First name
Paul
Middle name
L
Last name
Aronson

Title

The Champagne Tap: Time to Pop the Cork?

Year of Publication

2020

Number of Pages

1194-1198

Date Published

2020 11

ISSN Number

1553-2712

Abstract

<p><strong>BACKGROUND: </strong>A "champagne tap" is a lumbar puncture with no cerebrospinal fluid (CSF) red blood cells (RBCs). Clinicians disagree whether the absence of CSF white blood cells (WBCs) is also required.</p>

<p><strong>AIMS: </strong>As supervising providers frequently reward trainees after a champagne tap, we investigated how varying the definition impacted the frequency of trainee accolades.</p>

<p><strong>MATERIALS &amp; METHODS: </strong>We performed a secondary analysis of a retrospective cross-sectional study of infants ≤60&nbsp;days of age who had a CSF culture performed in the emergency department (ED) at one of 20 centers participating in a Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) endorsed study. Our primary outcomes were a champagne tap defined by either a CSF RBC count of 0&nbsp;cells/mm regardless of CSF WBC count or both CSF RBC and WBC counts of 0&nbsp;cells/mm .</p>

<p><strong>RESULTS: </strong>Of the 23,618 eligible encounters, 20,358 (86.2%) had both a CSF RBC and WBC count obtained. Overall, 3,147 (13.3%) had a CSF RBC count of 0&nbsp;cells/mm and 377 (1.6%) had both CSF WBC and RBC counts of 0&nbsp;cells/mm (relative rate 8.35, 95% confidence interval 7.51 to 9.27).</p>

<p><strong>CONCLUSIONS: </strong>In infants, a lumbar puncture with a CSF RBC count of 0&nbsp;cells/mm regardless of the CSF WBC count occurred eight-times more frequently than one with both CSF WBC and RBC counts of 0&nbsp;cells/mm . A broader champagne tap definition would allow more frequent recognition of procedural success, with the potential to foster a supportive community during medical training, potentially protecting against burnout.</p>

DOI

10.1111/acem.13966

Alternate Title

Acad Emerg Med

PMID

32187765

Title

Updates on pediatric sepsis.

Year of Publication

2020

Number of Pages

981-993

Date Published

2020 Oct

ISSN Number

2688-1152

Abstract

<p>Sepsis, defined as an infection with dysregulated host response leading to life-threatening organ dysfunction, continues to carry a high potential for morbidity and mortality in children. The recognition of sepsis in children in the emergency department (ED) can be challenging, related to the high prevalence of common febrile infections, poor specificity of discriminating features, and the capacity of children to compensate until advanced stages of shock. Sepsis outcomes are strongly dependent on the timeliness of recognition and treatment, which has led to the successful implementation of quality improvement programs, increasing the reliability of sepsis treatment in many US institutions. We review clinical, laboratory, and technical modalities that can be incorporated into ED practice to facilitate the recognition, treatment, and reassessment of children with suspected sepsis. The 2020 updated pediatric sepsis guidelines are reviewed and framed in the context of ED interventions, including guidelines for antibiotic administration, fluid resuscitation, and the use of vasoactive agents. Despite a large body of literature on pediatric sepsis epidemiology in recent years, the evidence base for treatment and management components remains limited, implying an urgent need for large trials in this field. In conclusion, although the burden and impact of pediatric sepsis remains substantial, progress in our understanding of the disease and its management have led to revised guidelines and the available data emphasizes the importance of local quality improvement programs.</p>

DOI

10.1002/emp2.12173

Alternate Title

J Am Coll Emerg Physicians Open

PMID

33145549

Title

Height of fever and invasive bacterial infection.

Year of Publication

2020

Date Published

2020 Aug 20

ISSN Number

1468-2044

Abstract

<p><strong>OBJECTIVE: </strong>We aimed to evaluate the association of height of fever with invasive bacterial infection (IBI) among febrile infants &lt;=60 days of age.</p>

<p><strong>METHODS: </strong>In a secondary analysis of a multicentre case-control study of non-ill-appearing febrile infants &lt;=60 days of age, we compared the maximum temperature (at home or in the emergency department) for infants with and without IBI. We then computed interval likelihood ratios (iLRs) for the diagnosis of IBI at each half-degree Celsius interval.</p>

<p><strong>RESULTS: </strong>The median temperature was higher for infants with IBI (38.8°C; IQR 38.4-39.2) compared with those without IBI (38.4°C; IQR 38.2-38.9) (p&lt;0.001). Temperatures 39°C-39.4°C and 39.5°C-39.9°C were associated with a higher likelihood of IBI (iLR 2.49 and 3.40, respectively), although 30.4% of febrile infants with IBI had maximum temperatures &lt;38.5°C.</p>

<p><strong>CONCLUSIONS: </strong>Although IBI is more likely with higher temperatures, height of fever alone should not be used for risk stratification of febrile infants.</p>

DOI

10.1136/archdischild-2019-318548

Alternate Title

Arch. Dis. Child.

