Acute otitis media in infants younger than two months of age: microbiology,clinical presentation and therapeutic approach

BACKGROUND: Information on the causative agents of acute otitis media (AOM) in infants <2 months of age is limited. OBJECTIVES OF THE STUDY: To analyze the etiology, pathogen susceptibility patterns, clinical presentation and frequency of serious bacterial infections in infants <2 months of age with AOM and to determine the relationship between the organisms isolated systemically and those isolated from the middle ear fluid in the patients with serious bacterial infections in the presence of AOM. METHODS: The medical records of 137 infants <2 months of age with AOM who underwent tympanocentesis in the emergency room of Soroka University Medical Center between January 1, 1995, and May 30, 1999, were reviewed. The main variables analyzed included demography, frequency of serious bacterial infections, bacteriologic results, susceptibility patterns of the pathogens and clinical presentation. RESULTS: Median age was 38.7 +/- 13 days; 112 of 137 (82%) infants were hospitalized. Six (4%), 27 (20%), 46 (34%) and 58 (42%) episodes were recorded at age 0 to 2, 3 to 4, 5 to 6 and 7 to 8 weeks, respectively. Fever (temperature >38 degrees C) was present in 96 (70%) of the cases. Culture-negative (bacterial) meningitis was diagnosed in 3 cases. Blood and urine cultures were positive in 1 and 6 infants, respectively. None of the afebrile infants developed serious bacterial infection. One hundred twenty-two bacterial pathogens were isolated from the middle ear fluid of 109 of 137 (80%) patients: Streptococcus pneumoniae in 56 (46%), Haemophilus influenzae in 41 (34%), group A Streptococcus in 12 (10%), enteric gram-negative bacilli in 9 (7%), Moraxella catarrhalis in 3 (2%) and Streptococcus faecalis in 1 (1%). Eleven (20%) of the 56 S. pneumoniae isolates were nonsusceptible to penicillin. Serious bacterial infections were diagnosed in 6 of 137 (4%) patients. Whereas blood and urine grew pathogens typical for blood and urinary tract infections, the middle ear fluid isolates represented different pathogens usually isolated in AOM without any correlation between these 2 groups of pathogens. CONCLUSIONS: (1) Most cases of AOM in infants <2 months of age are caused by pathogens similar to those causing AOM in older children; (2) antibiotic resistance may already be present at early age and should be considered in the empiric treatment of AOM in infants <2 months of age; (3) the presence of AOM does not predict a higher risk for serious bacterial infections in afebrile and febrile infants <2 months of age.     

Diagnostic testing for serious bacterial infections in infants aged 90 days or younger with bronchiolitis.

OBJECTIVES: To describe the different laboratory tests that are performed on young infants aged 90 days or younger with bronchiolitis and to identify historical and clinical predictors of infants on whom laboratory tests are performed. DESIGN: Cross-sectional study whereby information was obtained by retrospective review of medical records from November through March 1992 to 1995 of all infants with a clinical diagnosis of bronchiolitis. SETTING: Urban pediatric emergency department. PATIENTS: Two hundred eleven consecutive infants aged 90 days or younger (median age, 54 days) with 216 episodes of bronchiolitis. MAIN OUTCOME MEASURES: Historical and clinical data on each infant in addition to laboratory data that included a white blood cell count, urinalysis, and blood, urine, and cerebrospinal fluid cultures. RESULTS: Two or more laboratory tests (not including chest radiographs) were obtained in 48% of all infants and 78% of febrile infants. Of the 91 infants with a history of a temperature of 38.0 degrees C or more or temperature on presentation of 38.0 degrees C or more, white blood cell counts were obtained in 77%, blood cultures in 75%, urinalyses in 53%, urine cultures in 60%, and analyses-cultures of cerebrospinal fluid in 47%. Febrile infants were 10 times more likely to get at least 2 laboratory tests than afebrile infants (P<.01). All 6 studies were done in 42 (58%) of 72 febrile infants compared with 7 (16%) of 43 afebrile infants (P<.001). Multiple logistic regression analysis identified a history of a temperature of 38.0 degrees C or more or temperature on presentation of 38.0 degrees C or more (odds ratio [OR] 10.0; 95% confidence interval [CI], 4.8%-21.0%; P<.001), oxygen saturation less than 92% on presentation (OR, 4.7; 95% CI, 1.9%-12.1%; P<.01), and history of apnea (OR, 0.1; 95% CI, 0.02-0.35; P<.001) as significant clinical predictors of whether laboratory studies were obtained. History of preterm gestation, aged younger than 28 days, previous antibiotic use, and presence of otitis media were not associated with obtainment of laboratory studies. No cases of bacteremia, urinary tract infection, or meningitis were found among all infants with bronchiolitis who had blood, urine, and/or cerebrospinal fluid cultures. CONCLUSION: There is wide variability in the diagnostic testing of infants aged 90 days or younger with bronchiolitis. The risks of bacteremia, urinary tract infection, and meningitis in infants with bronchiolitis seems to be low. History or a documented temperature of 38.0 degrees C or more; oxygen saturation of less than 92%, and history of apnea were associated with laboratory testing for bacterial infections.     

