Meta-analysis to Determine Risk for Serious Bacterial Infection in Febrile Outpatient Neonates With RSV Infection.

OBJECTIVES: This study aimed to analyze a large group of febrile neonates 28 days or younger who received outpatient sepsis evaluation and nasopharyngeal aspirate antigen testing (NPAT) for respiratory syncytial viral (RSV) infection to determine whether there is a clinically significant association between viral study results and risk for serious bacterial infection (SBI: bacterial meningitis, bacteremia, urinary tract infection, bacterial enteritis). METHODS: We evaluated consecutive febrile neonates 28 days or younger presenting to our urban pediatric emergency department [Maimonides Medical Center (MMC)] during a 6-year period, all of whom received a sepsis evaluation (cerebrospinal fluid, blood, urine cultures) and RSV NPAT. To achieve adequate power (80%), the MMC data were combined with similar data reported from a prior prospective PEM-CRC study of like-aged febrile neonates who received similar evaluation. RESULTS: From the MMC data of consecutively evaluated cases, the prevalence rate of +RSV in 387 febrile neonates was 6%. Of these, 378 (98%) received both a sepsis evaluation and RSV NPAT; +SBI occurred in 4/22 (18.1%) with +RSV versus 58/356 (16.2%) with -RSV (P = 0.77). Combined with the PEM-CRC cohort of 411 febrile neonates 28 days or younger who received similar evaluation, a total of 789 cases were analyzed using meta-analysis. Overall, there were 117 (14.8%) cases of +SBI and 104 (13.2%) cases of +RSV. The rate of +SBI was 11.5% in those with +RSV versus 15.3% in those with -RSV. Meta-analysis performed showed no significant difference in rates of +SBI between those with and without +RSV (odds ratio, 0.78; 95% confidence interval, 0.41-1.50; P = 0.46). CONCLUSIONS: Rates of +SBI are not significantly different between febrile neonates 28 days or younger with and without +RSV. Respiratory viral infection status is not an accurate clinical determinant in distinguishing SBI risk in febrile neonates.

Appendicitis in preschool aged children: Regression analysis of factors associated with perforation outcome.

OBJECTIVES: Apply multivariate regression analysis to determine the significance of clinical variables for perforation outcome of a large series of preschool aged children with appendicitis. METHODS: Retrospective case review of 180 consecutive children<5 years of age diagnosed with appendicitis during an 8-year period. RESULTS: This age group accounted for only 9% of all cases of pediatric appendicitis at our institution during the study period. Perforation rate was inversely proportional to patient age, occurring in 100% aged<1 year, 91% ages 1-2 years, 76% ages 2-3 years, 73% ages 3-4 years, and 57% ages 4-5 years. Risk for perforation increased proportionately with duration of symptoms, ranging from 48% when<1 day vs 84% when>1 day; and 93% when>2 days. One-quarter with perforation had a prior recent medical evaluation with an alternative diagnosis rendered preappendicitis diagnosis. The mean duration of hospitalization was four times longer in those with perforation [8 days] vs no perforation [2 days]. Univariate analysis showed each of the following factors was significantly associated with perforation outcome: younger patient age, female gender, prior medical visit<48 hours of appendicitis diagnosis, symptom duration, presence of fever, and presence of appendicolith. Multivariate logistic regression combining all significant univariate predictors showed only duration of symptoms and presence of appendicolith were significantly associated with perforation outcome; receiver-operating characteristic curves are generated to evaluate the predictive accuracy of these two factors, both individually and when combined. CONCLUSIONS: Although relatively uncommon in this age group, appendicitis is frequently associated with delayed diagnosis and perforation outcome. Risk for perforation is directly proportional to increasing duration of symptoms. Clinicians must maintain a high index of suspicion for this condition in these younger children, as early diagnosis is essential to maximizing outcome.