Characteristics of oncology patients with fever and invasive bacterial infections diagnosed.

AIM: To describe the characteristics of febrile oncology patients seen in the Paediatric Emergency Department and microbiological characteristics of the invasive bacterial infections (IBIs) diagnosed. METHODS: We conducted a prospective observational study of febrile oncology patients seen between 2016 and 2022. We divided haematologic cancers by the aggressiveness of the chemotherapy received at the time. RESULTS: We included 418 episodes (272 haematologic cancers, 146 solid tumours). The median duration of fever was 2 h (interquartile range: 1-3) and 97.6% of patients were well-appearing on arrival. We diagnosed 61 IBIs (14.6%), including six episodes of bacterial sepsis. One other episode was coded as sepsis without microbiological confirmation, yielding seven episodes overall (1.7%). Rates of IBI and sepsis were higher among patients with high-risk haematologic cancers than those with low-risk haematologic cancers or solid tumours (22.9%, 5.4% and 10.3%, p < 0.01; 3.4%, 0% and 0.7%, p = 0.06, respectively). Leading causes were S. epidermidis (42.6%) and E. coli (14.7%). Gram-positive bacteria caused 67.2% of non-septic IBIs and 50% of septic episodes. CONCLUSION: Most febrile oncology patients are well-appearing and present with a very short history of fever. Prevalence of IBI and sepsis and the main disease-causing bacteria differ by cancer type and the presence of sepsis.

Performance of Febrile Infant Algorithms by Duration of Fever.

OBJECTIVES: To analyze the performance of commonly used blood tests in febrile infants ≤90 days of age to identify patients at low risk for invasive bacterial infection (bacterial pathogen in blood or cerebrospinal fluid) by duration of fever. METHODS: We conducted a secondary analysis of a prospective single-center registry that includes all consecutive infants ≤90 days of age with fever without a source evaluated at 1 pediatric emergency department between 2008 and 2021. We defined 3 groups based on caregiver-reported hours of fever (<2, 2-12, and ≥12) and analyzed the performance of the biomarkers and Pediatric Emergency Care Applied Research Network, American Academy of Pediatrics, and Step-by-Step clinical decision rules. RESULTS: We included 2411 infants; 76 (3.0%) were diagnosed with an invasive bacterial infection. The median duration of fever was 4 (interquartile range, 2-12) hours, with 633 (26.3%) patients with fever of <2 hours. The area under the curve was significantly lower in patients with <2 hours for absolute neutrophil count (0.562 vs 0.609 and 0.728) and C-reactive protein (0.568 vs 0.760 and 0.812), but not for procalcitonin (0.749 vs 0.780 and 0.773). Among well-appearing infants older than 21 days and negative urine dipstick with <2 hours of fever, procalcitonin ≥0.14 ng/mL showed a better sensitivity (100% with specificity 53.8%) than that of the combination of biomarkers of Step-by-Step (50.0% and 82.2%), and of the American Academy of Pediatrics and Pediatric Emergency Care Applied Research Network rules (83.3% and 58.3%), respectively. CONCLUSIONS: The performance of blood biomarkers, except for procalcitonin, in febrile young infants is lower in fever of very short duration, decreasing the accuracy of the clinical decision rules.

Clinical Prediction Rule for Distinguishing Bacterial From Aseptic Meningitis.

BACKGROUND: New biomarkers like procalcitonin and C-reactive protein may help design an accurate decision support tool used to identify children with pleocytosis at low or high risk of bacterial meningitis. Our objective was to develop and validate a score (that we call the meningitis score for emergencies [MSE]) to distinguish bacterial meningitis from aseptic meningitis in children with pleocytosis when initially evaluated at the emergency department. METHODS: We included children between 29 days and 14 years old with meningitis admitted to 25 Spanish emergency departments. A retrospective cohort from between 2011 and 2016 was used as the derivation set and a prospective cohort recruited during 2017 and 2018 was used as the validation set. RESULTS: Among the 1009 patients included, there were 917 cases of aseptic meningitis and 92 of bacterial meningitis. Using multivariable logistic regression analysis, we identified the following predictors of bacterial meningitis from the derivation set: procalcitonin >1.2 ng/mL, cerebrospinal fluid (CSF) protein >80 mg/dL, CSF absolute neutrophil count >1000 cells per mm3, and C-reactive protein >40 mg/L. Using the derivation set, we developed the MSE, assigning 3 points for procalcitonin, 2 points for CSF protein, and 1 point for each of the other variables. An MSE ≥1 predicted bacterial meningitis with a sensitivity of 100% (95% confidence interval [CI]: 95.0%-100%), a specificity of 83.2 (95% CI: 80.6-85.5), and a negative predictive value of 100% (95% CI 99.4-100.) CONCLUSIONS: The MSE accurately distinguishes bacterial from aseptic meningitis in children with CSF pleocytosis.

Performance of blood biomarkers to rule out invasive bacterial infection in febrile infants under 21 days old.

