Frequency of Treatment Failure of UTIs in Children With Congenital Urinary Tract Anomalies.

OBJECTIVES: Children with certain congenital anomalies of the kidney and urinary tract and neurogenic bladder (CAKUT/NGB) are at higher risk of treatment failure for urinary tract infections (UTIs) than children with normal genitourinary anatomy, but the literature describing treatment and outcomes is limited. The objectives of this study were to describe the rate of treatment failure in children with CAKUT/NGB and compare duration of antibiotics between those with and without treatment failure. METHODS: Multicenter retrospective cohort of children 0 to 17 years old with CAKUT/NGB who presented to the emergency department with fever or hypothermia and were diagnosed with UTI between 2017 and 2018. The outcome of interest was treatment failure, defined as subsequent emergency department visit or hospitalization for UTI because of the same pathogen within 30 days of the index encounter. Descriptive statistics and univariates analyses were used to compare covariates between groups. RESULTS: Of the 2014 patient encounters identified, 482 were included. Twenty-nine (6.0%) of the 482 included encounters had treatment failure. There was no difference in the mean duration of intravenous antibiotics (3.4 ± 2.5 days, 3.5 ± 2.8 days, P = .87) or total antibiotics between children with and without treatment failure (10.2 ± 3.8 days, 10.8 ± 4.0 days, P = .39) Of note, there was a higher rate of bacteremia in children with treatment failure (P = .04). CONCLUSIONS: In children with CAKUT/NGB and UTI, 6.0% of encounters had treatment failure. Duration of antibiotics was not associated with treatment failure. Larger studies are needed to assess whether bacteremia modifies the risk of treatment failure.

Risk Factors for Treatment Failure in Neonates With Skin and Soft Tissue Infection: A Retrospective Cohort Study.

We aimed to describe the frequency of treatment failure and associated risk factors for treatment failure amongst neonates with skin and soft tissue infections (SSTIs). We conducted a retrospective cohort study of neonates 0 to 28 days old with uncomplicated SSTIs presenting to the emergency department of a quaternary care children's hospital from 2009 to 2017. Data were collected via chart review. Skin and soft tissue infections included the following: cellulitis, abscess, mastitis, perirectal SSTI, carbuncle, and furuncle. Of the 202 neonates in the study, most were term, afebrile with mastitis, or perirectal SSTI. Treatment failure occurred in 8% (17/202) of neonates receiving oral antibiotics; 10 of these neonates had perirectal SSTIs and 2 had clindamycin and methicillin-resistant Staphylococcus aureus. Neonates with treatment failure had increased odds of having perirectal SSTIs (odds ratio [OR] = 4.08, 95% confidence interval [CI] = 1.46-11.31). Further studies are needed to identify strategies to prevent treatment failure in neonates with perirectal SSTIs.

Viral Coinfections in Kawasaki Disease: A Meta-analysis.

CONTEXT: Viral infections are suspected triggers in Kawasaki disease (KD); however, a specific viral trigger has not been identified. OBJECTIVES: In children with KD, to identify (1) overall prevalence of viral infections; (2) prevalence of specific viruses; and (3) whether viral positivity was associated with coronary artery aneurysms (CAAs) or refractoriness to intravenous immunoglobin (IVIG). DATA SOURCES: We searched Embase, Medline, and Cochrane databases and gray literature. STUDY SELECTION: Eligible studies were conducted between 1999 and 2019, and included children diagnosed with KD who underwent viral testing. DATA EXTRACTION: Two investigators independently reviewed full-text articles to confirm eligibility, extract data, appraise for bias, and assess evidence quality for outcomes using the Grading of Recommendations Assessment Development and Evaluation criteria. We defined viral positivity as number of children with a positive viral test divided by total tested. Secondary outcomes were CAA (z score ≥2.5) and IVIG refractoriness (fever ≥36 hours after IVIG). RESULTS: Of 3189 unique articles identified, 54 full-text articles were reviewed, and 18 observational studies were included. Viral positivity weighted mean prevalence was 30% (95% confidence interval [CI], 14-51) and varied from 5% to 66%, with significant between-study heterogeneity. Individual virus positivity was highest for rhinovirus (19%), adenovirus (10%), and coronavirus (7%). Odds of CAA (odds ratio, 1.08; 95% CI, 0.75-1.56) or IVIG refractoriness (odds ratio, 0.88; 95% CI, 0.58-1.35) did not differ on the basis of viral status. LIMITATIONS: Low or very low evidence quality. CONCLUSIONS: Viral infection was common with KD but without a predominant virus. Viral positivity was not associated with CAAs or IVIG refractoriness.

