Markers for bacterial infection in children with fever without source.

OBJECTIVES: To compare the diagnostic properties of procalcitonin (PCT), C reactive protein (CRP), total white blood cells count (WBC), absolute neutrophil count (ANC) and clinical evaluation to detect serious bacterial infection (SBI) in children with fever without source. DESIGN: Prospective cohort study. SETTING: Paediatric emergency department of a tertiary care hospital. PARTICIPANTS: Children aged 1-36 months with fever and no identified source of infection. INTERVENTION: Complete blood count, blood culture, urine analysis and culture. PCT and CRP were also measured and SBI probability evaluated clinically with a visual analogue scale before disclosing tests results. Outcome measure Area under the curves (AUC) of the receiver operating characteristic curves. RESULTS: Among the 328 children included in the study, 54 (16%) were diagnosed with an SBI: 48 urinary tract infections, 4 pneumonias, 1 meningitis and 1 bacteraemia. The AUC were similar for PCT (0.82; 95% CI 0.77 to 0.86), CRP (0.88; 95% CI 0.84 to 0.91), WBC (0.81; 95% CI 0.76 to 0.85) and ANC (0.80; 95% CI 0.75 to 0.84). The only statistically significant difference was between CRP and ANC (Δ AUC 0.08; 95% CI 0.01 to 0.16). It is important to note that all the surrogate markers were statistically superior to the clinical evaluation that had an AUC of only 0.59 (95% CI 0.54 to 0.65). CONCLUSION: The study data demonstrate that CRP, PCT, WBC and ANC had almost similar diagnostic properties and were superior to clinical evaluation in predicting SBI in children aged 1 month to 3 years.

Impact of procalcitonin on the management of children aged 1 to 36 months presenting with fever without source: a randomized controlled trial.

OBJECTIVE: The aim of the study was to evaluate the impact of procalcitonin (PCT) measurement on antibiotic use in children with fever without source. METHOD: Children aged 1 to 36 months presenting to a pediatric emergency department (ED) with fever and no identified source of infection were eligible to be included in a randomized controlled trial. Patients were randomly assigned to 1 of 2 groups as follows: PCT+ (result revealed to the attending physician) and PCT- (result not revealed). Patients from both groups also had complete blood count, blood culture, urine analysis, and culture performed. Chest radiography or lumbar puncture could be performed if required. RESULTS: Of the 384 children enrolled and equally randomized into the PCT+ and PCT- groups, 62 (16%) were diagnosed with a serious bacterial infection (urinary tract infection, pneumonia, occult bacteremia, or bacterial meningitis) by primary ED investigation. Ten were also found to be neutropenic (<500 x 10(6)/L). Of the remaining undiagnosed patients, 14 (9%) of 158 received antibiotics in the PCT+ group vs 16 (10%) of 154 in the PCT- group (Delta -2%; 95% confidence interval [CI], -8 to 5). A strategy to treat all patients with PCT of 0.5 ng/mL or greater with prophylactic antibiotic in this group of patients would have resulted in an increase in antibiotic use by 24% (95% CI, 15-33). CONCLUSION: Semiquantitative PCT measurement had no impact on antibiotic use in children aged 1 to 36 months who presented with fever without source. However, a strategy to use prophylactic antibiotics in all patients with abnormal PCT results would have resulted in an increase use of antibiotics.

Comparison of procalcitonin measurement by a semi-quantitative method and an ultra-sensitive quantitative method in a pediatric emergency department.

OBJECTIVE: To compare procalcitonin measurements between semi-quantitative and quantitative assays. METHOD: Procalcitonin was measured with the PCT-Q and the Kryptor assays in a pediatric emergency department. RESULTS: Among the 359 pairs of results, 103 had discordant results. The linear weighted kappa was 0.44 (95% CI 0.36, 0.51). The concordant/discordant results distribution varied depending on the laboratory technician (p=0.018). CONCLUSION: Agreement between procalcitonin measured semi-quantitatively and quantitatively was moderate. This is probably due to a subjective interpretation of the assay result.

Dexamethasone for the treatment of sore throat in children with suspected infectious mononucleosis: a randomized, double-blind, placebo-controlled, clinical trial.

OBJECTIVE: To evaluate the efficacy of a single oral dose of dexamethasone for pain relief in acute exudative pharyngitis associated with infectious mononucleosis. METHODS: We conducted a randomized, double-blind, placebo-controlled pediatric emergency department-based clinical trial. Patients aged between 8 and 18 years with a sore throat from clinically suspected infectious mononucleosis were eligible. Patients were randomized to receive either an oral dose of 0.3 mg/kg (maximum, 15 mg) of dexamethasone or a placebo. Patients completed a diary of symptoms and rated their pain on a visual analog scale from 0 to 100 mm at 0 hours, 12 hours, 24 hours, 48 hours, 72 hours, and on day 7. An improvement of 20 mm from baseline on the visual analog scale was evaluated as the primary end point. RESULTS: Twenty patients were recruited in each group; mean +/- SD age was 13.5 +/- 2.8 years. In comparison with the placebo group, a significantly greater proportion of patients given dexamethasone achieved pain relief within the first 12 hours (12/20 vs 5/19; P =.03). On further follow-up, the proportions achieving pain relief were similar between groups: 11 of 20 vs 6 of 20 at 24 hours (P =.10); 11 of 20 vs 11 of 20 at 48 hours (P>.99); 15 of 20 vs 15 of 19 at 72 hours (P =.93); and 18 of 19 vs 19 of 20 at day 7 (P>.99), with dexamethasone vs placebo, respectively. CONCLUSIONS: The short-lived relief of pain in acute exudative pharyngitis in children with suspected infectious mononucleosis may suggest that a single oral dose of dexamethasone may not be sufficient and that additional doses may be necessary for ensuring lasting relief.

Approach to the febrile child: A challenge bridging the gap between the literature and clinical practice.

The approach to the febrile child is always concerning for any physician despite the fact that most fevers are viral in origin. However, in rare cases, a missed bacterial infection can have serious consequences. How can fevers of viral origin be differentiated from those of bacterial origin? Do all febrile children with no obvious infection site need a blood culture? Should antibiotics be administered before the results of the blood culture have been received? In the past 30 years, there has been an overabundance of recommendations, advice, opinions and suggested treatments on this subject. The purpose of this review is to present the evidence that is known at this time concerning the management of the febrile child and to present one approach used in a large urban paediatric emergency department.