PMID

32819913

Title

Parenteral Antibiotic Therapy Duration in Young Infants With Bacteremic Urinary Tract Infections.

Year of Publication

2019

Date Published

2019 Aug 20

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVES: </strong>To determine the association between parenteral antibiotic duration and outcomes in infants ≤60 days old with bacteremic urinary tract infection (UTI).</p>

<p><strong>METHODS: </strong>This multicenter retrospective cohort study included infants ≤60 days old who had concomitant growth of a pathogen in blood and urine cultures at 11 children's hospitals between 2011 and 2016. Short-course parenteral antibiotic duration was defined as ≤7 days, and long-course parenteral antibiotic duration was defined as &gt;7 days. Propensity scores, calculated using patient characteristics, were used to determine the likelihood of receiving long-course parenteral antibiotics. We conducted inverse probability weighting to achieve covariate balance and applied marginal structural models to the weighted population to examine the association between parenteral antibiotic duration and outcomes (30-day UTI recurrence, 30-day all-cause reutilization, and length of stay).</p>

<p><strong>RESULTS: </strong>Among 115 infants with bacteremic UTI, 58 (50%) infants received short-course parenteral antibiotics. Infants who received long-course parenteral antibiotics were more likely to be ill appearing and have growth of a non- organism. There was no difference in adjusted 30-day UTI recurrence between the long- and short-course groups (adjusted risk difference: 3%; 95% confidence interval: -5.8 to 12.7) or 30-day all-cause reutilization (risk difference: 3%; 95% confidence interval: -14.5 to 20.6).</p>

<p><strong>CONCLUSIONS: </strong>Young infants with bacteremic UTI who received ≤7 days of parenteral antibiotics did not have more frequent recurrent UTIs or hospital reutilization compared with infants who received long-course therapy. Short-course parenteral therapy with early conversion to oral antibiotics may be considered in this population.</p>

DOI

10.1542/peds.2018-3844

Alternate Title

Pediatrics

PMID

31431480

Title

Factors Associated with Adverse Outcomes among Febrile Young Infants with Invasive Bacterial Infections.

Year of Publication

2018

Date Published

2018 Oct 05

ISSN Number

1097-6833

Abstract

<p><strong>OBJECTIVE: </strong>To determine factors associated with adverse outcomes among febrile young infants with invasive bacterial infections (IBIs) (ie, bacteremia and/or bacterial meningitis).</p>

<p><strong>STUDY DESIGN: </strong>Multicenter, retrospective cohort study (July 2011-June 2016) of febrile infants ≤60 days of age with pathogenic bacterial growth in blood and/or cerebrospinal fluid. Subjects were identified by query of local microbiology laboratory and/or electronic medical record systems, and clinical data were extracted by medical record review. Mixed-effect logistic regression was employed to determine clinical factors associated with 30-day adverse outcomes, which were defined as death, neurologic sequelae, mechanical ventilation, or vasoactive medication receipt.</p>

<p><strong>RESULTS: </strong>Three hundred fifty infants met inclusion criteria; 279 (79.7%) with bacteremia without meningitis and 71 (20.3%) with bacterial meningitis. Forty-two (12.0%) infants had a 30-day adverse outcome: 29 of 71 (40.8%) with bacterial meningitis vs 13 of 279 (4.7%) with bacteremia without meningitis (36.2% difference, 95% CI 25.1%-48.0%; P &lt; .001). On adjusted analysis, bacterial meningitis (aOR 16.3, 95% CI 6.5-41.0; P &lt; .001), prematurity (aOR 7.1, 95% CI 2.6-19.7; P &lt; .001), and ill appearance (aOR 3.8, 95% CI 1.6-9.1; P = .002) were associated with adverse outcomes. Among infants who were born at term, not ill appearing, and had bacteremia without meningitis, only 2 of 184 (1.1%) had adverse outcomes, and there were no deaths.</p>

<p><strong>CONCLUSIONS: </strong>Among febrile infants ≤60 days old with IBI, prematurity, ill appearance, and bacterial meningitis (vs bacteremia without meningitis) were associated with adverse outcomes. These factors can inform clinical decision-making for febrile young infants with IBI.</p>

DOI

10.1016/j.jpeds.2018.08.066

Alternate Title

J. Pediatr.

PMID

30297292

Title

Application of the Rochester Criteria to Identify Febrile Infants With Bacteremia and Meningitis.

