Predicting serious bacterial infection in young children with fever without apparent source

The aim of this study was to design a clinical rule to predict the presence of a serious bacterial infection in children with fever without apparent source. Information was collected from the records of children aged 1-36 mo who attended the paediatric emergency department because of fever without source (temperature > or = 38 degrees C and no apparent source found after evaluation by a general practitioner or history by a paediatrician). Serious bacterial infection included bacterial meningitis, sepsis, bacteraemia, pneumonia, urinary tract infection, bacterial gastroenteritis, osteomyelitis and ethmoiditis. Using multivariate logistic regression and the area under the receiver operating characteristic curve (ROC area), the diagnostic value of predictors for serious bacterial infection was judged, resulting in a risk stratification. Twenty-five percent of the 231 patients enrolled in the study (mean age 1.1 y) had a serious bacterial infection. Independent predictors from history and examination included duration of fever, poor micturition, vomiting, age, temperature < 36.7 degrees C or > or = 40 degrees C at examination, chest-wall retractions and poor peripheral circulation (ROC area: 0.75). Independent predictors from laboratory tests were white blood cell count, serum C-reactive protein and the presence of >70 white blood cells in urinalysis (ROC area: 0.83). The risk stratification for serious bacterial infection ranged from 6% to 92%. CONCLUSION: The probability of a serious bacterial infection in the individual patient with fever without source can be estimated more precisely by using a limited number of symptoms, signs and laboratory tests.     

Causes of fever in febrile seizures

The causes of pyrexia in 100 cases of febrile seizures were studied. The fever was due to a viral infection in 71 percent, primary complex in 15 percent, due to bronchopneumonia and lobar pneumonia in 8 per cent and 1 per cent cases were due to otitis media. No case of urinary tract infection, enteric fever or infective diarrhea was seen.     

C反应蛋白对不明原因发热儿童严重细菌感染诊断价值的系统评价

目的 系统评价CRP对不明原因发热儿童严重细菌感染的诊断价值。方法 检索Medline、EMBASE、Cochrane图书馆、维普中文科技期刊数据库、中国知网、万方数据库和中国生物医学文献数据库,纳入CRP对不明原因发热儿童严重细菌感染诊断价值的文献,检索时间均为建库至2012年10月。采用QUADAS量表对纳入文献进行质量评估,使用MetaDisc 1.4软件对纳入文献进行异质性检验及Meta分析。结果 初检到314篇文献,7篇文献符合纳入标准进入系统评价（n=2 179）。6篇为前瞻性研究,1篇为回顾性研究。CRP的最适界值为30~91 mg·L-1。严重细菌感染的患病率为1.7%~29.3%。4篇文献采用多变量Logistic回归分析显示,CRP是严重细菌感染独立的预测因素。报道敏感度和特异度文献间具有高度的异质性,采用描述性分析,CRP不同最适界值诊断严重细菌感染的敏感度为33%~89%,特异度为75%~97%。报道阳性似然比和阴性似然比的文献间具中度异质性,采用随机效应模式合并,合并阳性似然比为4.43 （95%CI：3.49~5.63）,阴性似然比为0.39（95%CI：0.29~0.54）。SROC曲线下面积为0.85,Q指数为0.78。结论 在以不明原因发热就诊的婴幼儿中,CRP对严重细菌感染具有中等的诊断价值,应用时尚需结合临床表现及其他实验室检查指标。     

Duration of recognized fever in febrile seizure predicts later development of epilepsy

