Assessing the Utility of Urine Testing in Febrile Infants 2 to 12 Months of Age With Bronchiolitis.

BACKGROUND: The utility of testing for urinary tract infection (UTI) in febrile infants with bronchiolitis is indeterminate. OBJECTIVE: The objective of this study was to investigate if the incidence of UTIs in febrile infants 2 to 12 months of age with bronchiolitis is higher than the presumed incidence of asymptomatic bacteriuria and determine risk factors associated with UTIs in this population. METHODS: This prospective multicenter cross-sectional study was conducted in the emergency departments of 6 children's hospitals between November 2011 and June 2015. We obtained a convenience sample of febrile infants with bronchiolitis 2 to 12 months of age who were tested for UTI. Patient characteristics analyzed included age, maximum temperature, duration of fever, ethnicity, sex, and circumcision status. RESULTS: A total of 442 patients (including 86 from a previously published pilot study) were enrolled. Mean age was 5.5 months, 65.2% were Latino, 50.9% were male, and 27.6% of male infants were circumcised. Urinary tract infections were found in 33 patients (7.69%, binomial; 95% confidence interval [CI], 5.19%-10.33%). Urinary tract infections were not related to age, height of temperature, duration of fever, or ethnicity. Uncircumcised males were significantly more likely to have UTIs than circumcised males (7.64% vs 0%, P = 0.03). Odds ratios (ORs) were lower for circumcised males but not uncircumcised males when compared with females (OR, 0.12; CI, 0.0-0.71; P = 0.01 vs OR, 0.77; CI, 0.33-1.74; P = 0.64). CONCLUSIONS: Febrile infants 2 to 12 months of age with bronchiolitis have a clinically significant incidence of UTI, suggesting that UTI evaluation should be considered in these patients.

A Rare Cause of Shock in an Infant: Cor Triatriatum.

Congenital heart disease can be difficult to diagnose in infants because they often present with nonspecific symptoms. Their clinical presentation can resemble that of respiratory infections or sepsis, yet typical treatments for these conditions such as fluid resuscitation may worsen their course. We report a case of an 8-week-old boy who had several weeks of viral symptoms and eventually presented to the emergency department in shock. An echocardiogram revealed the diagnosis of cor triatriatum, a rare congenital heart disease that requires urgent surgical repair. In this article, we review the evaluation and management of such patients and emphasize the importance of considering congenital heart disease in the differential diagnosis for an infant in shock.

Update on abusive head trauma.

PURPOSES OF REVIEW: This article provides an update on abusive head trauma (AHT), focusing on new developments most salient to the emergency medicine clinician, including epidemiology, clinical recognition, diagnostic work-up, management of neurologic injury, and public health implications. RECENT FINDINGS: The recent literature has focused on honing the clinician's ability to recognize AHT and its immediate sequelae, to more accurately distinguish between abusive and accidental head injuries by patterns of neuroimaging and retinal hemorrhages, and to appreciate the long-term impacts. Specifically, both a clinical prediction rule and biomarker show promise, and new research advocates for the early identification of subclinical seizures as well as cervical spine injuries. SUMMARY: The emergency medicine provider must be able to recognize and manage children who may have AHT and to appreciate when the diagnostic findings warrant consultation with a child protection team. These authors summarize the recent and notable advances in our understanding of AHT.

Ultrasound-guided femoral nerve block for pain control in an infant with a femur fracture due to nonaccidental trauma.

A 3-month-old infant girl was transferred to our emergency department (ED) with a subtrochanteric femoral neck fracture due to nonaccidental trauma. She received multiple doses of parenteral analgesics both before arrival and in our ED. We performed an ultrasound-guided femoral nerve block using 2.0 mL of 0.25% bupivicaine (approximately 1.25 mg/kg) before placing the patient in a Pavlik harness. Successful pain control was achieved within 15 minutes of the procedure allowing pain-free manipulation of the affected extremity. The patient required only a single dose of parenteral narcotics during the ensuing 18 hours. To our knowledge, this is the first report of an ultrasound-guided femoral nerve block used in the ED for pain control in a pediatric patient.

Secretory phospholipase A2: a marker of infection in febrile children presenting to a pediatric ED.