Year of Publication

2019

Number of Pages

22-27

Date Published

2019 Jan

ISSN Number

1535-1815

Abstract

<p><strong>OBJECTIVES: </strong>The Rochester criteria were developed to identify febrile infants aged 60 days or younger at low-risk of bacterial infection and do not include cerebrospinal fluid (CSF) testing. Prior studies have not specifically assessed criteria performance for bacteremia and bacterial meningitis (invasive bacterial infection). Our objective was to determine the sensitivity of the Rochester criteria for detection of invasive bacterial infection.</p>

<p><strong>METHODS: </strong>Retrospective cohort study of febrile infants aged 60 days or younger with invasive bacterial infections evaluated at 8 pediatric emergency departments from July 1, 2012, to June 30, 2014. Potential cases were identified from the Pediatric Health Information System using International Classification of Diseases, Ninth Revision diagnosis codes for bacteremia, meningitis, urinary tract infection, and fever. Medical record review was then performed to confirm presence of an invasive bacterial infection and to evaluate the Rochester criteria: medical history, symptoms or ill appearance, results of urinalysis, complete blood count, CSF testing (if obtained), and blood, urine, and CSF culture. An invasive bacterial infection was defined as growth of pathogenic bacteria from blood or CSF culture.</p>

<p><strong>RESULTS: </strong>Among 82 febrile infants aged 60 days or younger with invasive bacterial infection, the sensitivity of the Rochester criteria were 92.7% (95% confidence interval [CI], 84.9%-96.6%) overall, 91.7% (95% CI, 80.5%-96.7%) for neonates 28 days or younger, and 94.1% (95% CI, 80.9%-98.4%) for infants aged 29 to 60 days old. Six infants with bacteremia, including 1 neonate with bacterial meningitis, met low-risk criteria.</p>

<p><strong>CONCLUSIONS: </strong>The Rochester criteria identified 92% of infants aged 60 days or younger with invasive bacterial infection. However, 1 neonate 28 days or younger with meningitis was classified as low-risk.</p>

DOI

10.1097/PEC.0000000000001421

Alternate Title

Pediatr Emerg Care

PMID

29406479

Title

Herpes Simplex Virus Infection in Infants Undergoing Meningitis Evaluation.

Year of Publication

2018

Number of Pages

pii: e20171688

Date Published

2018 Feb

ISSN Number

1098-4275

Abstract

<p><strong>BACKGROUND: </strong>Although neonatal herpes simplex virus (HSV) is a potentially devastating infection requiring prompt evaluation and treatment, large-scale assessments of the frequency in potentially infected infants have not been performed.</p>

<p><strong>METHODS: </strong>We performed a retrospective cross-sectional study of infants ≤60 days old who had cerebrospinal fluid culture testing performed in 1 of 23 participating North American emergency departments. HSV infection was defined by a positive HSV polymerase chain reaction or viral culture. The primary outcome was the proportion of encounters in which HSV infection was identified. Secondary outcomes included frequency of central nervous system (CNS) and disseminated HSV, and HSV testing and treatment patterns.</p>

<p><strong>RESULTS: </strong>Of 26 533 eligible encounters, 112 infants had HSV identified (0.42%, 95% confidence interval [CI]: 0.35%-0.51%). Of these, 90 (80.4%) occurred in weeks 1 to 4, 10 (8.9%) in weeks 5 to 6, and 12 (10.7%) in weeks 7 to 9. The median age of HSV-infected infants was 14 days (interquartile range: 9-24 days). HSV infection was more common in 0 to 28-day-old infants compared with 29- to 60-day-old infants (odds ratio 3.9; 95% CI: 2.4-6.2). Sixty-eight (0.26%, 95% CI: 0.21%-0.33%) had CNS or disseminated HSV. The proportion of infants tested for HSV (35%; range 14%-72%) and to whom acyclovir was administered (23%; range 4%-53%) varied widely across sites.</p>

<p><strong>CONCLUSIONS: </strong>An HSV infection was uncommon in young infants evaluated for CNS infection, particularly in the second month of life. Evidence-based approaches to the evaluation for HSV in young infants are needed.</p>

DOI

10.1542/peds.2017-1688

Alternate Title

Pediatrics

PMID

29298827

Title

Concomitant Bacterial Meningitis in Infants With Urinary Tract Infection.

Year of Publication

2017

Number of Pages

908-910

Date Published

2017 09

ISSN Number

1532-0987

Abstract

<p>To determine age-stratified prevalence of concomitant bacterial meningitis in infants ≤60 days with a urinary tract infection, we performed a 23-center, retrospective study of 1737 infants with urinary tract infection. Concomitant bacterial meningitis was rare, but more common in infants 0-28 days of age [0.9%; 95% confidence interval (CI): 0.4%-1.9%) compared with infants 29-60 days of age (0.2%; 95% CI: 0%-0.8%).</p>

DOI

10.1097/INF.0000000000001626

Alternate Title

Pediatr. Infect. Dis. J.