Background: The current report examines the risk of and predictors for developing epilepsy in children with febrile seizure (FS). The present study addresses two factors that were previously identified as predictors of recurrent FS in previous reports: maximum temperature and duration of fever prior to the initial FS. Methods: Children aged 6 months–6 years with an initial simple FS were eligible for the study. The interview included questions about the child's illness, family history of seizures, and other exposure information. In particular, they were asked about the duration of recognized fever prior to the seizure. After the initial interview, parents were called every 3–4 months to ascertain whether any further seizures had occurred and the circumstances under which such seizures occurred. Follow up ≥3 years was attempted for all children. Statistical analysis was done with χ² test, Fisher's exact test, Mann–Whitney U‐tests and logistic regression analysis. Results: Five of 92 children (5.4%) experienced unprovoked seizures and were considered part of an epilepsy group. In four of these five patients, the duration of recognized fever prior to FS fell more than ±2.5 SD outside the distribution for the non‐epilepsy group. Either an unusually short or long recognized fever prior to the initial FS was associated with an increased risk of unprovoked seizures. Conclusions: The duration of recognized fever appears to provide useful information about the risk for the later development of epilepsy.     

Diagnostic values of C-reactive protein and complete blood cell to identify invasive bacterial infection in young febrile infants

Background

Newborn infants younger than 3 months old with a fever are frequently evaluated for the risk of invasive bacterial infections (IBIs), which include bacteremia and/or bacterial meningitis, in the pediatric emergency department (PED). The purpose of this study was to determine the individual complete blood cell count and biochemistry levels associated with IBIs in febrile infants.

Fever in the new millennium: a review of recent studies of markers of serious bacterial infection in febrile children

PURPOSE OF REVIEW: Evaluation of a febrile infant or child for serious bacterial infections (SBI) can be a challenging task; there is no single reliable predictor of SBI in infants. This review examines some of the recent work evaluating the usefulness of indicators for SBI, such as white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6). RECENT FINDINGS: While WBC is traditionally used as an indicator of serious infection, it appears to be the least specific and sensitive test in children. CRP and PCT are the most promising, but neither is an ideal single indicator by itself, especially in infants. There has been very limited experience with PCT in this country, however. IL-6 is more useful than WBC but less accurate than either CRP or PCT. SUMMARY: Much progress has been made in recent years in finding more accurate indicators of SBI than WBC. However, while recent developments have given clinicians some new tools in evaluating febrile infants and children, it remains a formidable undertaking. In the especially vulnerable infant population, the holy grail of a single ideal SBI indicator remains elusive.     

Typhoid fever in Hong Kong children

Abstract Experience with typhoid fever in 111 children over a 5-year period was reviewed. There were 66 boys and 45 girls, ranging in age from 1 to 11.5 years. The symptoms of typhoid fever were quite non-specific. Fever was the most common presenting symptom (in 98.3%). Other common presenting features were diarrhoea (25.7%), constipation (22%), vomiting (21.1%), cough (25%), abdominal pain (27.5%), headache (9.2%), epistaxis, meningism and convulsions. Rose spots were detected in 20% of cases, occurring mainly during the first 2 weeks of illness. Significant Widal reactions were present in 84.7% of cases. Blood and stool cultures were positive in 57% and 44% of cases, respectively. Peripheral blood white cell counts were not found to be of great diagnostic value. Chloramphenicol remained the drug of choice in the treatment of typhoid fever. It was more effective than ampicillin or co-trimoxazole. Complications were uncommon, occurring in only two patients. There were two deaths; both were admitted late and in moribund state. Early diagnosis and treatment is vital in typhoid fever and, as the presenting features are non-specific, a high index of suspicion is required.     