BACKGROUND: Fever is a common presenting complaint to the emergency department (ED), and the evaluation of the febrile child remains a challenging task. OBJECTIVE: The aim of this study was to examine the relationship between secretory phospholipase A2 (sPLA2) and infection in febrile children. METHODS: A prospective convenience sample of children presenting with fever to an urban pediatric ED were studied. Blood and urine cultures, a complete blood count, and serum concentrations of sPLA2 were obtained, and patients were compared based on their final diagnosis of either a viral or bacterial infection. RESULTS: In the 76 patients enrolled, 60 were diagnosed with a viral infection, 14 with a bacterial infection, 1 with Kawasaki disease, and 1 with acute lymphoblastic leukemia. The difference in the serum concentration of sPLA2 in patients with viral infections (22 ± 34 ng/mL) versus those with bacterial infections (190 ± 179 ng/mL) was statistically significant (P < .0001). Receiver operator characteristic curve analysis revealed that sPLA2 was more accurate at predicting bacterial infection (area under the curve = 0.89) than the total white blood cell count (area under the curve = 0.71) and that a value of more than 20 ng/mL had a sensitivity of 93%, specificity of 67%, positive predictive value of 39%, and negative predictive value of 97%. CONCLUSION: Secretory phospholipase A2 differs significantly in children with viral versus bacterial infection and seems to be a reliable screening test for bacterial infection in febrile children.

Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis.

OBJECTIVE: The goal of this study was to evaluate the effect of antibiotic administration before lumbar puncture on cerebrospinal fluid profiles in children with bacterial meningitis. METHODS: We reviewed the medical records of all children (1 month to 18 years of age) with bacterial meningitis who presented to 20 pediatric emergency departments between 2001 and 2004. Bacterial meningitis was defined by positive cerebrospinal fluid culture results for a bacterial pathogen or cerebrospinal fluid pleocytosis with positive blood culture and/or cerebrospinal fluid latex agglutination results. Probable bacterial meningitis was defined as positive cerebrospinal fluid Gram stain results with negative results of bacterial cultures of blood and cerebrospinal fluid. Antibiotic pretreatment was defined as any antibiotic administered within 72 hours before the lumbar puncture. RESULTS: We identified 231 patients with bacterial meningitis and another 14 with probable bacterial meningitis. Of those 245 patients, 85 (35%) had received antibiotic pretreatment. After adjustment for patient age, duration and severity of illness at presentation, and bacterial pathogen, longer duration of antibiotic pretreatment was not significantly associated with cerebrospinal fluid white blood cell count, cerebrospinal fluid absolute neutrophil count. However, antibiotic pretreatment was significantly associated with higher cerebrospinal fluid glucose and lower cerebrospinal fluid protein levels. Although these effects became apparent earlier, patients with >or=12 hours of pretreatment, compared with patients who either were not pretreated or were pretreated for <12 hours, had significantly higher median cerebrospinal fluid glucose levels (48 mg/dL vs 29 mg/dL) and lower median cerebrospinal fluid protein levels (121 vs 178 mg/dL). CONCLUSIONS: In patients with bacterial meningitis, antibiotic pretreatment is associated with higher cerebrospinal fluid glucose levels and lower cerebrospinal fluid protein levels, although pretreatment does not modify cerebrospinal fluid white blood cell count or absolute neutrophil count results.

Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis.

CONTEXT: Children with cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital and treated with parenteral antibiotics, although few have bacterial meningitis. We previously developed a clinical prediction rule, the Bacterial Meningitis Score, that classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria: positive CSF Gram stain, CSF absolute neutrophil count (ANC) of at least 1000 cells/microL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10,000 cells/microL, and a history of seizure before or at the time of presentation. OBJECTIVE: To validate the Bacterial Meningitis Score in the era of widespread pneumococcal conjugate vaccination. DESIGN, SETTING, AND PATIENTS: A multicenter, retrospective cohort study conducted in emergency departments of 20 US academic medical centers through the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. All children aged 29 days to 19 years who presented at participating emergency departments between January 1, 2001, and June 30, 2004, with CSF pleocytosis (CSF white blood cells > or =10 cells/microL) and who had not received antibiotic treatment before lumbar puncture. MAIN OUTCOME MEASURE: The sensitivity and negative predictive value of the Bacterial Meningitis Score. RESULTS: Among 3295 patients with CSF pleocytosis, 121 (3.7%; 95% confidence interval [CI], 3.1%-4.4%) had bacterial meningitis and 3174 (96.3%; 95% CI, 95.5%-96.9%) had aseptic meningitis. Of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old. A total of 2518 patients (80%) with aseptic meningitis were hospitalized. CONCLUSIONS: This large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to emergency departments with CSF pleocytosis.