Risk Of Serious Bacterial Infection Research Articles

Risk of serious bacterial infections in pediatric patients with hyperpyrexia.

Hyperpyrexia has been associated with a greater prevalence of bacterial infections in the pediatric population, which prior to routine childhood vaccinations, has led to invasive testing and empiric antibiotic use for urinary tract infections, bacterial pneumonia, bacteremia, and bacterial meningitis. Since the implementation of routine childhood vaccinations, the prevalence of serious bacterial infections (SBIs) has declined. This study aims to determine if there is an association between hyperpyrexia and serious bacterial infections in well-appearing febrile pediatric patients presenting to the emergency department (ED). This is a cross-sectional study conducted between January 1, 2019, and December 31, 2019, at a single urban tertiary care pediatric ED. Patients were included if they were between 61 days and ≤18 years old presenting with a chief complaint of fever. Patients were excluded if they received antibiotics within 3 days of presentation, underwent surgical procedures within 2weeks of presentation, had an ED visit for febrile illness within 2weeks of study visit, were transferred from another institution, or were ill appearing. Prevalence of SBI was described and compared by presence of hyperpyrexia, age group, chronic medical condition, gender, and vaccination status. Logistic regression was used to analyze the association between SBIs and hyperpyrexia. Of the 3862 charts reviewed, 2565 patients were included. The prevalence of SBI was 5.6%. A total of 413 patients presented with hyperpyrexia. Of the patients with hyperpyrexia, 31 (7.5%) had a serious bacterial infection. Hyperpyrexia was not significantly associated with SBIs in our logistic regression models (adjusted Odds Ratio 1.40, 95% confidence interval 0.92-2.12). Serious bacterial infections were uncommon in our population. There is no statistically significant association between hyperpyrexia and SBIs in well-appearing pediatric patients presenting to the ED with fever. The lack of a statistically significant association between hyperpyrexia and SBIs argues that clinicians should be cautious using hyperpyrexia as an independent risk factor for SBIs. More research is needed to identify independent and grouped SBI risk factors in well-appearing pediatric patients presenting to the ED.

Correlation between locally versus centrally processed serum procalcitonin during emergency department research evaluation of febrile infants aged 0–60 days

IntroductionProcalcitonin (PCT) is a useful biomarker in the initial evaluation of febrile infants for serious bacterial infections (SBIs). However, PCT is not always available locally and must at times be frozen and shipped to a reference laboratory for research studies. We sought to compare PCT measured locally versus centrally at a reference laboratory during a research study. Materials and methodsThis was a secondary analysis of a multicenter study of febrile infants ≤60 days evaluated for SBIs from June 2016 to April 2019. A PCT cutoff value of 0.5 ng/mL was used to stratify infants at low-versus high-risk of SBIs. Statistical analyses consisted of Spearman's correlation, Bland-Altman difference plotting, Passing-Bablok regression, Deming regression, and Fisher's exact testing at the 0.5 ng/mL threshold. Results241 febrile infants had PCT levels measured both locally and at the reference laboratory. PCT levels measured locally on 5 different platforms and from the frozen research samples demonstrated strong Spearman's correlation (ρ = 0.83) and had similar mean PCT values with an average relative difference of 0.02%. Eleven infants with SBIs had PCT values < 0.5 ng/mL in both the clinical and research samples. Six other infants had differences in SBI prediction based on PCT values at the 0.5 ng/mL threshold between the clinical and research platforms. ConclusionsWe found no significant differences in detection of febrile infants at high risk for SBI based on locally (on multiple platforms) versus centrally processed PCT. Testing at a central reference laboratory after freezing and shipping is an accurate and reliable alternative for research studies or when rapid turnaround is not required.