Hierarchy of Evidence Within the Medical Literature.

The quality of evidence from medical research is partially deemed by the hierarchy of study designs. On the lowest level, the hierarchy of study designs begins with animal and translational studies and expert opinion, and then ascends to descriptive case reports or case series, followed by analytic observational designs such as cohort studies, then randomized controlled trials, and finally systematic reviews and meta-analyses as the highest quality evidence. This hierarchy of evidence in the medical literature is a foundational concept for pediatric hospitalists, given its relevance to key steps of evidence-based practice, including efficient literature searches and prioritization of the highest-quality designs for critical appraisal, to address clinical questions. Consideration of the hierarchy of evidence can also aid researchers in designing new studies by helping them determine the next level of evidence needed to improve upon the quality of currently available evidence. Although the concept of the hierarchy of evidence should be taken into consideration for clinical and research purposes, it is important to put this into context of individual study limitations through meticulous critical appraisal of individual articles.

Association of Models of Care for Kawasaki Disease With Utilization and Cardiac Outcomes.

OBJECTIVES: Describe the prevalence of different care models for children with Kawasaki disease (KD) and evaluate utilization and cardiac outcomes by care model. METHODS: Multicenter, retrospective cohort study of children aged 0 to 18 hospitalized with KD in US children's hospitals from 2017 to 2018. We classified hospital model of care via survey: hospitalist primary service with as-needed consultation (Model 1), hospitalist primary service with automatic consultation (Model 2), or subspecialist primary service (Model 3). Additional data sources included administrative data from the Pediatric Health Information System database supplemented by a 6-site chart review. Utilization outcomes included laboratory, medication and imaging usage, length of stay, and readmission rates. We measured the frequency of coronary artery aneurysms (CAAs) in the full cohort and new CAAs within 12 weeks in the 6-site chart review subset. RESULTS: We included 2080 children from 44 children's hospitals; 21 hospitals (48%) identified as Model 1, 19 (43%) as Model 2, and 4 (9%) as Model 3. Model 1 institutions obtained more laboratory tests and had lower overall costs (P < .001), whereas echocardiogram (P < .001) and immune modulator use (P < .001) were more frequent in Model 3. Secondary outcomes, including length of stay, readmission rates, emergency department revisits, CAA frequency, receipt of anticoagulation, and postdischarge CAA development, did not differ among models. CONCLUSIONS: Modest cost and utilization differences exist among different models of care for KD without significant differences in outcomes. Further research is needed to investigate primary service and consultation practices for KD to optimize health care value and outcomes.

Antibiotic Regimens and Associated Outcomes in Children Hospitalized With Staphylococcal Scalded Skin Syndrome.

BACKGROUND: Controversy exists regarding the optimal antibiotic regimen for use in hospitalized children with staphylococcal scalded skin syndrome (SSSS). Various regimens may confer toxin suppression and/or additional coverage for methicillin-susceptible Staphylococcus aureus (MSSA) or methicillin-resistant S aureus (MRSA). OBJECTIVES: To describe antibiotic regimens in hospitalized children with SSSS and examine the association between antistaphylococcal antibiotic regimens and patient outcomes. DESIGN/METHODS: Retrospective cohort study of children hospitalized with SSSS using the Pediatric Health Information System database (2011-2016). Children who received clindamycin monotherapy, clindamycin plus MSSA coverage (eg, nafcillin), or clindamycin plus MRSA coverage (eg, vancomycin) were included. The primary outcome was hospital length of stay (LOS); secondary outcomes were treatment failure and cost. Generalized linear mixed-effects models were used to compare outcomes among antibiotic groups. RESULTS: Of 1,259 children included, 828 children received the most common antistaphylococcal antibiotic regimens: clindamycin monotherapy (47%), clindamycin plus MSSA coverage (33%), and clindamycin plus MRSA coverage (20%). Children receiving clindamycin plus MRSA coverage had higher illness severity (44%) compared with clindamycin monotherapy (28%) and clindamycin plus MSSA (32%) (P =.001). In adjusted analyses, LOS and treatment failure did not differ among the 3 regimens (P =.42 and P =.26, respectively). Cost was significantly lower for children receiving clindamycin monotherapy and highest in those receiving clindamycin plus MRSA coverage (mean, $4,839 vs $5,348, respectively; P <.001). CONCLUSIONS: In children with SSSS, the addition of MSSA or MRSA coverage to clindamycin monotherapy was associated with increased cost and no incremental difference in clinical outcomes.