Concurrent serious bacterial infections in 2396 infants and children hospitalized with respiratory syncytial virus lower respiratory tract infections

BACKGROUND: At Driscoll Children's Hospital (Corpus Christi, Tex), we observed that most infants and children hospitalized for treatment of respiratory syncytial virus (RSV) bronchiolitis and/or pneumonia received broad-spectrum intravenous antibiotics despite having typical RSV signs and symptoms and positive RSV-rapid-antigen tests on admission. Physicians were concerned about the possibility of concurrent serious bacterial infections, especially in infants younger than 3 months and in those with infiltrates present on the chest x-ray films. OBJECTIVE: To report the frequency of concurrent serious bacterial infections in infants and children hospitalized for treatment of RSV lower respiratory tract infections. METHODS: The medical records of 2396 infants and children admitted to Driscoll Children's Hospital with RSV bronchiolitis and/or pneumonia during 7 RSV seasons from July 1, 1991, through June 30, 1998, were reviewed. RESULTS: There were positive cultures obtained from initial sepsis/meningitis workups on admission in 39 infants and children (1.6%). Of these, 12 (31%) were positive blood cultures and 27 (69%) were positive urine cultures. There were no positive cerebrospinal fluid cultures. All of the positive blood cultures contained either Staphylococcus epidermidis, Staphylococcus warneri, or Bacillus species, which are common contaminants. None of the patients received a standard 10-day course of intravenous antibiotic therapy. All of the positive urine cultures were typical urinary tract pathogens. All of the patients were treated. CONCLUSIONS: Concurrent serious bacterial infections are rare in infants and children hospitalized with RSV lower respiratory tract infections and the empiric use of broad-spectrum intravenous antibiotics is unnecessary in children with typical signs and symptoms of RSV bronchiolitis.     

Incidence of serious infections in afebrile neonates with a history of fever

A retrospective analysis was performed of 109 previously well infants younger than 4 weeks of age with a history of fever who were evaluated for sepsis in an emergency department. The objective was to assess whether infants who were afebrile at the time of evaluation were at similar risk for serious bacterial infection compared with infants with documented fever at the time of evaluation. Of 109 infants evaluated 54 were afebrile and 55 had fever (rectal temperature, greater than 38 degrees C). Serious bacterial infection occurred in 8 (14.5%) infants with documented fever and in none of those who were afebrile at the time of presentation (P = 0.003). An initial complete blood count profile of the two groups showed that nearly all (96%) in the afebrile group had a complete blood count differential ratio [% of lymphocytes + % of monocytes)/(% of polymorphonuclear leukocytes + % band forms] of greater than 1, whereas the majority (87.5%) of febrile infants with serious infection had a differential ratio of less than 1. The neonate with a history of fever who is afebrile upon presentation should receive a complete evaluation for possible bacterial infection. The neonate who appears well, has no focal source of infection on examination and whose laboratory data do not reveal any abnormality represents a low risk for serious bacterial infection.     

Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone.