Serious bacterial infection risk in recently immunized febrile infants in the emergency department

Study objectivesFever following immunizations is a common presenting chiefcomplaint among infants. The 2021 American Academy of Pediatrics (AAP) febrile infant clinical practice guidelines exclude recently immunized (RI) infants. This is a challenge for clinicians in the management of the febrile RI young infant. The objective of this study was to assess the prevalence of SBI in RI febrile young infants between 6 and 12 weeks of age. MethodsThis was a retrospective chart review of infants 6–12 weeks who presented with a fever ≥38 °C to two U.S. military academic Emergency Departments over a four-year period. Infants were considered recently immunized (RI) if they had received immunizations in the preceding 72 h prior to evaluation and not recently immunized (NRI) if they had not received immunizations during this time period. The primary outcome was prevalence of serious bacterial infection (SBI) further delineated into invasive-bacterial infection (IBI) and non-invasive bacterial infection (non-IBI) based on culture and/or radiograph reports. ResultsOf the 508 febrile infants identified, 114 had received recent immunizations in the preceding 72 h. The overall prevalence of SBI was 11.4% (95% CI = 8.9–14.6) in our study population. The prevalence of SBI in NRI infants was 13.7% (95% CI = 10.6–17.6) compared to 3.5% (95% CI = 1.1–9.3) in RI infants. The relative risk of SBI in the setting of recent immunizations was 0.3 (95% CI = 0.1–0.7). There were no cases of invasive-bacterial infections (IBI) in the RI group with all but one of the SBI being urinary tract infections (UTI). The single non-UTI was a case of pneumonia in an infant who presented with respiratory symptoms within 24 h of immunizations. ConclusionThe risk of IBI (meningitis or bacteremia) in RI infants aged 6 to 12 weeks is low. Non-IBI within the first 24 h following immunization was significantly lower than in febrile NRI infants. UTIs remain a risk in the RI population and investigation with urinalysis and urine culture should be encouraged. Shared decision making with families guide a less invasive approach to the care of these children. Future research utilizing a large prospective multi-center data registry would aid in further defining the risk of both IBI and non-IBI among RI infants.

Do Children Less Than 3 Years with Sickle Cell Disease Need to be Routinely Admitted with Fever?

Background Due to functional asplenia, patients with sickle cell disease (SCD) are at increased risk of serious bacterial infection (SBI) with encapsulated organisms. With the advent of prophylactic penicillin, Haemophilus and Pneumococcal vaccination, this risk has decreased, though recommendations for admission in young children are not standardized and based on institutional practice. Historically, our standard at Benioff Children Hospital Oakland (CHO) has been to admit all children with SCD &amp;lt; 3 years with fever due to these historical concerns. We hypothesized that in a well appearing febrile cohort, the risk of complication would be very low (i.e., &amp;lt;3-5%), allowing liberalization of this stringent recommendation. Methods After IRB approval, we conducted a retrospective review of electronic medical records of children with SCD &amp;lt;3 years of age admitted with fever (i.e., ≥38.3ºC) from October 1 st, 2013 to May 30 th 2022 at CHO. We excluded patients who presented with fever and other complications in the emergency department (ED) that would have otherwise required admission including: 1) splenic sequestration; 2) acute chest syndrome (ACS); 3) hypoxia and/or respiratory distress; 4) vaso-occlusive crisis (VOC); 5) hemoglobin (Hb) drop ≥2 g/dL from baseline; 6) severe dehydration; 7) seizures or other neurological concerns; 8) complicated/complex medical history; 9) SARS-CoV-2 infection; 10) age &amp;lt;2 months; 11) soft tissue infection; and 12) UA concerning for infection. Results Sixty-four unique patients with 127 encounters were included with baseline features outlined in Table 1. Ninety-seven encounters were excluded due to presenting signs/symptoms. Rate of bacteremia was 1.6% (2 of 127). Twenty-six of the 127 encounters (20%, 21 unique patients) were deemed complicated, due to: 1) bacteremia (n=2); 2) splenic sequestration (n=6); 3) acute chest syndrome (n=1); 4) worsening anemia requiring transfusion (n=11); 5) pain crisis (n=1); 6) persistent fever (n=4) and 7) norovirus gastroenteritis (n=1). Eighty-five percent were in children 2 years or less. Complicated admissions were statistically longer and had lower hemoglobin and platelets at presentation than uncomplicated admissions (Table 2). There was no difference in age, white blood cell count (WBC) and maximum fever during presentation in the ED (Table 2). Fourteen of 26 complications (54%) occurred in the first two days of admission and the rest thereafter. Conclusions Although the rate of bacteremia was low as expected in children with SCD &amp;lt;3 years of age presenting to the ED with fever and without concerning presenting features, the overall rate of complications during admission for those encounters was much higher than our acceptable a priori threshold. Retrospectively, there were no easily discernible presenting features in this otherwise well-appearing cohort to determine need for admission. Complications often occurred beyond day 2 of admission. The majority of complications occurred in children ≤2 years of age; we therefore will continue to admit all children with SCD and fever ≤ 2 years of age with a low threshold for ongoing admission beyond the 48 hour rule out. Institutional standards must closely monitor for increased adverse events if utilizing more lenient ED discharge criteria in this population.