婴幼儿发热性尿路感染的影像学检查评价

目的 探讨肾脏超声检查(US)、放射性核素肾静态扫描(DMSA)和排泄性膀胱尿道造影(VCUG)检查在婴幼儿发热性尿路感染(UTI)中的应用价值.方法 发热性UTI患儿人院1周内进行US及DMSA检查,2周后进行VCUG检查,急性期DMSA异常者6个月复查,并对US、DMSA和VCUG检查结果进行回顾性分析.结果 婴幼儿发热性UTI患儿160例,急性期接受US、DMSA和VCUG三项检查的共75例,VCUG检出VUR患儿23例(35个VUR肾输尿管单位),检出率为30.7%;35个VUR肾输尿管单位中,Ⅰ级反流0个,Ⅱ级8个(22.9%).Ⅲ级11个(31.4%),Ⅳ级14个(40.0%),V级2个(5.7%).35个反流肾输尿管单位中,US提示反流的有15个;无反流的114个肾输尿管单位中US提示反流的有12个,US筛查VUR的敏感性为42.9%,特异性为89.5%,阳性预测率为55.6%,阴性预测率为83.6%.35个反流的肾输尿管单位中,DMSA提示异常的有31个;无反流的114个肾输尿管单位中,DMSA提示异常的有61个,DMSA筛查VUR的敏感性为88.6%,特异性为46.5%,阳性预测率为33.7%,阴性预测率为93.0%.24例6个月后DMSA复查发现肾瘢痕形成15例,占62.5%,其中VUR患儿有10例,反流程度均为Ⅲ级或Ⅲ级以上.结论 发热性UTI婴幼儿中VUR的发生率高,以严重VUR多见,且容易形成肾瘢痕,US、VCUG和DMSA均应作为常规评估检查.     

Evaluation of 80 children with prolonged fever

BACKGROUND: Several studies have been published regarding the etiology and evaluation of a child with prolonged fever, however, the reasons for the prolonged fever have changed during the years. The present study aims to determine the causes of prolonged fever, to investigate the relationship of fever using some basic laboratory tests, and to establish guidelines for the approach in those children. METHODS: The charts of 80 out of 17490 hospitalized children who were seen between 1996 and 2001 with prolonged fever of longer than 2 weeks and unknown origin were reviewed in the university hospital of Izmir, Turkey. Their charts were evaluated in respect of age, sex, growth curves, educational level of their families, the duration and the magnitude of fever, causes of fever, and basic laboratory investigations such as white blood cell, blood smear, hemoglobin, erythrocyte sedimentation rate, and C-reactive protein. RESULTS: Forty-four (55.00%) were boys and 36 (45.00%) were girls. Forty-four children (55.00%) were aged between 1 month and 2 years, 21 (26.25%) were aged 3-6 years, seven (8.75%) were aged 7-10 years, and eight (10.00%) were older than 10 years. The mean age was 3.87 +/- 4.17 years (range 3 months-17 years). Forty-six children (57.50%) had a prolonged fever that had lasted from 15-30 days, 18 (22.50%) from 31-60 days, and 16 (20.00%) had fever lasting more than 60 days. Final diagnosis had been reached in 70 of the 80 children (87.50%). The most common causes were infection (47/80), followed by immune deficiency (6/80), collagen tissue disorder (5/80), neoplasia (2/80), and miscellaneous (10/80) such as central fever in three, diabetes insipidus in two, familial Mediterranean fever in two, Kawasaki disease, foreign body in the respiratory system, and Crohn disease in one patient each. Among the laboratory tests white blood cell count, hemoglobin level and blood smear distribution of infection group were statistically significant. CONCLUSIONS: The most common cause of fever of unknown origin remains infection. The proportion of collagen tissue disorders and neoplasia have been found to be decreased. Unusual reasons such as diabetes insipidus and foreign body in the respiratory system in the miscellaneous group have been detected. Age plays important role in the diagnosis of prolonged fever, while some basic laboratory tests might give clues in the evaluation and may suggest a diagnosis.     