Effectiveness of Modalities to Teach Evidence Based Medicine to Pediatric Clerkship Students: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effectiveness of a traditional didactic session (TDS) as compared to a self-paced, interactive, multimedia module (SPM) on the application of evidence-based medicine (EBM) skills among medical students during their inpatient pediatric rotation. METHODS: We conducted a randomized controlled trial from June, 2017 to June, 2018 at a quaternary care children's hospital. Students were randomized to TDS or SPM during each 2-week block. All students completed a critical appraisal tool (CAT) of evidence related to a clinical question in a standardized appraisal form and self-reflected about the EBM process. The primary outcome was the numeric score of the CAT derived by using the validated Fresno tool. Secondary outcomes of knowledge, attitudes, confidence, and self-reported behaviors related to EBM were measured using validated surveys. Statistical analysis was performed using Student's t test for CAT scores and mixed-model procedure (PROC MIXED), with subject as random effect and time as repeated measure for the secondary outcomes. RESULTS: One hundred twenty-seven clerkship students were included. Overall, there was no significant difference in mean CAT scores for TDS (n = 59) versus SPM (n = 66) groups (90.3 vs 92.0, P = .65). There were no significant differences between SPM and TDS groups for knowledge (P = .66), attitudes (P = .97), confidence (P  = .55), and accessing evidence (P = .27). Both groups showed significant gains in knowledge, attitudes, confidence, and accessing evidence from baseline to postcourse. Improvements in knowledge and confidence were sustained at 3-months. CONCLUSION: A SPM learning module is as effective as a TDS module for application of EBM concepts and knowledge to patient care.

Invasive Bacterial Infections in Infants Younger Than 60 Days With Skin and Soft Tissue Infections.

OBJECTIVE: The objective of this study was to describe the frequency of invasive bacterial infections (IBIs) in young infants with skin and soft tissue infections (SSTIs) and the impact of IBI evaluation on disposition, length of stay (LOS), and cost. METHODS: This retrospective (2009-2014) cohort study used data from 35 children's hospitals in the Pediatric Health Information System. We included infants younger than 60 days who presented to an emergency department (ED) with SSTI. Invasive bacterial infection was defined as bacteremia/sepsis, bone/joint infection, or bacterial meningitis. Readmission and return ED visits within 30 days were evaluated to identify missed IBIs for infants. RESULTS: A total of 2734 infants were included (median age, 33 days; interquartile range [IQR], 21-44); 62% were hospitalized. Invasive bacterial infection was identified in 2%: bacteremia (1.8%), osteomyelitis (0.1%), and bacterial meningitis (0.1%). Hospitalization occurred in 78% of infants with blood cultures, 95% with cerebrospinal fluid cultures, and 23% without cultures. Median hospitalization LOS was 2 days (IQR, 1-3). Median cost was US $4943 for infants with cerebrospinal fluid cultures (IQR, US $3475-6780) compared with US $419 (IQR, US $215-1149) for infants without IBI evaluations (P < 0.001). Five infants (0.2%) returned to the ED within 30 days with new IBI diagnoses (4 bacteremia, 1 meningitis). CONCLUSIONS: Invasive bacterial infection occurs infrequently in infants younger than 60 days who present to children's hospital EDs with SSTI. Bacteremia is the most common IBI. More extensive evaluation for IBI is associated with increased rate of admission, LOS, and cost. Further studies are needed to evaluate the safety of a limited IBI evaluation in young infants with SSTI.

Clinical Predictors for Abnormal Renal Bladder Ultrasound in Hospitalized Young Children With a First Febrile Urinary Tract Infection.