99. Predictive model for serious bacterial infections in infants less than 90 days of age based on clinical data and a combination of high-threshold inflammatory biomarkers

Abstract Background Serious bacterial infection (SBI) is a life-threatening condition affecting infants less than 90 days of age, and prompt differentiation from non-bacterial infection (NBI) is crucial. Recent guidelines recommend a combination of low-threshold inflammatory biomarkers that need further validation. The aim of this study is to develop predictive models for SBI in infants &amp;lt; 29 days and in infants aged 29-90 days. The study uses detailed clinical data and inflammatory biomarkers with high thresholds. Methods This retrospective cohort study was conducted between 2010 and 2019 in a tertiary referral hospital in northern Israel. The study included previously healthy and term infants &amp;lt; 90 days of age who were admitted to the pediatric units of the hospital with febrile illnesses. SBI was defined as bacteremia, meningitis, or urinary tract infection, while NBI was defined as absence of signs of bacterial infection. Detailed clinical and laboratory data were collected for each of the two age groups. Chart flow of infants included in the study a Serious bacterial infection, b Non-bacterial infection, c Urinary tract infection, d Respiratory viruses including Respiratory Syncytial Virus, Adenovirus, Influenza A, Influenza B, Parainfluenza, Human Metapneumovirus. Abbreviations: EBV Epstein bar virus, CMV- Cytomegalovirus Results A total of 1250 infants met the inclusion criteria, of whom 515 (41.2%) were &amp;lt; 29 days old and 735 (58.8%) were between 29 and 89 days old. In the younger group, 95 (18.4%) had SBI. Risk factors for SBI were diarrhea, absolute neutrophil count (ANC) &amp;gt; 7,500mm3 and CRP &amp;gt; 3mg/dL. Viral symptoms in family members proved to be protective. In the older group, 111 (15.1%) had SBI. Risk factors for SBI were ANC &amp;gt; 7,500mm3 and CRP &amp;gt; 3mg/dL, while male sex, viral symptoms in family members and diarrhea were protective. The study developed a predictive model, the "NeoSBIscore", based on the above predictors, focal infection on physical examination or abnormal urinalysis. The model showed a sensitivity of 94.7% and a negative predictive value (NPV) of 96.9% in infants younger than 29 days and a sensitivity of 93.7% and a NPV of 96.2% in the older group. Only cases with urinary tract infections or bacteriuria were missed in both age groups. "NeoSBIscore" model to identify infants admitted with febrile illness and at increased risk for serious bacterial infection. Conclusion The "NeoSBIscore" model successfully identified infants with SBI, and the use of higher-threshold inflammatory biomarkers did not result in missed cases of SBI, with the exception of a few cases with UTI or bacteriuria. However, external validation is required before this model can be used in clinical practice. Disclosures All Authors: No reported disclosures

Bacterial coinfection in young febrile infants with SARS-CoV-2 infection.

