial infection, 11% were resistant to third-generation cephalosporins alone.
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Affiliation(s)
- Christopher Woll
- Departments of Pediatrics and of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Mark I. Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Christopher M. Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Marie E. Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA
| | - Eugene D. Shapiro
- Departments of Pediatrics, of Epidemiology, and of Investigative Medicine, Yale University, New Haven, CT
| | - Samir S. Shah
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Russell J. McCulloh
- Division of Infectious Diseases, Children’s Mercy Hospital, Kansas City, MO,Division of Hospital Medicine, Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO
| | - Lise. E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Sanyukta Desai
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Adrienne G. DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO
| | - Rianna C. Leazer
- Division of Hospital Medicine, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Richard D. Marble
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Frances Balamuth
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Laura Sartori
- Divisions of Pediatric Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Whitney L. Browning
- Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Paul L. Aronson
- Departments of Pediatrics and of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT,Address Correspondence to: Paul L. Aronson, MD, Section of Pediatric Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511. Phone: 203-785-3849, Fax: 203-737-7447,
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12
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Aronson PL, Wang ME, Nigrovic LE, Shah SS, Desai S, Pruitt CM, Balamuth F, Sartori L, Marble RD, Rooholamini SN, Leazer RC, Woll C, DePorre AG, Neuman MI. Time to Pathogen Detection for Non-ill Versus Ill-Appearing Infants ≤60 Days Old With Bacteremia and Meningitis. Hosp Pediatr 2018; 8:379-384. [PMID: 29954839 PMCID: PMC6145376 DOI: 10.1542/hpeds.2018-0002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES We sought to determine the time to pathogen detection in blood and cerebrospinal fluid (CSF) for infants ≤60 days old with bacteremia and/or bacterial meningitis and to explore whether time to pathogen detection differed for non-ill-appearing and ill-appearing infants. METHODS We included infants ≤60 days old with bacteremia and/or bacterial meningitis evaluated in the emergency departments of 10 children's hospitals between July 1, 2011, and June 30, 2016. The microbiology laboratories at each site were queried to identify infants in whom a bacterial pathogen was isolated from blood and/or CSF. Medical records were then reviewed to confirm the presence of a pathogen and to extract demographic characteristics, clinical appearance, and the time to pathogen detection. RESULTS Among 360 infants with bacteremia, 316 (87.8%) pathogens were detected within 24 hours and 343 (95.3%) within 36 hours. A lower proportion of non-ill-appearing infants with bacteremia had a pathogen detected on blood culture within 24 hours compared with ill-appearing infants (85.0% vs 92.9%, respectively; P = .03). Among 62 infants with bacterial meningitis, 55 (88.7%) pathogens were detected within 24 hours and 59 (95.2%) were detected within 36 hours, with no difference based on ill appearance. CONCLUSIONS Among infants ≤60 days old with bacteremia and/or bacterial meningitis, pathogens were commonly identified from blood or CSF within 24 and 36 hours. However, clinicians must weigh the potential for missed bacteremia in non-ill-appearing infants discharged within 24 hours against the overall low prevalence of infection.
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Affiliation(s)
- Paul L Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut;
| | - Marie E Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, California
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Samir S Shah
- Divisions of Hospital Medicine and
- Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Fran Balamuth
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Richard D Marble
- Division of Emergency Medicine, Ann and Robert H Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sahar N Rooholamini
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington
| | - Rianna C Leazer
- Division of Hospital Medicine, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia; and
| | - Christopher Woll
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Adrienne G DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
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13
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Schroeder LL, Marble RD, Jackson MA. Case 03-1994: an adolescent with fever and hip pain. Pediatr Emerg Care 1994; 10:183-8. [PMID: 8058566 DOI: 10.1097/00006565-199406000-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- L L Schroeder
- Division of Emergency Medicine, Children's Mercy Hospital, Kansas City, Missouri 64108-9898
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Knapp JF, Tarantino CA, Foster J, Marble RD. Case 04-1993: an adolescent female with abdominal pain and iron deficiency anemia. Pediatr Emerg Care 1993; 9:310-5. [PMID: 8247940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- J F Knapp
- Division of Emergency Medicine, Children's Mercy Hospital, Kansas City, MO 64108
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Berkowitz CD, Uchiyama N, Tully SB, Marble RD, Spencer M, Stein MT, Orr DP. Fever in infants less than two months of age: spectrum of disease and predictors of outcome. Pediatr Emerg Care 1985; 1:128-35. [PMID: 3842882 DOI: 10.1097/00006565-198509000-00005] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Four hundred thirty-four febrile infants two months of age or younger were evaluated in the emergency departments of five major teaching hospitals over a one-year period. A culture-proven bacterial infection was present in 3.5% of the infants; bacteremia was detected in 3.3%. Bacterial meningitis was present in 2.4%, and aseptic meningitis was noted in 13.4%. Twenty-one percent had clinically apparent serious disease including pneumonia, otitis media, and gastroenteritis with dehydration. Six variables (age less than 1 month, lethargy, no contact with an ill individual, breast-feeding, total polymorphonuclear greater than or equal to 10,000/mm3 and band count greater than or equal to 500/mm3) were correlated with bacterial infection by step-wise discriminant analysis. However, these findings were neither sensitive nor specific enough to be clinically useful. Management varied, and 62% of the infants were hospitalized. Fifty-four percent, some of whom were managed as outpatients, received antibiotics. Febrile infants two months of age or younger require a comprehensive emergency department assessment, including appropriate laboratory studies (CBC, differential, urinalysis and culture, lumbar puncture, and blood culture), since 3.5% have bacterial infection that may be life-threatening. Hospitalization is warranted if the infant appears ill, laboratory studies indicate serious infection, or follow-up care is uncertain.
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Abstract
A 6-day-old male infant was treated for rapidly progressive pneumonia. The infection was not responsive to antibiotic and symptomatic treatment, and the infant died within 48 hours of admission. Herpes simplex type II grew from premortem respiratory and postmortem lung cultures, and immunoperoxidase staining confirmed the presence of this organism in lung tissue. Pathologic findings were limited to the lungs. A maternal origin for the virus was suspected but could not be proved. We believe this patient represents the first reported case of isolated herpes simplex type II pneumonia in a neonate.
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Gerstmann DR, Marble RD. Bilaterally enlarged testicles in a newborn: an atypical presentation of intrauterine spermatic cord torsion. Am J Dis Child 1980; 134:992-4. [PMID: 7191631 DOI: 10.1001/archpedi.1980.02130220068022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Marble RD, Thomas RG, Sterling ML. Screening for angel dust in newborns. Pediatrics 1980; 66:334. [PMID: 7402828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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