BACKGROUND: Physicians often obtain a routine renal bladder ultrasound (RBUS) for young children with a first febrile urinary tract infection (UTI). However, few children are diagnosed with serious anatomic anomalies, and opportunity may exist to take a focused approach to ultrasonography. We aimed to identify characteristics of the child, prenatal ultrasound (PNUS), and illness that could be used to predict an abnormal RBUS and measure the impact of RBUS on management. METHODS: We conducted a single-center prospective cohort study of hospitalized children 0 to 24 months of age with a first febrile UTI from October 1, 2016, to December 23, 2018. Independent variables included characteristics of the child, PNUS, and illness. The primary outcome, abnormal RBUS, was defined through consensus of a multidisciplinary team on the severity of ultrasound findings important to identify during a first UTI. RESULTS: A total of 211 children were included; the median age was 1.0 month (interquartile range 0-2), and 55% were uncircumcised boys. All mothers had a PNUS with 10% being abnormal. Escherichia coli was the pathogen in 85% of UTIs, 20% (n = 39 of 197) had bacteremia, and 7% required intensive care. Abnormal RBUS was found in 36% (n = 76 of 211) of children; of these, 47% (n = 36 of 76) had moderately severe findings and 53% (n = 40 of 76) had severe findings. No significant difference in clinical characteristics was seen among children with and without an abnormal RBUS. One child had Foley catheter placement, and 33% received voiding cystourethrograms, 15% antibiotic prophylaxis, and 16% subspecialty referrals. CONCLUSIONS: No clinical predictors were identified to support a focused approach to RBUS examinations. Future studies should investigate the optimal timing for RBUS.

Caregivers' Perceptions and Hospital Experience After a Brief Resolved Unexplained Event: A Qualitative Study.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics published guidelines for evaluation and management of lower-risk infants for a brief resolved unexplained event (BRUE). The guideline identified gaps in knowledge related to caregiver satisfaction, anxiety, and family-centered educational strategies to improve caregiver experience and patient outcomes. The objective of this study was to understand caregivers' experience with hospitalization for infants with BRUE, including their perception of the hospital stay, the diagnosis of BRUE, and their feelings toward the upcoming discharge from the hospital. METHODS: We conducted a qualitative study using semistructured interviews with caregivers of infants aged 0 to 12 months who were admitted to a quaternary care children's hospital for a BRUE. Interviews were conducted within 24 hours of discharge. Two investigators coded transcripts and identified themes using consensus. RESULTS: Eighteen caregivers of 13 infants were interviewed. No infants met criteria for being low risk according to the American Academy of Pediatrics guidelines. The coding scheme produced 3 major themes. First, parents felt reassured by hospital monitoring, diagnostic evaluation, and staff support in the hospital. Second, parents felt unsettled by the uncertainty of the child's condition and whether BRUE's "unexplainable" quality is understood as being part of normal infant behavior. Third, these themes manifested as conflicting emotions about caregivers' readiness for discharge. CONCLUSIONS: Although hospital monitoring may provide reassurance for some caregivers, they continue to struggle with the uncertainty of the diagnosis. Caregiver perspectives can inform physicians' strategies to improve hospital experience and discharge readiness.

Variation in Antibiotic Selection and Clinical Outcomes in Infants <60 Days Hospitalized With Skin and Soft Tissue Infections.

OBJECTIVES: To describe variation in empirical antibiotic selection in infants <60 days old who are hospitalized with skin and soft-tissue infections (SSTIs) and to determine associations with outcomes, including length of stay (LOS), 30-day returns (emergency department revisit or readmission), and standardized cost. METHODS: Using the Pediatric Health Information System, we conducted a retrospective study of infants hospitalized with SSTI from 2009 to 2014. We analyzed empirical antibiotic selection in the first 2 days of hospitalization and categorized antibiotics as those typically administered for (1) staphylococcal infection, (2) neonatal sepsis, or (3) combination therapy (staphylococcal infection and neonatal sepsis). We examined the association of antibiotic selection and outcomes using generalized linear mixed-effects models. RESULTS: A total of 1319 infants across 36 hospitals were included; the median age was 30 days (interquartile range [IQR]: 17-42 days). We observed substantial variation in empirical antibiotic choice, with 134 unique combinations observed before categorization. The most frequently used antibiotics included staphylococcal therapy (50.0% [IQR: 39.2-58.1]) and combination therapy (45.4% [IQR: 36.0-56.0]). Returns occurred in 9.2% of infants. Compared with administration of staphylococcal antibiotics, use of combination therapy was associated with increased LOS (adjusted rate ratio: 1.35; 95% confidence interval: 1.17-1.53) and cost (adjusted rate ratio: 1.39; 95% confidence interval: 1.21-1.58), but not with 30-day returns. CONCLUSIONS: Infants who are hospitalized with SSTI experience wide variation in empirical antibiotic selection. Combination therapy was associated with increased LOS and cost, with no difference in returns. Our findings reveal the need to identify treatment strategies that can be used to optimize resource use for infants with SSTI.