We aimed to assess the prevalence of serious bacterial infections (SBIs) in febrile infants < 90days of age with SARS-CoV-2 infection versus SARS-CoV-2-negative febrile infants.A retrospective cohort study was conducted in a tertiary pediatric emergency department between March 2020 and October 2022. Febrile infants < 90days of age who underwent SARS-CoV-2 testing were included. SBIs were defined as urinary tract infection (UTI), bacteremia, and/or bacterial meningitis; bacteremia and bacterial meningitis were considered invasive bacterial infections (IBIs). SBIs rates were compared between SARS-CoV-2-positive and negative infants and stratified by age.We included 779 infants: 221 (28.4%) SARS-CoV-2-positive and 558 (71.6%) SARS-CoV-2-negative. The SBI rate in the SARS-CoV-2-positive group was 5.9% vs 22.9% in the SARS-CoV-2-negative group (p < 0.001; relative risk (RR) 0.26; [95% CI 0.15-0.44]); the most common infections were UTI (5.4% vs 22.0%; p < 0.001). The IBI rate was 0.5% in the SARS-CoV-2-positive group vs. 3.2% in the negative group (p = 0.024; RR 0.14 [95% CI 0.02-1.04]). There were no cases of bacterial meningitis in the positive infants. SARS-CoV-2-positive infants > 28days of age had a decreased likelihood of SBI (RR 0.22 [95% CI 0.11-0.43]), with no cases of IBI identified. Conclusions: Febrile infants < 90days of age with SARS-CoV-2 infection are at significantly lower risk of SBIs than those who are SARS-CoV-2-negative. Nevertheless, the rate of UTI remains considerable in SARS-CoV-2-positive infants. SARS-CoV-2 detection may be relevant in considering IBI risk for well-appearing febrile infants 29-89days of age. What is Known: • Febrile infants with laboratory-confirmed viral infections have a significantly lower risk of serious bacterial infections when compared to those without them. Data focusing on very young febrile infants with a SARS-CoV-2 infection is still limited. What is New: • Young febrile infants with SARS-CoV-2 infection are at significantly lower risk of serious bacterial infections than those who are SARS-CoV-2-negative. Nevertheless, the rate of urinary tract infection remains considerable. SARS-CoV-2 detection may be relevant in considering invasive bacterial infection risk for well-appearing febrile infants 29-89days of age.

167 Risk of Serious Bacterial Infections in Febrile Infants Aged 7-90 Days With COVID-19

167 Risk of Serious Bacterial Infections in Febrile Infants Aged 7-90 Days With COVID-19

Febrile infants risk score at triage (FIRST) for the early identification of serious bacterial infections

We aimed to derive the Febrile Infants Risk Score at Triage (FIRST) to quantify risk for serious bacterial infections (SBIs), defined as bacteremia, meningitis and urinary tract infections. We performed a prospective observational study on febrile infants < 3 months old at a tertiary hospital in Singapore between 2018 and 2021. We utilized machine learning and logistic regression to derive 2 models: FIRST, based on patient demographics, vital signs and history, and FIRST + , adding laboratory results to the same variables. SBIs were diagnosed in 224/1002 (22.4%) infants. Among 994 children with complete data, age (adjusted odds ratio [aOR] 1.01 95%CI 1.01–1.02, p < 0.001), high temperature (aOR 2.22 95%CI 1.69–2.91, p < 0.001), male sex (aOR 2.62 95%CI 1.86–3.70, p < 0.001) and fever of ≥ 2 days (aOR 1.79 95%CI 1.18–2.74, p = 0.007) were independently associated with SBIs. For FIRST + , abnormal urine leukocyte esterase (aOR 16.46 95%CI 10.00–27.11, p < 0.001) and procalcitonin (aOR 1.05 95%CI 1.01–1.09, p = 0.009) were further identified. A FIRST + threshold of ≥ 15% predicted risk had a sensitivity of 81.8% (95%CI 70.5–91.0%) and specificity of 65.6% (95%CI 57.8–72.7%). In the testing dataset, FIRST + had an area under receiver operating characteristic curve of 0.87 (95%CI 0.81–0.94). These scores can potentially guide triage and prioritization of febrile infants.

FeBRILe3: Safety Evaluation of Febrile Infant Guidelines Through Prospective Bayesian Monitoring.

Despite evidence supporting earlier discharge of well-appearing febrile infants at low risk of serious bacterial infection (SBI), admissions for ≥48 hours remain common. Prospective safety monitoring may support broader guideline implementation. A sequential Bayesian safety monitoring framework was used to evaluate a new hospital guideline recommending early discharge of low-risk infants. Hospital readmissions within 7 days of discharge were regularly assessed against safety thresholds, derived from historic rates and expert opinion, and specified a priori (8 per 100 infants). Infants aged under 3 months admitted to 2 Western Australian metropolitan hospitals for management of fever without source were enrolled (August 2019-December 2021), to a prespecified maximum 500 enrolments. Readmission rates remained below the prespecified threshold at all scheduled analyses. Median corrected age was 34 days, and 14% met low-risk criteria (n = 71). SBI was diagnosed in 159 infants (32%), including urinary tract infection (n = 140) and bacteraemia (n = 18). Discharge occurred before 48 hours for 192 infants (38%), including 52% deemed low-risk. At study completion, 1 of 37 low-risk infants discharged before 48 hours had been readmitted (3%), for issues unrelated to SBI diagnosis. In total, 20 readmissions were identified (4 per 100 infants; 95% credible interval 3, 6), with >0.99 posterior probability of being below the prespecified noninferiority threshold, indicating acceptable safety. A Bayesian monitoring approach supported safe early discharge for many infants, without increased risk of readmission. This framework may be used to embed safety evaluations within future guideline implementation programs to further reduce low-value care.