降钙素原对不同热程不明原因发热儿童严重细菌感染诊断价值的Meta分析

目的 探讨降钙素原（PCT）对不同热程不明原因发热儿童严重细菌感染(SBIs)的诊断价值。方法 计算机检索获得PCT对不明原因发热儿童SBIs诊断价值的文献,检索时间为建库至2014年7月,按照QUADAS标准对纳入文献进行质量评估。使用MetaDisc 1.4软件进行Meta分析,对不同平均热程（<24、～48和>48 h）PCT、WBC和中性粒细胞绝对计数（ANC）诊断SBIs的敏感度、特异度等指标进行汇总,并进行异质性检验,绘制综合受试者工作特征曲线（SROC）,计算曲线下面积（AUC）。使用Stata 12.0软件判断发表偏倚并绘制漏斗图。结果 初检到442篇文献,11篇文献符合纳入标准进入Meta分析（中文1篇,英文10篇）。①平均热程<24 h对SBIs的诊断价值：PCT的汇总敏感度和特异度分别为0.75（95％CI：0.69~0.80）和0.80（95％CI：0.77~0.83）,SROC AUC为0.870（95％CI：0.817~0.923）;WBC的汇总敏感度和特异度分别为0.48（95％CI：0.41~0.55）和0.54（95％CI：0.51~0.58）,AUC为0.484（95％CI：0.440~0.663）;ANC的汇总敏感度和特异度分别为0.30（95％CI：0.21~0.40）和0.78（95％CI：0.73~0.83）。②平均热程24~48 h对SBIs的诊断价值：PCT的汇总敏感度和特异度分别为0.86（95％CI：0.79~0.91）和0.63（95％CI：0.60~0.67）,AUC为0.857（95％CI：0.761~0.953）;WBC的汇总敏感度和特异度分别为0.54（95％CI：0.44~0.65）和0.46（95％CI：0.41~0.51）,AUC为0.558（95％CI：0.479~0.636）;ANC的汇总敏感度和特异度分别为0.47（95％CI：0.28~0.66）和0.12（95％CI：0.08~0.17）。③平均热程>48 h对SBIs的诊断价值：PCT 的汇总敏感度和特异度分别为0.83（95％CI：0.75~0.90）和0.55（95％CI：0.50~0.59）,AUC为0.816（95％CI：0.596~0.996）;2篇WBC文献的敏感度分别为0.69（95％CI：0.41~0.89）和0.34（95％CI：0.28~0.41）,特异度分别为0.81（95％CI：0.69~0.91）和0.29（95％CI：0.24~0.35）;ANC的敏感度和特异度分别为0.87（95％CI：0.75~0.95）和0.40（95％CI：0.34~0.46）。结论 对不明原因发热儿童诊断SBIs的价值,发热<24 h检测PCT有较高的特异度;发热24~48 h检测PCT有较高的敏感度。     

The prevention and treatment of bacterial infections in children with asplenia or hyposplenia: practice considerations at the Hospital for Sick Children, Toronto

Children born without a spleen or who have impaired splenic function, due to disease or splenectomy, are at significantly increased risk of life-threatening bacterial sepsis. The mainstays of prevention are education, immunization, and prophylactic antibiotics. The availability of conjugate 7-valent pneumococcal vaccines for use in children to age 9 years at least, as well as conjugate meningococcal C vaccine in some countries, for use beginning in infancy, appear to represent beneficial additions, but not substitutions, to previous recommendations for the use of polysaccharide 23-valent pneumococcal and quadrivalent A, C, Y, W-135 vaccines. Routine immunization against H. influenzae type b should continue with non-immunized children older than age 5 years receiving two doses 2 months apart, similar to children who have not previously received conjugate pneumococcal vaccine in infancy. Annual influenza immunization, which reduces the risk of secondary bacterial infection, is also recommended for asplenic children and their household contacts. Many experts continue prophylaxis indefinitely although prophylaxis of the penicillin allergic child remains suboptimal.     

Clinical outcome of febrile neutropenia in children with cancer using ceftazidime and aminoglycosides

To determine treatment outcome using ceftazidime-aminoglycosides in febrile neutropenic children with cancer, the authors conducted a prospective cohort study in 216 episodes. Early and complete responses to antibiotics were 108/216 (50.0%) and 133/216 (61.6%) episodes, respectively. Death, a modification of antibiotic(s), and resistance to ceftazidime were 2/118 (1.7%), 73/216 (33.8%), and 4/216 (1.9%) episodes, respectively. Primary bacteremia and emerging bacteremia during treatment were 20/216 (9.3%) and 5/216 (2.3%) episodes. Ceftazidime-aminoglycosides was found to be a reasonable initial treatment of febrile neutropenia in the authors' institution. Imipenem is considered in patients who have clinical sepsis and who fail to respond to initial treatment.