STUDY OBJECTIVE: To determine the outcome of outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. DESIGN: Prospective consecutive cohort study. SETTING: Urban emergency department. PATIENTS: Five hundred three infants 28 to 89 days of age with temperatures greater than or equal to 38 degrees C who did not appear ill, had no source of fever detected on physical examination, had a peripheral leukocyte count less than 20 x 10(9) cells/L, had a cerebrospinal fluid leukocyte count less than 10 x 10(6)/L, did not have measurable urinary leukocyte esterase, and had a caretaker available by telephone. Follow-up was obtained for all but one patient (99.8%). INTERVENTION: After blood, urine, and cerebrospinal fluid cultures had been obtained, the infants received 50 mg/kg intramuscularly administered ceftriaxone and were discharged home. The infants returned for evaluation and further intramuscular administration of ceftriaxone 24 hours later; telephone follow-up was conducted 2 and 7 days later. RESULTS: Twenty-seven patients (5.4%) had a serious bacterial infection identified during follow-up; 476 (94.6%) did not. Of the 27 infants with serious bacterial infections, 9 (1.8%) had bacteremia (8 of these had occult bacteremia and 1 had bacteremia with a urinary tract infection), 8 (1.6%) had urinary tract infections without bacteremia, and 10 (2.0%) had bacterial gastroenteritis without bacteremia. Clinical screening criteria did not enable discrimination between infants with and those without serious bacterial infections. All infants with serious bacterial infections received an appropriate course of antimicrobial therapy and were well at follow-up. One infant had osteomyelitis diagnosed 1 week after entry into the study, received an appropriate course of intravenous antimicrobial therapy, and recovered fully. CONCLUSIONS: After a full evaluation for sepsis, outpatient treatment of febrile infants with intramuscular administration of ceftriaxone pending culture results and adherence to a strict follow-up protocol is a successful alternative to hospital admission.     

Utility of sepsis evaluation in infants 90 days of age or younger with fever and clinical bronchiolitis

OBJECTIVE: To identify the clinical utility of obtaining blood, urine and cerebrospinal fluid for bacterial culture among febrile infants <90 days of age with clinical bronchiolitis. DESIGN: Retrospective chart review from 1995 to 2000. SETTING: Urban emergency department of a tertiary children's hospital. PARTICIPANTS: All infants <90 days of age presenting with fever and clinical bronchiolitis. MAIN OUTCOME MEASURES: Result of the cultures of blood, urine and cerebrospinal fluid. RESULTS: Of 3051 (11%) febrile infants, 329 met criteria for clinical bronchiolitis. Blood for culture was obtained from 309 (94%), urine for culture was obtained from 273 (83%) and cerebrospinal fluid for culture was obtained from 200 (61%). One hundred eighty-seven (57%) infants had all 3 specimens sent for culture. No cases of bacteremia [0%; 95% confidence interval (CI), 0, 1.1%] or meningitis (0%; 95% CI 0, 1.8%) occurred among these infants. However, 6 infants (2%; 95% CI 0.8, 5.7%), all male, had a culture of urine consistent with infection (4 Escherichia coli, 1 Staphylococcus aureus, 1 viridans streptococci). CONCLUSION: The risk of bacteremia or meningitis among infants <90 days with fever and bronchiolitis is low in this age group. The risk of urinary tract infection in this age group is also low, but not negligible, at 2%.     

Evaluation of the necessity for hospitalization of the febrile infant less than three months of age

We reviewed records of 443 consecutive infants less than 3 months of age who were hospitalized during a 28-month period for complete evaluation of fever (rectal temperature greater than or equal to 38 degrees C), close observation and consideration of antimicrobial therapy. Infants less than 2 weeks of age were more likely to be treated with parenterally administered antibiotics than older infants (67%, 39%, 29% and 31% in the first and second two weeks of life, second and third months, respectively), and were more likely to have bacteremia and bacterial meningitis (4.8%, 2.1%, 0.5% and 2.3%, respectively), as well as serious bacterial illness (25%, 13%, 7% and 14%, respectively). Five infants (2.5% of those not initially treated) had unexpectedly positive blood (1), urine (3) or stool (1) cultures and were treated with parenteral antibiotics when culture results were known. None was less than 2 weeks of age and all had good outcomes that did not appear to be altered by the delay in diagnosis and treatment. No infant's therapy was modified as a result of clinical deterioration or persistent fever. We conclude that many febrile infants who are hospitalized "for observation" can be managed as outpatients provided that a thorough initial evaluation is performed, that parents can reliably monitor the infant closely at home and that dependable follow-up can be assured.     