Variation in Diagnostic Test Use and Associated Outcomes in Staphylococcal Scalded Skin Syndrome at Children's Hospitals.

OBJECTIVES: The incidence of staphylococcal scalded skin syndrome (SSSS) is rising, but current practice variation in diagnostic test use is not well described. Our aim was to describe the variation in diagnostic test use in children hospitalized with SSSS and to determine associations with patient outcomes. METHODS: We performed a retrospective (2011-2016) cohort study of children aged 0 to 18 years from 35 children's hospitals in the Pediatric Health Information System database. Tests included blood culture, complete blood count, erythrocyte sedimentation rate, C-reactive protein level, serum chemistries, and group A streptococcal testing. K-means clustering was used to stratify hospitals into groups of high (cluster 1) and low (cluster 2) test use. Associations between clusters and patient outcomes (length of stay, cost, readmissions, and emergency department revisits) were assessed with generalized linear mixed-effects modeling. RESULTS: We included 1259 hospitalized children with SSSS; 84% were ≤4 years old. Substantial interhospital variation was seen in diagnostic testing. Blood culture was the most commonly obtained test (range 62%-100%), with the most variation seen in inflammatory markers (14%-100%). Between hospital clusters 1 and 2, respectively, there was no significant difference in adjusted length of stay (2.6 vs 2.5 days; P = .235), cost ($4752 vs $4453; P = .591), same-cause 7-day readmission rate (0.8% vs 0.4%; P = .349), or emergency department revisit rates (0.1% vs 0.6%; P = .148). CONCLUSIONS: For children hospitalized with SSSS, lower use of diagnostic tests was not associated with changes in outcomes. Hospitals with high diagnostic test use may be able to reduce testing without adversely affecting patient outcomes.

Current Evidence on the Evaluation and Management of Fever Without a Source in Infants Aged 0-90 Days: A Review.

BACKGROUND: Despite development of risk stratification tools decades ago, the best strategy for evaluation and management of young infants with fever without a clear source remains uncertain. OBJECTIVE: To describe the variability in current practice and review recently published evidence in three key areas: inflammatory markers were used as a tool for risk stratification, impact of viral testing, and optimal observation time on antibiotics. METHOD: Articles were identified using PubMed, Scopus, and Cochrane databases and via experts. Abstracts were screened and potential articles underwent full review if they focused on febrile infants 0- 90 days with fever without a source and outcomes for key topics. RESULTS: Thirty-two articles were included. Recent studies show that variability exists for most aspects of evaluation and management. C reactive protein and procalcitonin (PCT) perform poorly for identification of serious bacterial infections (SBIs). However, PCT has good diagnostic accuracy for detection of invasive bacterial infections (IBIs), such as bacteremia and meningitis. When PCT is combined with urinalysis and clinical appearance in the Step-by-Step method, the sensitivity for detection of IBI is 92% for infants > 21 days of age. Infants with lab-confirmed viral infection were found to have reduced risk for SBI. Blood culture yield for true pathogens was the highest in the first 12-36 hours after incubation. CONCLUSION: Recent studies suggest viral testing and inflammatory markers (specifically PCT) can help better stratify young febrile infants at risk for IBIs. Infants who are deemed low risk may benefit from shorter observation times and tailored or discontinued antibiotic therapy.

Prevalence of Concomitant Acute Bacterial Meningitis in Neonates with Febrile Urinary Tract Infection: A Retrospective Cross-Sectional Study.