OBJECTIVES: To determine the performance of procalcitonin (PCT), C reactive protein (CRP) and absolute neutrophil count (ANC) in identifying invasive bacterial infection (IBI) among well-appearing infants ≤21 days old with fever without source and no leukocyturia. To compare this performance with that in those 22-90 days old. DESIGN: Substudy of a prospective single-centre registry performed between September 2008 and August 2017. SETTING: Paediatric emergency department of a tertiary teaching hospital. PATIENTS: 196 infants ≤21 days old and 1331 infants 22-90 days old. MAIN OUTCOME MEASURES: Sensitivity and negative likelihood ratio of blood tests for ruling out IBI (positive blood or cerebrospinal fluid culture). Abnormal blood test results: PCT ≥0.5 ng/mL, CRP >20 mg/L and ANC >10 000/µL. RESULTS: Prevalence of IBI in infants ≤21 days old with normal or any abnormal blood test result was 3.6% and 6.8%, respectively (OR 0.52 (95% CI 0.13 to 2.01)), compared with 0.2% and 4.5% in older infants (OR 0.03 (95% CI 0 to 0.17)). Sensitivity and negative likelihood ratio of the blood tests for ruling out IBI in infants ≤21 days were 44.4% (95% CI 18.9% to 73.3%) and 0.79 (95% CI 0.43 to 1.44), respectively (vs 84.6% (95% CI 57.8% to 95.7%)%) and 0.19 (95% CI 0.05 to 0.67) in older infants). The values improved in infants with fever ≥6 hours aged 22-90 days, but not in those ≤21 days. CONCLUSIONS: PCT, CRP and ANC are not useful for ruling out IBI in febrile infants ≤21 days old. It is still recommended that these patients are admitted and given empirical antibiotic therapy, regardless of their general appearance or blood test results.

Initial Asthma Severity Assessment Tools as Predictors of Hospitalization.

BACKGROUND: Assessment tools to classify and prioritize patients, such as systems of triage, and indicators of severity, such as clinical respiratory scores, are helpful in guiding the flow of asthmatic patients in the emergency department. OBJECTIVE: Our aim was to assess the performance of the Pediatric Assessment Triangle (PAT), triage level (TL), Pulmonary Score (PS), and initial O2 saturation (O2 sat), in predicting hospitalization in pediatric acute asthma exacerbations. STUDY DESIGN: Retrospective study evaluating PAT, TL, and PS at presentation, and initial O2 sat of asthmatic children in the pediatric emergency department (PED). The primary outcome measure was the rate of hospitalization. Secondary outcomes were length of stay (LOS) in the PED and admission to the pediatric intensive care unit (PICU). RESULTS: PAT, TL, PS, and initial O2 sat were recorded in 14,953 asthmatic children. Multivariate analysis yielded the following results: Abnormal PAT and more severe TLs (I-II) were independent risk factors for hospitalization (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.4-1.8; OR 3.4, 95% CI 2.6-4.3, respectively) and longer LOS (OR 1.5, 95% CI 1.3-1.7; OR 2.6, 95% CI 2-3.3, respectively). PS > 3 showed a strong association with hospitalization (OR 8.1, 95% CI 7-9.4), PICU admission (OR 9.6, 95% CI 3-30.9) and longer LOS (OR 6.2, 95% CI 5.6-6.9). O2 sat < 94% was an independent predictor of admission (OR 5.2, 95% CI 4.6-5.9), PICU admission (OR 4.6, 95% CI 4.5-4.6), and longer LOS (OR 4.6, 95% CI 4.1-5.2). CONCLUSIONS: PAT, TL, PS, and initial O2 sat are good predictors of hospitalization in pediatric acute asthma exacerbations.

[Emergency department consultations due to foreign body ingestion]. / Consultas relacionadas con la ingesta de un cuerpo extraño en Urgencias.

INTRODUCTION: Foreign body (FB) ingestion is an uncommon reason for going to the Paediatric Emergency Department (PED). The aim of this study was to assess the clinical and epidemiological characteristics of foreign body ingestion and the management of these patients. PATIENTS AND METHODS: Retrospective study, including children under 14 years old with suspected foreign body ingestion seen in the PED between 2010 and 2013. An analysis was made of the circumstances of the FB ingestion, its management in the PED, and patient outcomes. RESULTS: Of the 226,666 presentations recorded, 1,608 (0.7%) were for a FB, 970 corresponding to ingestion of mainly fish bones (367, 38.7%) and coins (181, 18.7%), except in children under 1 year (plastic objects). The median age was 4.7 years, with boys being more common in those older than 4 years (58.5%). A total of 557 patients (57.3%) reported some symptom, and complementary tests were performed in 414 (42.7%). Another specialist was called in 315 (32.4%) cases, mainly from Ear, Nose and Throat (fish bones) or Surgery (coins). The FB was removed in 305 (31.4%) cases, which were mostly fish bones or sunflower seeds. Seventy-one patients (7.3%) were admitted, especially ingestion of fish bones or coins. No patient died. DISCUSSION: Ingestion of fish bones or coins by young children is a relatively common presentation in the PED, and it is associated with frequent medical interventions. Although the overall prognosis is good, and improving the health education of the population should be considered to reduce the frequency of these episodes.