Cytology of middle ear fluid during acute otitis media.

BACKGROUND: Limited information is available on the cellular characteristics of the middle ear fluid (MEF) during acute otitis media (AOM). OBJECTIVES: To determine the white blood cell (WBC) composition of the MEF in AOM before and during antibiotic therapy. MATERIALS AND METHODS: Total WBC and differential counts were determined in the MEF of 96 infants and children (ages 2 weeks to 3 years) with AOM who were receiving antibiotics. WBC counts were reported as number of WBC/mg MEF (mean +/- sd). RESULTS: One hundred forty-five MEF samples were obtained by tympanocentesis at enrollment (Day 1), and 36 samples were collected on Days 4 to 5 after initiation of antibiotic therapy. Sixty-one percent of the patients were <1 year of age, and 38% were receiving antibiotic therapy at enrollment. Twenty-eight MEF samples were paired (same ear, Day 1 and Days 4 to 5). One hundred twelve pathogens were isolated from 95 of 145 (66%) culture-positive samples obtained on Day 1: 67 Haemophilus influenzae, 40 Streptococcus pneumoniae and 5 others. MEF WBC counts were lower on Day 1 in patients who had received previous antibiotic therapy than in those who had not (432.4+/- 412.8 vs. 590.5 +/- 436.8, P = 0.03). WBC counts were higher on Day 1 in culture-positive than in culture-negative samples (603.9 +/- 504.9 vs.421.4 +/- 373.4, P = 0.02). WBC counts were higher on Day 1 in MEF samples positive for S. pneumoniae than in those positive for H. influenzae (799.2 +/- 641.5 vs.506.4 +/- 401.9, P = 0.04). There were no differences in the number of neutrophil WBC present in the samples obtained on Day 1 vs.Days 4 to 5 or between samples positive vs.samples negative for bacterial pathogens. CONCLUSIONS: WBC counts were higher in the MEF of patients with culture-positive AOM than in those with culture-negative AOM and in those with AOM caused by S. pneumoniae.     

Risk of bacterial infection in previously healthy respiratory syncytial virus-infected young children admitted to the intensive care unit

OBJECTIVE: To evaluate the risk of bacterial infection and use of antibiotics in otherwise healthy children infected with respiratory syncytial virus (RSV) admitted to the intensive care unit (ICU). METHODS: Demographics, clinical information, interventions and outcomes were extracted from the charts of consecutive patients with laboratory-confirmed RSV infection at Children's Hospital, Boston from October 1990 through April 2002. Patients born at <36 weeks gestational age or with preexisting medical conditions were excluded. RESULTS: The median age of the 165 previously healthy infants infected with RSV was 42 days. Almost all patients received supplementary FiO2, and 63 (38.2%) patients required mechanical ventilator support. No patients died. The median length of stay was 3 days in the ICU and 7 days in the hospital. Most patients had bacterial cultures sent: 155 (93.9%), blood cultures; 121 (73.3%), urine cultures; and 85 (51.5%) cerebrospinal fluid cultures. Only 1 blood culture was positive, and 1 potential urinary tract infection was identified in a patient with a negative urinalysis. All intubated patients and 80.4% of nonintubated patients received antibiotic therapy. CONCLUSIONS: In otherwise healthy infants admitted to the ICU with RSV infection, bacteremia, urinary tract infection and meningitis are uncommon. Although bacterial pneumonia in this cohort may be more prevalent, overdiagnosis is common.     

