Internationally Acquired Severe Systemic Infections in Febrile Pediatric Travelers Presenting to the Emergency Department.

OBJECTIVES: Most children in the United States who visit the emergency department (ED) with fever have minor illnesses not requiring treatment or hospitalization. However, when a child has recently immigrated or traveled abroad, internationally acquired severe systemic infections (ISSIs) must be considered. We sought to describe children who have traveled internationally and present to the ED with a complaint of fever and to determine risk factors associated with ISSIs in these patients. METHODS: We conducted a retrospective study of children younger than 18 years who presented to 2 pediatric EDs in Bronx, NY (June 2007 to May 2017). Patients were included if they had both fever within 24 hours and international travel within 30 days. We compared groups using bivariate analyses and created a prediction model for ISSIs using multivariable logistic regression. RESULTS: Of the 353 children included, 44 (12%) had ISSI: 25 (57%), malaria; 6 (14%), dengue; and 13 (30%), bacteremia. Eight (18%) of those with ISSI presented with fever to another medical provider in the week prior but did not receive bloodwork. Four variables were independently associated with ISSIs: headache (odds ratio [OR], 21.7; 95% confidence interval [CI], 6.8-69.3), travel to Africa or Asia (OR, 18.8; 95% CI, 4.8-73.2), platelets of 150,000/µL or less (OR, 15.1; 95% CI, 4.7-48.6), and alanine aminotransferase level of 30 IU/L or greater (OR, 8.9; 95% CI, 3.1-25.3). CONCLUSIONS: Children who travel internationally and present with fever upon return are at substantial risk for developing ISSIs. The diagnosis of ISSIs is often overlooked, but certain risk factors have the potential to aid clinicians.

A survey of the management of febrile infants in pediatric emergency departments.

OBJECTIVE: To determine whether emergency departments (EDs) at pediatric emergency medicine (PEM) fellowship training institutions have a departmental policy regarding the evaluation and management of febrile infants and if reported policies are based on published guidelines (PGs). METHODS: A 32-item telephone survey was administered to PEM fellowship directors (FDs). Departmental demographics and criteria used to evaluate febrile infants were collected. Scenarios were presented regarding the evaluation and management of low-risk febrile infants. Reported consistency among ED attending physicians at the same institution was also assessed. RESULTS: The response rate was 83% (53 of 64). Fifty-one percent (26 of 53) of FDs reported the existence of a departmental policy regarding the evaluation of febrile infants. Of those who have a departmental policy, 19% (5 of 26) stated that it was one of the PGs. The FDs who reported the existence of a departmental policy were significantly more likely to report consistent management by all ED attending physicians in their department compared with those without a departmental policy (81% vs 19%, P < 0.05). The most frequent age and temperature cutoff for a mandatory sepsis evaluation were 28 days (45%, 28 of 53) and 100.4°F (66%, 35 of 53). The FDs reported a lack of consistency among ED attending physicians at the same institution regarding age and temperature (66% and 17% of the time, respectively). Eighty-five percent (45 of 53) of FDs reported that a new guideline is needed. CONCLUSIONS: Nearly one half of EDs at PEM fellowship training institutions are reported not to have a departmental policy regarding the management of febrile infants, and departmental policies rarely conform to any of the PGs. There is substantial interdepartmental and intradepartmental practice variability regarding the management of febrile infants and a strong consensus regarding the need for a new guideline.

Evaluating appendicitis scoring systems using a prospective pediatric cohort.

STUDY OBJECTIVE: This article evaluates the performance of the previously published Alvarado and Samuel appendicitis scoring systems in a prospectively identified pediatric cohort. METHODS: A prospective cohort of patients, aged 3 to 21 years, being evaluated for appendicitis was enrolled during 20 consecutive months at a large, urban, pediatric hospital. Study forms were completed by pediatric emergency medicine attending physicians before imaging or surgery. Final diagnosis was determined by pathology or follow-up telephone call. Each score was tested as proposed by the original authors. Sensitivity, specificity, and predictive values were calculated for all patients and prepubertal patients younger than 10 years. RESULTS: Five hundred eighty-eight patients were studied. The median age was 11.9 years (interquartile range [IQR] 8.5; 14.9 years). Thirty-four percent of patients had appendicitis. An Alvarado score greater than or equal to 7 yielded a sensitivity of 72% (95% confidence interval [CI] 66% to 78%), specificity 81% (76% to 84%), negative predictive value (NPV) 85% (81% to 89%), and positive predictive value (PPV) 65% (59% to 72%). A Samuel score greater than or equal to 6 yielded a sensitivity of 82% (77% to 87%), specificity 65% (60% to 70%), NPV 88% (84% to 91%), and PPV 54% (48% to 60%). When analysis was limited to patients younger than 10 years, n=206, an Alvarado score greater than or equal to 7 yielded a sensitivity of 73% (62% to 84%), specificity 80% (73% to 86%), NPV 89% (83% to 94%), and PPV 58% (45% to 69%). A Samuel score greater than or equal to 6, when patients younger than 10 years were considered, yielded a sensitivity of 77% (66% to 87%), specificity 65% (56% to 72%), NPV 88% (82% to 94%), and PPV 45% (35% to 55%). Receiver operator characteristic curves had an area under the curve of 0.83 (95% CI 0.79 to 0.86) (Alvarado) and 0.81 (95% CI 0.78 to 0.85) (Samuel). CONCLUSION: Although the Alvarado and Samuel scores provide measurably useful diagnostic information in evaluating children with suspected appendicitis, neither method provides sufficient PPV to be used in clinical practice as the sole method for determination of the need for surgery.