The Impact of Respiratory Symptoms on the Risk of Serious Bacterial Infection in Febrile Infants < 60 Days Old.

We aimed to evaluate the impact of respiratory symptoms and positive viral testing on the risk of serious bacterial infections (SBIs). A retrospective study was conducted that included infants (0-60 days) presenting with a fever between 2001 and 2022 at a tertiary hospital in northern Israel. Demographic, clinical, and laboratory parameters were collected, and risk factors for SBIs were analyzed. Data from a total of 3106 infants, including data from blood, urine, and CSF cultures, were obtained in 96.6%, 89%, and 29% of cases, respectively. A fever without respiratory symptoms (fever only) was present in 1312 infants, while 1794 had a fever and respiratory symptoms-427 were positive for a respiratory virus (virus+), 759 tested negative (virus-), and 608 were not tested. The SBI rate was 5.1% vs. 7.5% in the fever-and-respiratory group vs. the fever-only group (p = 0.004, OR = 0.65 (95% CI = 0.49-0.88)) and 2.8% vs. 7% in the virus+ vs. virus- group (p = 0.002, OR = 0.385, (95% CI = 0.203-0.728)). The male gender, an age < 1 month, leukocytosis > 15 × 109/L, or a CRP > 2 mg/dL increased the risk of SBIs. Respiratory symptoms or a confirmed viral infection reduced the risk of SBIs in the presence of the above risk factors. Respiratory symptoms and a positive viral test decreased the risk of SBIs. Combining rapid viral testing with clinical variables may identify low-risk infants. Despite the relatively low risk of SBIs in individuals with viral infections, conducting prospective studies remains essential for accurately predicting the occurrence of these potentially life-threatening infections.

Serious Bacterial Infections in Preterm Infants: Should Their Age Be "Corrected"?

Adjusting the chronological age of preterm infants according to their gestational age is a widely accepted practice in the field of neurodevelopment. It has been suggested for the assessment of preterm infants with suspected infection, but has been poorly validated. Correcting for chronological age is especially critical in infants with a chronological age above 3 months, but a corrected age below 3 months due to the differences in assessment protocols. This study assessed the difference in incidence of serious bacterial infection (SBI) according to chronological and corrected age in preterm infants. A retrospective analysis of pediatric emergency department (PED) presentations was conducted for all 448 preterm infants born in between January 2010 and August 2019. Of the 448 preterm infants, 204 (46%) presented at one of 3 PEDs in Jerusalem, Israel, during their first year of life. Overall, 141 (31.4%) presented with fever and were included in the study. The infants were divided into 3 age groups: 1-corrected age >3 months; 2-chronological age >3 months, but corrected age <3 months; 3-chronological and corrected age <3 months. SBI was diagnosed in 2.6%, 16.7%, and 33.3% of the infants in groups 1, 2 and 3, respectively; (p < 0.01, p = 0.17, p < 0.001). The incidence of SBI in the control group of 300 term infants <3 months presenting to the PED due to fever was 15.3%. Preterm infants with a corrected age <3 months are at increased risk for SBI, similarly to term infants <3 months of age. Age correction should thus be considered for preterm infants presenting with fever.

Are children with prolonged fever at a higher risk for serious illness? A prospective observational study

ObjectivesTo describe the characteristics and clinical outcomes of children with fever ≥5 days presenting to emergency departments (EDs).DesignProspective observational study.Setting12 European EDs.PatientsConsecutive febrile children <18 years between January 2017 and...

Severe Acute Respiratory Syndrome Coronavirus 2 in Infants Younger Than 90 Days Presenting to the Pediatric Emergency Department: Clinical Characteristics and Risk of Serious Bacterial Infection.