Bacteremia in feverish children presenting to the emergency department: a retrospective study and literature review

Aim: To evaluate the incidence of bacteremia, and the isolated pathogens, in well‐appearing children with fever without source (FWS) presenting to the pediatric emergency department (PED), after pneumococcal conjucate vaccine ‐ 7 valent (PCV‐7) widespread introduction in the Veneto region of north‐eastern Italy, and to review the main literature contributions on the subject. Methods: Blood cultures performed at the PED of Padova from 1 June 2006 to 31 January 2009 in febrile children aged 1–36 months were retrospectively retrieved. Medical records of previously healthy well‐appearing children with FWS were identified and reviewed. Results: The study finally included 392 patients. Bacteremia rate was 0.34% (95% CI 0–1) in the age group 3–36 months and 2% (95% CI 0–4.7) in infants 1–3 months. No Streptococcus pneumoniae was isolated. The literature review identified 10 relevant studies carried out in the USA and Spain showing an overall bacteremia rate <1% for feverish children aged 3–36 months, with values <0.5% in settings with high PCV‐7 coverage. Conclusion: Overall bacteremia rate is currently <0.5% in well‐appearing children aged 3–36 months with FWS attending the PED in areas with PCV‐7 widespread vaccination and is sufficiently low to preclude laboratory testing in favour of close follow‐up. Further research is needed to evaluate a more conservative approach in infants 2–3 months of age.     

Bacterial and viral pathogens causing fever in infants less than 3 months old

We studied 182 sick, febrile (temperature greater than 38 degrees C) infants less than 3 months of age, who presented at our Tripler Army Medical Center, Honolulu, during a one-year period, to determine the relative causes of fever in this age group. Blood, cerebrospinal fluid, urine, nasopharyngeal secretions, and stool specimens were cultured for bacterial and viral pathogens. Paired acute and convalescent sera were collected to serologically confirm infection in infants from whom viral isolations were obtained only from the nasopharynx or stool. A viral pathogen was isolated in 75 infants (41%) and a bacterial pathogen was isolated in 27 infants (15%). Nonpolio enteroviruses were the most common pathogens demonstrated. They were isolated from 64 infants (35%), and 40 (62%) of these infants had aseptic meningitis, the most frequently made diagnosis. Urinary tract infection was the most common bacterial infection observed. It occurred in 20 infants (11%) and was most often seen without associated pyuria in uncircumcised male infants. Salmonellosis, the second most common bacterial infection, was observed in six infants (3%), and two of these did not have diarrhea or other gastrointestinal tract symptoms. No infant had septicemia and only one infant had bacterial (group B streptococcal) meningitis.     

Lack of usefulness of an abnormal white blood cell count for predicting a concurrent serious bacterial infection in infants and young children hospitalized with respiratory syncytial virus lower respiratory tract infection

BACKGROUND: There continues to be controversy on the most appropriate way to manage infants and young children with fever and documented RSV lower respiratory tract infection (LRTI). The objective of this study was to determine the usefulness of an abnormal white blood cell (WBC) count for predicting a concurrent serious bacterial infection in patients admitted with RSV LRTI. METHODS: The medical records were reviewed of patients discharged with RSV LRTI during the 5 RSV seasons from July 1, 2000 through June 30, 2005. Data were collected on age and gender as well as temperature, complete blood count with manual differential and bacterial cultures obtained at admission. RESULTS: The inclusion criteria was met by 1920 patients. There were 672 febrile patients who had a complete blood count and a bacterial culture. One (5.0%) of 20 patients with a WBC <5000 had a positive culture, 23 (4.7%) of 492 patients with a WBC 5000-14,999 had a positive culture, 5 (4.8%) of 105 patients with a WBC 15,000-19,999 had a positive culture, 2 (5.7%) of 35 patients with a WBC 20,000-24,999 had a positive culture, none of 11 patients with a WBC 25,000-29,999 had a positive culture and 3 (33%) of 9 patients with a WBC >30,000 had a positive culture. Overall, cultures were positive in 34 (5.1%; 95% CI: 3.4-6.8%) of the febrile patients tested and almost all (32; 94%) showed positive urine cultures. CONCLUSION: The probability of an abnormal WBC count <5000 and 15,000-30,000 being associated with a concurrent serious bacterial infection was very low and no different from that of a normal WBC count in febrile patients admitted with RSV LRTI.     