Outpatient management of selected young febrile infants without antibiotics.

OBJECTIVE: To analyse the outpatient management of selected febrile infants younger than 90 days without systematic lumbar puncture and antibiotics. METHODS: A prospective registry-based cohort study including all the infants ≤90 days with fever without a source (FWS) who were evaluated in a paediatric emergency department (ED) over a 7-year period (September 2007-August 2014). We analysed the outcome of those infants with low-risk criteria for serious bacterial infection (SBI) managed as outpatients without antibiotics and without undergoing a lumbar puncture. Low-risk criteria: Well appearing, older than 21 days of age, no leucocyturia, absolute neutrophil count ≤10 000, serum C reactive protein ≤20 mg/L, procalcitonin <0.5 ng/mL and no clinical deterioration during the stay in the ED (always <24 hours). RESULTS: 1472 infants with FWS attended the ED. Of these, 676 were classified to be at low risk for SBI without performing a lumbar puncture. After staying <24 hours in the short-stay unit of the ED, 586 (86.6%) were managed as outpatients without antibiotics. Two patients were diagnosed with SBI: one occult bacteraemia and one bacterial gastroenteritis. Both were afebrile when evaluated again and did well. No patient returned to the ED due to clinical deterioration. Fifty-one infants (8.7%) returned to the ED mainly due to persistence of fever or irritability. None was diagnosed with definite SBI or non-bacterial meningitis. CONCLUSIONS: Outpatient management without antibiotics and systematic lumbar puncture is appropriate for selected febrile infants younger than 3 months of age with close follow-up.

Is this child sick? Usefulness of the Pediatric Assessment Triangle in emergency settings / Esta criança está doente? Utilidade do Triângulo de Avaliação Pediátrica nas configurações de emergência

Abstract Objective: The Pediatric Assessment Triangle is a rapid assessment tool that uses only visual and auditory clues, requires no equipment, and takes 30-60 s to perform. It's being used internationally in different emergency settings, but few studies have assessed its performance. The aim of this narrative biomedical review is to summarize the literature available regarding the usefulness of the Pediatric Assessment Triangle in clinical practice. Sources: The authors carried out a non-systematic review in the PubMed®, MEDLINE®, and EMBASE® databases, searching for articles published between 1999-2016 using the keywords "pediatric assessment triangle," "pediatric triage," "pediatric assessment tools," and "pediatric emergency department." Summary of the findings: The Pediatric Assessment Triangle has demonstrated itself to be useful to assess sick children in the prehospital setting and make transport decisions. It has been incorporated, as an essential instrument for assessing sick children, into different life support courses, although little has been written about the effectiveness of teaching it. Little has been published about the performance of this tool in the initial evaluation in the emergency department. In the emergency department, the Pediatric Assessment Triangle is useful to identify the children at triage who require more urgent care. Recent studies have assessed and proved its efficacy to also identify those patients having more serious health conditions who are eventually admitted to the hospital. Conclusions: The Pediatric Assessment Triangle is quickly spreading internationally and its clinical applicability is very promising. Nevertheless, it is imperative to promote research for clinical validation, especially for clinical use by emergency pediatricians and physicians.

Resumo Objetivo: O Triângulo de Avaliação Pediátrica é uma ferramenta de avaliação rápida que usa apenas pistas visuais e auditivas, não necessita de equipamentos e leva de 30-60 segundos. Tem sido usado internacionalmente em diferentes configurações de emergência, porém poucos estudos avaliaram seu desempenho. O objetivo desta análise biomédica narrativa é resumir a literatura disponível com relação à utilidade do Triângulo de Avaliação Pediátrica na prática clínica. Fontes: Fizemos uma análise não sistemática nas bases de dados do PubMed®, Medline® e Embase® em busca de artigos publicados entre 1999-2016 com as palavras-chave "triângulo de avaliação pediátrica", "triângulo pediátrico", "ferramentas de avaliação pediátrica" e "departamento de emergência pediátrica". Resumo dos achados: O Triângulo de Avaliação Pediátrica demonstrou ser útil na avaliação de crianças doentes na configuração pré-hospitalar e na tomada de decisões de transporte. Ele foi incorporado, como um instrumento essencial na avaliação de crianças doentes, em diferentes cursos de apoio de vida, apesar de pouco ter sido escrito sobre a eficácia de ensino do Triângulo de Avaliação Pediátrica. Pouco foi publicado sobre o desempenho do Triângulo de Avaliação Pediátrica na avaliação inicial no departamento de emergência (DE). No DE, o Triângulo de Avaliação Pediátrica é útil para identificar, na triagem, crianças que exigem cuidado mais urgente. Estudos recentes avaliaram e provaram a eficácia do Triângulo de Avaliação Pediátrica também na identificação dos pacientes com doenças de saúde mais graves e, eventualmente, são internados no hospital. Conclusões: O Triângulo de Avaliação Pediátrica se difunde rapidamente de forma internacional e sua aplicabilidade clínica é muito promissora. Contudo, é essencial promover pesquisa para validação clínica, principalmente para o uso clínico por pediatras e médicos de emergência.