There are scant data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in infants younger than 90 days. This study was designed to characterize COVID-19 presentation and clinical course in this age group and evaluate the risk of serious bacterial infection. Data on all SARS-CoV-2-polymerase chain reaction-positive infants presenting to the pediatric emergency department (PED) were retrospectively collected, followed by a case-control study comparing those infants presenting with fever (COVID group) to febrile infants presenting to the PED and found to be SARS-CoV-2 negative (control group). Of the 96 PCR-positive SARS-CoV-2 infants who met the inclusion criteria, the most common presenting symptom was fever (74/96, 77.1%) followed by upper respiratory tract infection symptoms (42/96, 43.8%). Four (4.2%) presented with symptoms consistent with brief resolved unexplained event (4.2%).Among the febrile infants, the presenting symptoms and vital signs were similar in the COVID and control groups, with the exception of irritability, which was more common in the control group (8% and 26%; P < 0.01). The SARS-CoV-2-positive infants had decreased inflammatory markers including: C-reactive protein (0.6 ± 1 mg/dL vs 2.1 ± 2.7 mg/dL; P < 0.0001), white blood cell count (9.3 ± 3.4 × 10 9 /L vs 11.8 ± 5.1 × 10 9 /L; P < 0.001), and absolute neutrophils count (3.4 ± 2.4 × 10 9 /L vs 5.1 ± 3.7 × 10 9 /L; P < 0.001). The rate of invasive bacterial infection was similar between groups (1.4% and 0%; P = 0.31). No mortality was recorded. Although not significantly different, urinary tract infections were less common in the COVID group (7% and 16%; P = 0.07). The SARS-CoV-2 infection in infants aged 0 to 90 days who present to the PED seems to be mostly mild and self-limiting, with no increased risk of serious bacterial infection.

Heart rate and respiratory rate in predicting risk of serious bacterial infection in febrile children given antipyretics: prospective observational study

Clinical algorithms used in the assessment of febrile children in the Paediatric Emergency Departments are commonly based on threshold values for vital signs, which in children with fever are often outside the normal range. Our aim was to assess the diagnostic value of heart and respiratory rate for serious bacterial infection (SBI) in children after temperature lowering following administration of antipyretics. A prospective cohort of children presenting with fever between June 2014 and March 2015 at the Paediatric Emergency Department of a large teaching hospital in London, UK, was performed. Seven hundred forty children aged 1 month–16 years presenting with a fever and ≥ 1 warning signs of SBI given antipyretics were included. Tachycardia or tachypnoea were defined by different threshold values: (a) APLS threshold values, (b) age-specific and temperature-adjusted centiles charts and (c) relative difference in z-score. SBI was defined by a composite reference standard (cultures from a sterile site, microbiology and virology results, radiological abnormalities, expert panel). Persistent tachypnoea after body temperature lowering was an important predictor of SBI (OR 1.92, 95% CI 1.15, 3.30). This effect was only observed for pneumonia but not other SBIs. Threshold values for tachypnoea > 97th centile at repeat measurement achieved high specificity (0.95 (0.93, 0.96)) and positive likelihood ratios (LR + 3.25 (1.73, 6.11)) and may be useful for ruling in SBI, specifically pneumonia. Persistent tachycardia was not an independent predictor of SBI and had limited value as a diagnostic test. Conclusion: Among children given antipyretics, tachypnoea at repeat measurement had some value in predicting SBI and was useful to rule in pneumonia. The diagnostic value of tachycardia was poor. Overreliance on heart rate as a diagnostic feature following body temperature lowering may not be justified to facilitate safe discharge.What is Known:• Abnormal vital signs at triage have limited value as a diagnostic test to identify children with SBI, and fever alters the specificity of commonly used threshold values for vital signs.• The observed temperature response after antipyretics is not a clinically useful indicator to differentiate the cause of febrile illness.What is New:• Persistent tachycardia following reduction in body temperature was not associated with an increased risk of SBI and of poor value as a diagnostic test, whilst persistent tachypnoea may indicate the presence of pneumonia.

Impact on Emergency Department Interventions After Implementing a Guideline Based on the Pediatric Emergency Care Applied Research Network Prediction Rule for Identifying Low-Risk Febrile Infants 29 to 60 Days Old.