Risk of concurrent bacterial infection in preterm infants hospitalized due to respiratory syncytial virus infection

OBJECTIVE: To evaluate the risk of concurrent bacterial infection in preterm infants hospitalized due to respiratory syncytial virus (RSV) disease. PATIENTS AND METHODS: Retrospective cohort analysis of all infants hospitalized due to RSV infection between January 1, 2001 and July 31, 2005. Patients were identified by ICD-10 diagnosis of RSV infection including codes J21.0, J21.9, J12.1, J20.5 and B97.4. Medical charts were reviewed and RSV infection had to be confirmed by positive antigen detection test on nasopharyngeal aspirates. RESULTS: A total of 464 infants had been hospitalized due to RSV infection and 42 (9.1%) were born<37 weeks of gestational age. Concurrent bacterial infections were diagnosed by either positive blood or urine cultures, stool culture, tracheal aspirates or smears in 4 of 42 preterm (9.5%) compared to 13 of 422 term (3.1%) infants (p=0.017, RR 3.092, CI 95% 1.251-7.641). Excluding the infants admitted to the intensive care unit (ICU) the total rate of bacterial co-infection was 1.9%. Ten of 42 preterm (23.8%) compared to 25 of 422 term (5.2%) infants were referred to ICU (p<0.001, RR 3.349, CI 95% 1.882-5.959). All preterm infants had pneumonia, and isolates were Streptococcus pneumoniae, Chlamydia pneumoniae and Streptococcus pneumoniae with Haemophilus influenzae. Mean length of stay in preterm infants with bacterial co-infection was 22.3 days compared to 10.3 days without bacterial co-infection (p<0.006). CONCLUSION: The overall low risk of concurrent bacterial infection was significantly increased in preterm infants associated with prolonged hospitalization and ICU admission.     

Analysis of the efficacy of urine culture as part of sepsis evaluation in the premature infant

BACKGROUND: Premature infants have a higher incidence of urinary tract infection (UTI) than full term infants. UTI in premature infants can present with signs of sepsis: poor weight gain; temperature instability; metabolic acidosis; poor feeding; and abdominal distention. OBJECTIVE: The purpose of this study was to determine the usefulness of routine urine culture as part of a sepsis evaluation in the preterm infants. METHODS: We conducted a retrospective review of all infants with birth weight <1500 g (very low birth weight) who underwent sepsis evaluation at MetroHealth Medical Center between January 1991 and February 1998. All infants from whom urine and blood specimens were collected concomitantly for culture as part of a sepsis evaluation were included. RESULTS: Included were 538 infants. Their mean gestational age was 28.5 +/- 2.7 weeks, and mean birth weight was 1072 +/- 276 g. Blood and urine specimens for culture were taken from 349 infants on admission or in the first 24 h of life (Group A), their mean birth weight was 1147 +/- 244 g, and mean gestational age was 28.9 +/- 2.6 weeks. None of these infants had positive urine cultures; 8 infants (2%) had positive blood cultures. Blood and urine specimens were obtained from 189 infants later between Days 6 and 150 of life (Group B); their mean birth weight was 933 +/- 278 g, and mean gestational age was 27.5 +/- 2.5 weeks. Forty-eight infants (25.3%) in Group B had positive urine cultures, and 79 infants (41.7%) had positive blood cultures. Eighteen infants (38%) with positive urine cultures had positive blood cultures, and 30 infants (62%) had negative blood cultures. CONCLUSIONS: There is minimal benefit in obtaining urine cultures from very low birth weight infants as part of a sepsis evaluation in the first 24 h of life. It is important to obtain urine cultures from older infants with signs of sepsis to identify patients with UTI with or without bacteremia.     

