Diagnostic value of immature neutrophils (bands) in the cerebrospinal fluid of children with cerebrospinal fluid pleocytosis.

OBJECTIVE: We evaluated the diagnostic utility of the presence and number of cerebrospinal fluid (CSF) bands in distinguishing bacterial from aseptic meningitis among children with CSF pleocytosis. METHODS: We identified retrospectively a cohort of children 29 days to 19 years of age with CSF pleocytosis (> or =10 x 10(6) leukocytes per L) who were treated in the emergency departments of 8 pediatric centers between January 2001 and June 2004 and whose CSF was evaluated for the presence of bands. We performed bivariate and multivariate analyses to determine the ability of CSF bands to distinguish bacterial from aseptic meningitis. RESULTS: Among 1116 children whose CSF was evaluated for the presence of bands, 48 children (4% of study patients) had bacterial meningitis. Bacterial meningitis, compared with aseptic meningitis, was associated with a greater CSF band proportion (0.03 vs 0.01; difference: 0.02; 95% confidence interval: 0.00-0.04) and CSF absolute band count (392 x 10(6) cells per L vs 3 x 10(6) cells per L; difference: 389 x 10(6) cells per L; 95% confidence interval: -77 x 10(6) cells per L to 855 x 10(6) cells per L). In addition, 29% of patients with bacterial meningitis, compared with 18% of patients with aseptic meningitis, had any bands detected in the CSF. After adjustment for other factors associated with bacterial meningitis, however, CSF band presence, CSF absolute band count, and CSF band proportion were not independently associated with bacterial meningitis. CONCLUSION: In this multicenter study, neither the presence nor quantity of CSF bands independently predicted bacterial meningitis among children with CSF pleocytosis.

Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis.

OBJECTIVE: The goal of this study was to evaluate the effect of antibiotic administration before lumbar puncture on cerebrospinal fluid profiles in children with bacterial meningitis. METHODS: We reviewed the medical records of all children (1 month to 18 years of age) with bacterial meningitis who presented to 20 pediatric emergency departments between 2001 and 2004. Bacterial meningitis was defined by positive cerebrospinal fluid culture results for a bacterial pathogen or cerebrospinal fluid pleocytosis with positive blood culture and/or cerebrospinal fluid latex agglutination results. Probable bacterial meningitis was defined as positive cerebrospinal fluid Gram stain results with negative results of bacterial cultures of blood and cerebrospinal fluid. Antibiotic pretreatment was defined as any antibiotic administered within 72 hours before the lumbar puncture. RESULTS: We identified 231 patients with bacterial meningitis and another 14 with probable bacterial meningitis. Of those 245 patients, 85 (35%) had received antibiotic pretreatment. After adjustment for patient age, duration and severity of illness at presentation, and bacterial pathogen, longer duration of antibiotic pretreatment was not significantly associated with cerebrospinal fluid white blood cell count, cerebrospinal fluid absolute neutrophil count. However, antibiotic pretreatment was significantly associated with higher cerebrospinal fluid glucose and lower cerebrospinal fluid protein levels. Although these effects became apparent earlier, patients with >or=12 hours of pretreatment, compared with patients who either were not pretreated or were pretreated for <12 hours, had significantly higher median cerebrospinal fluid glucose levels (48 mg/dL vs 29 mg/dL) and lower median cerebrospinal fluid protein levels (121 vs 178 mg/dL). CONCLUSIONS: In patients with bacterial meningitis, antibiotic pretreatment is associated with higher cerebrospinal fluid glucose levels and lower cerebrospinal fluid protein levels, although pretreatment does not modify cerebrospinal fluid white blood cell count or absolute neutrophil count results.

Pediatric patient safety in the prehospital/emergency department setting.

The unique characteristics of the pediatric population expose them to errors in the emergency department (ED) with few standard practices for the safety of care. Young children and high-acuity patients are at increased risk of adverse events both in the prehospital and ED settings. We provide an overview of the problems and possible solutions to the threats to pediatric patient safety in the ED. Endorsing a culture of safety and training to work in a team are discussed. Medication errors can be reduced by using organizational systems, and manufacturing and regulatory systems, by educating health care providers, and by providing caregivers tools to monitor prescribing. The consensus is that a safe environment with a high quality of care will reduce morbidity and mortality in ED pediatric patients.

Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis.

CONTEXT: Children with cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital and treated with parenteral antibiotics, although few have bacterial meningitis. We previously developed a clinical prediction rule, the Bacterial Meningitis Score, that classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria: positive CSF Gram stain, CSF absolute neutrophil count (ANC) of at least 1000 cells/microL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10,000 cells/microL, and a history of seizure before or at the time of presentation. OBJECTIVE: To validate the Bacterial Meningitis Score in the era of widespread pneumococcal conjugate vaccination. DESIGN, SETTING, AND PATIENTS: A multicenter, retrospective cohort study conducted in emergency departments of 20 US academic medical centers through the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. All children aged 29 days to 19 years who presented at participating emergency departments between January 1, 2001, and June 30, 2004, with CSF pleocytosis (CSF white blood cells > or =10 cells/microL) and who had not received antibiotic treatment before lumbar puncture. MAIN OUTCOME MEASURE: The sensitivity and negative predictive value of the Bacterial Meningitis Score. RESULTS: Among 3295 patients with CSF pleocytosis, 121 (3.7%; 95% confidence interval [CI], 3.1%-4.4%) had bacterial meningitis and 3174 (96.3%; 95% CI, 95.5%-96.9%) had aseptic meningitis. Of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old. A total of 2518 patients (80%) with aseptic meningitis were hospitalized. CONCLUSIONS: This large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to emergency departments with CSF pleocytosis.

Cutaneous community-associated methicillin-resistant staphylococcus aureus among all skin and soft-tissue infections in two geographically distant pediatric emergency departments.

OBJECTIVES: To describe the culture results of cutaneous infections affecting otherwise healthy children presenting to two pediatric emergency departments (EDs) in the southeastern United States and southern California. METHODS: Medical records of 920 children who presented to the pediatric EDs with skin infections and abscesses (International Classification of Diseases, Ninth Revision codes 680.0-686.9) during 2003 were reviewed. Chronically ill children with previously described risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) were excluded. Data abstracted included the type of infection; the site of infection; and, if a culture was obtained, the organism grown, along with their corresponding sensitivities. RESULTS: Of the 270 children who had bacterial cultures obtained, 60 (22%) were CA-MRSA-positive cultures, most cultured from abscesses (80%). Of all abscesses cultured, CA-MRSA grew in more than half (53%). All CA-MRSA isolates tested were sensitive to vancomycin, trimethoprim-sulfamethoxazole, rifampin, and gentamicin. One isolate at each center was resistant to clindamycin. The sensitivities at both institutions were similar. CONCLUSIONS: The authors conclude that CA-MRSA is responsible for most abscesses and that the pattern of CA-MRSA infections in these geographically distant pediatric EDs is similar. These data suggest that optimal diagnostic and management strategies for CA-MRSA will likely be widely applicable if results from a larger, more collaborative study yield similar findings.

Coarctation of the aorta and cerebellar infarction: a case report.

A 5-year-old child presented to our emergency department with a sudden onset of symptoms consistent with cerebellar infarction. Evaluation lead us to discover an undiagnosed coarctation of the aorta in association with a thrombotic cerebellar infarction. A review of coarctation follows.