PMID

28472006

Title

Empiric Antibiotic Use and Susceptibility in Infants With Bacterial Infections: A Multicenter Retrospective Cohort Study.

Year of Publication

2017

Date Published

2017 Jul 20

ISSN Number

2154-1663

Abstract

<p><strong>OBJECTIVES: </strong>To assess hospital differences in empirical antibiotic use, bacterial epidemiology, and antimicrobial susceptibility for common antibiotic regimens among young infants with urinary tract infection (UTI), bacteremia, or bacterial meningitis.</p>

<p><strong>METHODS: </strong>We reviewed medical records from infants &lt;90 days old presenting to 8 US children's hospitals with UTI, bacteremia, or meningitis. We used the Pediatric Health Information System database to identify cases and empirical antibiotic use and medical record review to determine infection, pathogen, and antimicrobial susceptibility patterns. We compared hospital-level differences in antimicrobial use, pathogen, infection site, and antimicrobial susceptibility.</p>

<p><strong>RESULTS: </strong>We identified 470 infants with bacterial infections: 362 (77%) with UTI alone and 108 (23%) with meningitis or bacteremia. Infection type did not differ across hospitals (P = .85). Empirical antibiotic use varied across hospitals (P &lt; .01), although antimicrobial susceptibility patterns for common empirical regimens were similar. A third-generation cephalosporin would have empirically treated 90% of all ages, 89% in 7- to 28-day-olds, and 91% in 29- to 89-day-olds. The addition of ampicillin would have improved coverage in only 4 cases of bacteremia and meningitis. Ampicillin plus gentamicin would have treated 95%, 89%, and 97% in these age groups, respectively.</p>

<p><strong>CONCLUSIONS: </strong>Empirical antibiotic use differed across regionally diverse US children's hospitals in infants &lt;90 days old with UTI, bacteremia, or meningitis. Antimicrobial susceptibility to common antibiotic regimens was similar across hospitals, and adding ampicillin to a third-generation cephalosporin minimally improves coverage. Our findings support incorporating empirical antibiotic recommendations into national guidelines for infants with suspected bacterial infection.</p>

DOI

10.1542/hpeds.2016-0162

Alternate Title

Hosp Pediatr

PMID

28729240

Title

Interpretation of Cerebrospinal Fluid White Blood Cell Counts in Young Infants With a Traumatic Lumbar Puncture.

Year of Publication

2016

Date Published

2016 Dec 29

ISSN Number

1097-6760

Abstract

<p><strong>STUDY OBJECTIVE: </strong>We determine the optimal correction factor for cerebrospinal fluid WBC counts in infants with traumatic lumbar punctures.</p>

<p><strong>METHODS: </strong>We performed a secondary analysis of a retrospective cohort of infants aged 60 days or younger and with a traumatic lumbar puncture (cerebrospinal fluid RBC count ≥10,000 cells/mm(3)) at 20 participating centers. Cerebrospinal fluid pleocytosis was defined as a cerebrospinal fluid WBC count greater than or equal to 20 cells/mm(3) for infants aged 28 days or younger and greater than or equal to 10 cells/mm(3) for infants aged 29 to 60 days; bacterial meningitis was defined as growth of pathogenic bacteria from cerebrospinal fluid culture. Using linear regression, we derived a cerebrospinal fluid WBC correction factor and compared the uncorrected with the corrected cerebrospinal fluid WBC count for the detection of bacterial meningitis.</p>

<p><strong>RESULTS: </strong>Of the eligible 20,319 lumbar punctures, 2,880 (14%) were traumatic, and 33 of these patients (1.1%) had bacterial meningitis. The derived cerebrospinal fluid RBCs:WBCs ratio was 877:1 (95% confidence interval [CI] 805 to 961:1). Compared with the uncorrected cerebrospinal fluid WBC count, the corrected one had lower sensitivity for bacterial meningitis (88% uncorrected versus 67% corrected; difference 21%; 95% CI 10% to 37%) but resulted in fewer infants with cerebrospinal fluid pleocytosis (78% uncorrected versus 33% corrected; difference 45%; 95% CI 43% to 47%). Cerebrospinal fluid WBC count correction resulted in the misclassification of 7 additional infants with bacterial meningitis, who were misclassified as not having cerebrospinal fluid pleocytosis; only 1 of these infants was older than 28 days.</p>

<p><strong>CONCLUSION: </strong>Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.</p>

DOI

10.1016/j.annemergmed.2016.10.008

Alternate Title

Ann Emerg Med

PMID

28041826

WATCH THIS PAGE

Subscription is not available for this page.