Correlating reported fever in young infants with subsequent temperature patterns and rate of serious bacterial infections

A retrospective study was performed of 292 infants younger than 2 months of age with a history of fever who received a standardized evaluation and were admitted to the hospital for possible sepsis. The purpose was to correlate the presence of this symptom with subsequent temperature patterns and the rate of serious bacterial infections (SBI). Caretakers reported fever per rectum via thermometer in 244 infants and tactile fever in 48 infants. Of 244 infants with reported fever per rectum, 224 (92%) had fever on presentation or during the subsequent 48 hours of hospitalization; by contrast, only 22 of 48 infants (46%) with reported tactile fever had fever on presentation or during the subsequent 48 hours of hospitalization (P less than 0.0001). Of 26 infants with tactile fever who were afebrile on presentation, none had subsequent fever during hospitalization and only 1 (3.8%) had SBI (urinary tract infection); of 40 infants with reported fever per rectum who were afebrile on presentation, 8 (20%) had subsequent fever during hospitalization and 4 (10%) had SBI (meningitis, bacteremia, osteomyelitis and urinary tract infection). There were a total of 19 infants (6.5%) with SBI; although 5 (27%) were afebrile on presentation (4 with reported fever per rectum, 1 with tactile fever), all 19 exhibited abnormal clinical and/or laboratory features on evaluation which were suggestive of underlying serious infection. Management decisions for young infants with reported fever should be based on both clinical findings and temperature-pattern profiles.     

Aseptic meningitis in infants younger than six months of age hospitalized with urinary tract infections

BACKGROUND: Aseptic meningitis associated with urinary tract infection (UTI) in young infants has not been described in detail in the literature. We performed a retrospective study to determine the incidence and clinical features of aseptic meningitis accompanying UTI. METHODS: We retrospectively reviewed the medical records of all infants younger than 6 months of age hospitalized with a UTI at Miller Children's Hospital from March 1995 through March 2000. UTI was defined as a urine culture growing > or =10,000 colony-forming units/ml of a single organism from a catheterized specimen or > or =100,000 colony-forming units/ml of a single organism from a bagged urine specimen. Meningitis was defined as a positive cerebrospinal fluid culture or cerebrospinal fluid with >35 white blood cells/mm3 in infants < or =30 days of age or with >10 white blood cells/mm3 in infants >30 days of age. RESULTS: Of 386 infants with UTI, a lumbar puncture was performed in 260, and 31 (11.9%) had aseptic meningitis. One infant had bacterial meningitis. None of the 26 infants with UTI and bacteremia had aseptic meningitis. Two infants with meningitis had confirmed enteroviral infections, but aseptic meningitis did not occur more frequently in any particular month or during times of peak enteroviral activity. CONCLUSIONS: A cerebrospinal fluid pleocytosis is relatively common in hospitalized infants <6 months of age who have a UTI and usually does not reflect bacterial meningitis. Knowledge of this may prevent unnecessary courses of antibiotics for presumed bacterial meningitis and lead to evaluation for other possible causes of aseptic meningitis including viral or congenital infections.     

Role of genital mycoplasmas in young infants with suspected sepsis

To establish the prevalence of Mycoplasma hominis and Ureaplasma urealyticum in infants up to 3 months of age with suspected sepsis, blood, cerebrospinal fluid, and urine specimens from 203 patients with clinical signs and symptoms of sepsis were cultured for Mycoplasma in addition to routine bacterial cultures. Proved bacterial infections were identified in 24 patients, four of whom had bacteremia. M. hominis and U. urealyticum were not isolated from any of the 191 blood and 199 CSF specimens tested. Of 170 specimens of urine cultured for Mycoplasma, M. hominis was isolated in six patients, U. urealyticum in nine patients, and both organisms in one patient. Twelve of the positive cultures were voided urine specimens, and four were suprapubic bladder aspiration specimens. Genital mycoplasmas appear to be uncommon causes of sepsis or meningitis in young infants. Further studies are required to assess their role in abnormal conditions of the urinary tract in childhood.     