The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule identifies febrile infants at low risk for serious bacterial infection (SBI). However, its impact on avoidable interventions in the emergency department remains unknown. To study the impact on lumbar puncture (LP) performance, empiric antibiotic use, and admissions after implementing a febrile infant clinical practice guideline for infants aged 29 to 60 days based on the PECARN prediction rule in the pediatric emergency department. This single center preintervention to postintervention study included infants 29 to 60 days old who presented with a chief complaint of fever from November 2018 to November 2021 and were assessed for SBI via blood culture and either urinalysis or urine culture. A new clinical practice guideline based on the PECARN prediction rule was implemented on December 2019. Lumbar puncture attempts, antibiotic administration, and admissions were compared preimplementation and postimplementation and in subgroups of low- and high-risk patients. Of 1597 (PRE: 785, POST: 812) infants presenting with fever, 1032 (PRE: 500, POST: 532) met inclusion criteria. Adoption of guideline recommendations (measured as procalcitonin order rate) was 89.7% in eligible infants postimplementation. Overall, there was a significant decrease in LPs (PRE: 30.6%, POST: 22.6%, P < 0.05) and no significant change in antibiotics or admissions. Among low-risk infants, there was a significant reduction in LPs (PRE: 17.2%, POST: 4.4%, P < 0.05) and antibiotics (PRE: 14.5%, POST: 4.1%; P < 0.05). There was no change in missed SBI (PRE: 3, POST: 2, P = 0.65). No cases of missed meningitis preimplementation or postimplementation were observed. After implementation of a guideline based on the PECARN prediction rule, we observed a reduction of LPs and antibiotics in low-risk infants. Overall, a decrease in LPs was observed, whereas antibiotic use and admissions remained unchanged.

The evolving relationship between COVID-19 and serious bacterial infection evaluation in febrile neonates.

The COVID-19 omicron variant surge highlighted the evolving impact of COVID-19. Febrile infants <60 days old are high risk for serious bacterial infections (SBI). This study evaluated the rate of SBI based on COVID-19 infection. We conducted a retrospective chart review at an urban, academic paediatric emergency department. The study enrolled infants 60 days old or less with documented fever. The primary outcome was SBI diagnosed by blood, urine, and/or cerebrospinal fluid cultures. We compared the rate of SBI between COVID-19 groups with an omicron variant and 29- to 60-day-old subgroup analyses. Two hundred and thirty-three (233) infants meet the criteria. The incidence of SBI was 18.7% in the COVID-19 negative and 1.7% in the COVID-19-positive group which is statistically significant (p < 0.001). Omicron subgroup analysis did not achieve statistical significance (p=0.62) while COVID-19-positive infants 29-60 days old had a statistically significant lower rate of SBI (p=0.006). The omicron variant surge provided an additional understanding of the impact of COVID-19 on these high-risk infants. These results can lead to decreased invasive testing and exposure to antibiotics as well as examine the utility of viral testing for risk stratification.

Temperature threshold in the screening of bacterial infections in young infants with hypothermia

BackgroundYoung infants with hypothermia presenting to the emergency department (ED) are at risk for serious bacterial infections (SBI), however there is no consensus temperature to prompt evaluation for SBI among...

A nomogram for predicting the development of serious bacterial infections in febrile term neonates: A single medical center experience in Southern Taiwan.

Serious bacterial infections (SBIs) could lead to mortality or severe long-term sequelae in neonates and infants aged <3 months. Accordingly, the aim of this study was to develop a quantitative and accurate assessment tool for predicting the risk of SBIs in febrile neonates. This retrospective study enrolled 131 febrile term neonates (aged <30 days) who were hospitalized at Kaohsiung Veterans General Hospital between January 2005 and December 2020. These neonates were classified into SBI and nonbacterial infection (NBI) groups on the basis of microbiological laboratory reports. The clinical characteristics and routine blood tests of both groups at the time of admission were analyzed. Stepwise logistic regression was applied to create and validate the nomogram for SBI prediction. Among the 131 febrile neonates, 38 and 93 developed SBIs and NBIs, respectively. At the time of admission, ill clinical appearance, serum myelocyte/metamyelocyte presence, C-reactive protein (CRP) > 2.5 mg/dL, and pyuria were associated with an increased risk of SBIs. Accordingly, these four factors were used to develop a nomogram for SBI prediction, which exhibited significantly high performance (area under curve = 0.848, p < 0.001) in predicting SBI risk. We developed a nomogram combining clinical appearance, serum myelocyte/metamyelocyte presence, CRP, and pyuria for predicting SBI risk in febrile neonates. This tool can assist clinicians in making early diagnoses and delivering the appropriate treatment.