OBJECTIVE: To describe the frequency of concomitant acute bacterial meningitis (ABM) in neonates with febrile urinary tract infection (UTI). STUDY DESIGN: This was a retrospective cross-sectional study from 2005 to 2013 of infants ≤30 days old evaluated in the emergency department of a quaternary care children's hospital with fever and laboratory-confirmed UTI. Definite ABM was defined as cerebrospinal fluid (CSF) culture with growth of pathogenic bacteria and probable ABM if pleocytosis with ≥ 20 white blood cell was present in an antibiotic-pretreated patient. The timing of lumbar puncture and first antibiotic dose was recorded to assess for antibiotic pretreatment. RESULTS: A total of 236 neonates with UTI were included. Mean age was 18.6 days (SD 6.2); 79% were male infants. Twenty-three (9.7%) had bacteremia. Fourteen (6%) were pretreated. No neonate (0%; 95% CI 0%-1.6%) had definite ABM and 2 (0.8%; 95% CI 0.1%-3.0%) neonates with bloody CSF had probable ABM. CSF white blood cell count was 25 and 183 for these 2 infants, and CSF red blood cell count was 3100 and 61 932, respectively. Another neonate had herpes simplex virus meningoencephalitis. CONCLUSIONS: The frequency of ABM in neonates with febrile UTI is low. Further prospective studies are needed to evaluate the safety of a tiered approach to evaluate for serious bacterial infection, in which lumbar puncture potentially could be avoided in well-appearing febrile neonates with suspected UTI.

Impact of Enterovirus Testing on Resource Use in Febrile Young Infants: A Systematic Review.

CONTEXT: Enterovirus infection commonly causes fever in infants aged 0 to 90 days and, without testing, is difficult to differentiate from serious bacterial infection. OBJECTIVE: To determine the cost savings of routine enterovirus testing and identify subgroups of infants with greater potential impact from testing among infants 0 to 90 days old with fever. DATA SOURCES: Studies were identified systematically from published and unpublished literature by using Embase, Medline, the Cochrane database, and conference proceedings. STUDY SELECTION: Inclusion criteria were original studies, in any language, of enterovirus infection including the outcomes of interest in infants aged 0 to 90 days. DATA EXTRACTION: Standardized instruments were used to appraise each study. The evidence quality was evaluated using Grading of Recommendations Assessment, Development, and Evaluation criteria. Two investigators independently searched the literature, screened and critically appraised the studies, extracted the data, and applied the Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS: Of the 257 unique studies identified and screened, 32 were completely reviewed and 8 were included. Routine enterovirus testing was associated with reduced hospital length of stay and cost savings during peak enterovirus season. Cerebrospinal fluid pleocytosis was a poor predictor of enterovirus meningitis. The studies were all observational and the evidence was of low quality. CONCLUSIONS: Enterovirus polymerase chain reaction testing, independent of cerebrospinal fluid pleocytosis, can reduce length of stay and achieve cost savings, especially during times of high enterovirus prevalence. Additional study is needed to identify subgroups that may achieve greater cost savings from testing to additionally enhance the efficiency of testing.

An Examination of Physician-, Caregiver-, and Disease-Related Factors Associated With Readmission From a Pediatric Hospital Medicine Service.

OBJECTIVES: The purpose of this study was to describe the characteristics and reasons for pediatric hospital medicine readmissions. We also aimed to describe characteristics of potentially preventable cases and the reliability of classification. METHODS: Retrospective descriptive study from December 2008 through June 2010 in a large academic tertiary care children's hospital in Houston, Texas. Children were included if they were readmitted to the hospital within 30 days of discharge from the pediatric hospital medicine service. Reasons for readmission were grouped into three categories: physician-related, caretaker-related, and disease-related. Readmissions with physician- or caretaker-related reasons were considered potentially preventable. RESULTS: The overall readmission rate was 3.1%, and a total of 204 subjects were included in the analysis. Lymphadenitis and failure to thrive had the highest readmission rates with 21%, and 13%, respectively. Twenty percent (n=41/204) of readmissions were preventable with 24% (n=10/41) being physician-related, 12% (n=5/41) caregiver-related, and 63% (n=26/41) for mixed reasons. When comparing classification of readmissions into preventable status, there was moderate agreement between 2 reviewers (K=0.44, 95% confidence interval: 0.28-0.60). Among patients with preventable readmission, the probability of having had a readmission by 7 days and 15 days was 73% and 78%, respectively. CONCLUSIONS: Reliable identification of preventable pediatric readmissions using individual reviewers remains a challenge. Additional studies are needed to develop a reliable approach to identify preventable readmissions and underlying modifiable factors. A focused review of 7-day readmissions and diagnoses with high readmission rates may allow use of fewer resources.

