Affecting Length of Stay in Well-appearing Febrile Infants.

The management of infants under 2 months of age presenting with fever has perplexed pediatricians for decades. The University of Illinois at Chicago was selected as one of the primary sites for the REVISE (Reducing Variation in Infant Sepsis Evaluations) study through the American Academy of Pediatrics. Our primary objective was to decrease the length of stay (LOS) for well-appearing febrile infants by 20% over 8 months from December 2016 to August 2017. METHODS: We introduced the use of a decision support smartphone application to providers caring for febrile infants. Monthly retrospective chart review of patients 7-59 days old with fever seen in the emergency department or the inpatient setting was performed from September 2015 to August 2016 for baseline data, from December 2016 to August 2017 for intervention data, and from September 2017 to December 2018 for surveillance data. RESULTS: A total of 1013 patients of ages 7-59 days seen in the emergency department or inpatient unit between September 2015 to December 2018 were screened for study inclusion. Forty-one febrile, well-appearing infants of ages 7-59 days met inclusion criteria. During the baseline period, there was a mean LOS of 48 hours. Intervention and surveillance data did not change the mean from baseline. CONCLUSIONS: Infants with a negative diagnostic evaluation for urinary tract infection, bacteremia, or meningitis drove our LOS. Further study is needed to affect the LOS in febrile infants with diagnoses of urinary tract infection, bacteremia, or meningitis.

Bartonella Osteomyelitis of the Acetabulum: Case Report and Review of the Literature.

INTRODUCTION: Bartonella henselae commonly involves the mononuclear phagocyte system (MPS), and its most common presentation is lymphadenitis. Rarely, it can cause isolated osteomyelitis. We present a case of a 3 year old with constitutional symptoms and new onset of limp. Previously reported cases of osteomyelitis due to B. henselae are also reviewed here, keeping the index case in mind. METHODS: We conducted a Medline search using MeSH subject headings Bartonella and osteomyelitis, limited to humans. RESULTS: The index case is a 3-year-old female who had a subacute presentation with new-onset leg pain and fever. Subsequent imaging demonstrated osteomyelitis of the acetabulum. Multiple diagnostic attempts were unsuccessful, and the patient did not respond to empiric therapy. Despite indeterminate serology, the diagnosis of Bartonella osteomyelitis was eventually confirmed by PCR on bone biopsy of the lesion. The literature search revealed 48 publications, which were reduced to 28 when limiting articles to the English language and the pediatric population. After a report of 36 pediatric cases in 2007, there have been an additional 12 pediatric cases since 1998. Generally, these patients had a subacute presentation with relatively mild constitutional symptoms. Most commonly, bone involvement occurred as osteolytic lesions of the axial skeleton. Of the total 48 cases reported, only four reported involvement of the axial skeleton. CONCLUSION: We present the first case, to our knowledge, of pediatric osteomyelitis of the pelvis due to B. henselae with indeterminate serologic and positive PCR results. Bartonella osteomyelitis should be included in the differential diagnosis when typical pathogens are not identified or if the patient is slow to respond to standard therapies. The sensitivity of tissue PCR for Bartonella osteomyelitis is now better than the current gold standard of serology, and new management guidelines may need to reflect this.

Nocardia farcinica Meningitis Masquerading as Central Nervous System Metastasis in a Child With Cerebellar Pilocytic Astrocytoma.

Juvenile pilocytic astrocytoma, the most common pediatric central nervous system (CNS) neoplasm, characteristically displays an indolent growth pattern and rarely demonstrates metastatic dissemination. Reports of infections mimicking CNS metastatic disease are also rare and can impact treatment. We report the youngest known case of a child with a CNS Nocardia farcinica infection who had a known cerebellar pilocytic astrocytoma, review other infections that may masquerade as CNS neoplasms, and discuss N. farcinica CNS infections.

Common childhood viral infections.

Infections caused by viruses are universal during childhood and adolescence. Clinicians will regularly care for children and adolescents who present with infections caused by a wide number of viral pathogens. These infections have varied presentations. Many infections may have clinical presentations that are specific to the infecting virus but present differently, based on the age and immunocompetence of the patient. Some children are directly impacted early in their lives when maternal disease results in an in utero infection (cytomegalovirus, rubella virus, or parvovirus B19). Other viruses may infect children in a predictable pattern as they grow older (rhinovirus or influenza virus). Fortunately, many viral infections frequently encountered in the past are no longer extant due to widespread immunization efforts. Recognition of these vaccine-preventable infections is important because outbreaks of some of these diseases (mumps or measles) continue to occur in the United States. Vigilance in vaccine programs against these viral agents can prevent their re-emergence. In addition, an increasing number of viral infections (herpes simplex virus, influenza virus, varicella zoster virus, or cytomegalovirus) can now be successfully treated with antiviral medications. Most viral infections in children result in self-limited illness and are treated symptomatically and infected children experience full recovery. This review will address the epidemiology, clinical presentation, diagnosis, treatment, and prevention of viral infections commonly encountered by the clinician.