Procalcitonin, IL-6, IL-8, IL-1 receptor antagonist and C-reactive protein as identificators of serious bacterial infections in children with fever without localising signs

Fever without localising signs in very young children remains a diagnostic problem. Until present, a clinical scoring system combined with leucocyte count, urine analysis and determination of CRP are recognised as being helpful to identify patients at risk of serious bacterial illness. In this study we asked the question whether the determination of procalcitonin (PCT), interleukin (IL)-6, IL-8 and interleukin-1 receptor antagonist (IL-1Ra) was superior to these commonly used markers for the prediction of a serious bacterial infection (SBI). Children, 7 days to 36 months of age, with a rectal temperature above 38 °C and without localising signs of infection were prospectively enrolled. For each infant, we performed a physical examination, a clinical score according to McCarthy, a complete white cell count, an urine analysis and a determination of CRP. We further determined PCT, IL-6, IL-8, and IL-1Ra concentrations and compared their predictive value with those of the usual management of fever without localising signs. Each infant at risk of SBI had blood culture, urine and cerebrospinal fluid cultures when indicated, and received antibiotics until culture results were available. A total of 124 children were included of whom 28 (23%) had SBI. Concentrations of PCT, CRP and IL-6 were significantly higher in the group of children with SBI but IL-8 and IL-1Ra were comparable between both groups. PCT showed a sensitivity of 93% and a specificity of 78% for detection of SBI and CRP had a sensitivity of 89% and a specificity of 75%. Conclusion Compared to commonly used screening methods such as the McCarthy score, leucocyte count and other inflammatory markers such as interleukin-6, interleukin-8 and interleukin-1 receptor antagonist, procalcitonin and C-reactive protein offer a better sensitivity and specificity in predicting serious bacterial infection in children with fever without localising signs. Received: 29 May 2000 and in revised form: 15 September 2000 / Accepted: 25 September 2000     

C-reactive protein as a marker of serious bacterial infections in hospitalized febrile infants

Objective:  To determine the potential predictive power of C-reactive protein (CRP) as a marker of serious bacterial infection (SBI) in hospitalized febrile infants aged ≤3 months.
Patients and Methods:  Data on blood CRP levels were collected prospectively on admission for all infants aged ≤3 months who were hospitalized for fever from 2005 to 2008. The patients were divided into two groups by the presence or absence of findings of SBI.
Results:  A total of 892 infants met the inclusion criteria, of whom 102 had a SBI. Mean CRP level was significantly higher in the infants who had a bacterial infection than in those who did not (5.3 ± 6.3 mg/dL vs. 1.3 ± 2.2 mg/dL, p < 0.001). The area under the ROC curve (AUC) was 0.74 (95% CI: 0.67–0.80) for CRP compared to 0.70 (95% CI: 0.64–0.76) for white blood cell (WBC) count. When analyses were limited to predicting bacteremia or meningitis only, the AUCs for CRP and WBC were 0.81 (95% CI: 0.66–0.96) and 0.63 (95% CI: 0.42–0.83), respectively.
Conclusion:  C-reactive protein is a valuable laboratory test in the assessment of febrile infants aged ≤3 months old and may serve as a better diagnostic marker of SBI than total WBC count.     

Febrile infants less than eight weeks old. Predictors of infection

Febrile infants less than eight weeks old frequently are admitted and receive parenteral antibiotics for treatment of possible sepsis. The authors assess 52 infants less than eight weeks old with a rectal temperature of 38.1 degrees C or higher as having either a readily identifiable focus of infection by physical examination, appearing "toxic" without a focus, or appearing well. The authors screened patients by using white blood cell (WBC) counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and chest radiographs in addition to blood, cerebrospinal fluid and urine cultures. The authors found a 9.6% incidence of bacteria in the 52 infants evaluated, with a 4.3% incidence in those febrile infants who appeared well. Five patients had positive blood cultures with Group B B Hemolytic streptococcus (four patients), and Viridans streptococcus (one patient). A clinical assessment of toxicity and a total band count greater than or equal to 0.5 x 10(3) cells/uL together were sensitive indicators of bacteremia, as were toxicity and a positive CRP. A "toxic" appearance, a WBC count greater than or equal to 15 x 10(3) cells/uL and an ESR greater than 30 were specific indicators of bacteria. Based on these data, identification of bacteremia in febrile infants may be possible with clinical assessment and screening laboratory tests. Because of the relatively small sampling size of this study, the authors feel that evaluation of a larger number of patients is warranted to evaluate these sensitivities in a more diffuse patient population.