Renal Ultrasound for Infants Younger Than 2 Months With a Febrile Urinary Tract Infection.

OBJECTIVE: The purpose of this study is to determine the performance of renal ultrasound for detecting vesicoureteral reflux (VUR) and obstructive uropathies in infants younger than 2 months with a febrile urinary tract infection (UTI). MATERIALS AND METHODS: We performed a retrospective cohort study of infants younger than 2 months with fever and culture-proven UTI presenting from July 1, 2008, through December 31, 2011, with renal ultrasound and voiding cystourethrogram (VCUG) performed within 30 days of UTI diagnosis. Two pediatric radiologists independently reviewed the renal ultrasound and VCUG findings. Results of the renal ultrasound were deemed abnormal if collecting system dilation, renal size asymmetry, collecting system duplication, urothelial thickening, ureteral dilation, or bladder anomalies were present. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of renal ultrasound were calculated using VCUG as reference standard. RESULTS: Of the 197 patients included (mean [SD] age, 33 [ 15 ] days; male-to-female ratio, 2:1), 25% (n = 49) had VUR grades I-V, with 16% (n = 31) having VUR grades III-V and 8% (n = 15) having VUR grades IV-V. For grades I-V VUR, sensitivity was 32.7% (95% CI, 20.0-47.5%), specificity was 69.6% (95% CI, 61.5-76.9%), PPV was 26.2% (95% CI, 15.8-39.1%), and NPV was 75.7% (95% CI, 67.6-82.7%). For grades III-V VUR, sensitivity was 51.6% (95% CI, 33.1-69.9%), specificity was 72.9% (95% CI, 65.5-79.5%), PPV was 26.2% (95% CI, 15.8-39.1%), and NPV was 89.0% (95% CI, 82.5-93.7%). For grades IV-V VUR, sensitivity was 86.7% (95% CI, 59.5-98.3%), specificity was 73.6% (95% CI, 66.6-79.9%), PPV was 21.3% (95% CI, 11.9-33.7%), and NPV was 98.5% (95% CI, 94.8-99.8%). No obstructive uropathies were diagnosed by VCUG in patients with normal renal ultrasound findings. CONCLUSION: In infants younger than 2 months, a normal renal ultrasound makes the presence of grades IV and V VUR highly unlikely but does not rule out lower grades of VUR.

Risk factors for complications in hospitalized young infants presenting with uncomplicated pertussis.

OBJECTIVE: We sought to identify risk factors for complications in hospitalized young infants with uncomplicated pertussis. METHODS: Retrospective cohort study of hospitalized infants 0 to 6 months of age with confirmed pertussis from 2005 to 2009. Subjects presenting without complications or need for initial intensive care admission were deemed to have uncomplicated pertussis. Complications during hospitalization were defined as apnea, pneumonia, seizures, or encephalopathy. Univariate analysis was performed by estimating odds ratios (OR) and 95% confidence intervals (CI) for the association between each variable and the occurrence of complications. Multivariable analysis was performed using logistic regression. Clinical variables included demographics, historical, laboratory, and imaging data. RESULTS: Of 126 study subjects, 46 (36.5%) developed complications in the hospital: 43 with apnea (two required endotracheal intubation), seven with pneumonia, and three with seizures; there were no cases of encephalopathy and no deaths. Age less than 60 days (OR, 2.71; 95% CI, 1.08-6.82), cough duration less than 7 days (OR, 5.38; 95% CI, 1.79-16.18), history of color change (OR, 5.24; 95% CI, 1.14-24.07), parental intervention (OR, 10.05; 95% CI, 1.67-60.39), and need for oxygen in the emergency department (OR. 3.94; 95% CI. 1.37-11.36) were associated with development of complications. The median duration of cough at the time of complication was 9 days (range 2-30 days). Initial complete blood cell count and radiographic findings were not associated with complications. CONCLUSIONS: Infants with uncomplicated pertussis may be at low risk for developing respiratory failure or death. Historical information may assist practitioners in determining risk for serious complications.