Febrile illness in high-risk children: a prospective, international observational study

To assess and describe the aetiology and management of febrile illness in children with primary or acquired immunodeficiency at high risk of serious bacterial infection, as seen in emergency departments in tertiary hospitals. Prospective data on demographics, presenting features, investigations, microbiology, management, and outcome of patients within the ‘Biomarker Validation in HR patients’ database in PERFORM, were analysed. Immunocompromised children (< 18 years old) presented to fifteen European hospitals in nine countries, and one Gambian hospital, with fever or suspected infection and clinical indication for blood investigations. Febrile episodes were assigned clinical phenotypes using the validated PERFORM algorithm. Logistic regression was used to assess the effect size of predictive features of proven/presumed bacterial or viral infection. A total of 599 episodes in 482 children were analysed. Seventy-eight episodes (13.0%) were definite bacterial, 67 episodes probable bacterial (11.2%), and 29 bacterial syndrome (4.8%). Fifty-five were definite viral (9.2%), 49 probable viral (8.2%), and 23 viral syndrome (3.8%). One hundred ninety were unknown bacterial or viral infections (31.7%), and 108 had inflammatory or other non-infectious causes of fever (18.1%). Predictive features of proven/presumed bacterial infection were ill appearance (OR 3.1 (95% CI 2.1–4.6)) and HIV (OR 10.4 (95% CI 2.0–54.4)). Ill appearance reduced the odds of having a proven/presumed viral infection (OR 0.5 (95% CI 0.3–0.9)). A total of 82.1% had new empirical antibiotics started on admission (N = 492); 94.3% proven/presumed bacterial (N = 164), 66.1% proven/presumed viral (N = 84), and 93.2% unknown bacterial or viral infections (N = 177). Mortality was 1.9% (N = 11) and 87.1% made full recovery (N = 522). Conclusion: The aetiology of febrile illness in immunocompromised children is diverse. In one-third of cases, no cause for the fever will be identified. Justification for standard intravenous antibiotic treatment for every febrile immunocompromised child is debatable, yet effective. Better clinical decision-making tools and new biomarkers are needed for this population.What is Known:• Immunosuppressed children are at high risk for morbidity and mortality of serious bacterial and viral infection, but often present with fever as only clinical symptom.• Current diagnostic measures in this group are not specific to rule out bacterial infection, and positivity rates of microbiological cultures are low.What is New:• Febrile illness and infectious complications remain a significant cause of mortality and morbidity in HR children, yet management is effective.• The aetiology of febrile illness in immunocompromised children is diverse, and development of pathways for early discharge or cessation of intravenous antibiotics is debatable, and requires better clinical decision-making tools and biomarkers.

The risk of serious bacterial infections among young ex-premature infants with fever.

Background and ObjectivesTo determine the rate of serious-bacterial-infections (SBI) in young ex-premature infants with fever, and to develop a risk-stratification algorithm for these patients.MethodsA retrospective cohort study including all infants who presented to the pediatric emergency department (ED) of a tertiary-care university-hospital between 2010 and 2020 with fever (≥38°C), were born prematurely (<37-weeks), had post-conception age of <52-weeks, and had available blood, urine, or CSF cultures. The rates of SBI by age-of-birth and age-at-visit were calculated and compared to a cohort of matched full-term controls.ResultsThe study included a total of 290 ex-premature cases and 290 full-term controls. There were 11 cases (3.8%) with an invasive bacterial infection (IBI) of either bacteremia, meningitis or both and only six controls (2.1%) with IBI (p = 0.32). Over 28-days chronologic-age, there were 10 (3.6%) IBIs among cases and no IBIs among the controls (p = 0.02). There were eight (3%) cases and three (1%) controls with IBI who were well-appearing on physical examination (p = 0.19). All eight well-appearing ex-premature infants were under 60-days adjusted-age, seven of whom (88%) were also under 28-days adjusted-age. There were 28 (10.6%) cases and 34 (12%) controls with urinary tract infection (UTI) (p = 0.5). Among cases under 60-days adjusted-age, urinalysis was not reliable to exclude UTI (50% negative).ConclusionsWell-appearing ex-preterm infants have a significant risk for IBI until the adjusted age of 28-days and for UTI until the adjusted age of 60-days. Further studies are needed to evaluate the approach to fever in this unique population.