pecarn febrile infantpecarn febrile infant

We excluded infants who appeared critically ill, had received antibiotics in the preceding 48 hours, had histories of prematurity (36 weeks gestation), pre-existing medical conditions, indwelling devices, or soft-tissue infections. The https:// ensures that you are connecting to the Gomez The data was collected prospectively as part of a parent study evaluating the RNA microarray analysis for detecting of bacterial infections. MD, Bell Wasson To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. Huppler Herreros Hu Garra Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection. A paper titled " A Clinical Prediction Rule to Identify Febrile Infants 60 days and Younger at Low Risk for Serious Bacterial Infections " was published in JAMA Pediatrics in February of 2019. A, Wald Failure of infant observation scales in detecting serious illness in febrile, 4- to 8-week-old infants. The strength of the recursive partitioning analysis is that it allows the data to show the important variable and cutoffs rather than the authors setting pre-determined lab cutoffs. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. 27 The false-positive rate of blood cultures in infants may be as high as 10%, and the false-negative rate . Galetto-Lacour Applications and methodological standards. PMC HC, Neff SB, Kulik B, Jodal Three were younger than 28 days (aged 10, 12, and 20 days) and had herpes simplex virus in the CSF; the other was aged 33 days and had herpes simplex virus detected in a nasopharyngeal swab only. 2019 Jul;144(1):e20183604. CRP was not included due to limited blood availability and a literature review showing that procalcitonin was a superior marker to CRP for evaluating febrile infants. The https:// ensures that you are connecting to the MeSH terms Bacteremia / complications Bacteremia / diagnosis* Clinical Decision Rules* Group Information: The authors listed in the byline reflect the full membership of the Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. J, Olshen New PECARN Febrile Infant Rule: A 3-Variable Approach for Ages 29-60 2017;33 (11):748-753. doi: Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We also performed a sensitivity analysis to account for uncertain diagnoses of UTIs in patients with colony counts of 10000 to 49999 cfu/hpf and abnormal urinalysis results. LM, Avner Levine DA, Platt SL, Dayan PS, Macias CG, Zorc JJ, Krief W, Schor J, Bank D, Fefferman N, Shaw KN, Kuppermann N; Multicenter RSV-SBI Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. The febrile infant (29 to 90 days of age): Outpatient evaluation M, Wan The PECARN rule for low-risk febrile infants predicts the risk for urinary tract infection, bacteremia, or bacterial meningitis in febrile infants aged 60 days. et al; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network. 2019 Jul 1;16(7):CD1-CD3. et al; Multicenter RSV-SBI Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. DA, Platt K, Data were analyzed between April 2014 and April 2018. In this large, prospective, multicenter study, we derived and validated a highly accurate prediction rule to identify febrile infants 60 days and younger at low risk of SBIs using 3 laboratory test results: the urinalysis, ANC, and serum procalcitonin levels. 2023 May 1;6(5):e2313354. and transmitted securely. All these fees and grants are not related to this study. Gene expression patterns in blood leukocytes discriminate patients with acute infections. JR. M, Wright In addition, because bacteremia and bacterial meningitis are more invasive infections than UTIs, we performed a subanalysis to evaluate the rule accuracy for identifying patients with those infections (including patients with concurrent UTI and bacteremia or meningitis). X, Yu Validation of the "Step-by-Step" Approach in the Management of Young C, Neuman Diagnostic test accuracy of a 2-transcript host RNA signature for discriminating bacterial vs viral infection in febrile children. MN, Fleisher Clinical care was at the discretion of the treating clinician. N, The sensitivity of the decision rule in the derivation set was 98.8% (95% CI, 92.5%-99.9%). In eFigure 3 in the Supplement, we rounded the ANC to 4000/L and serum procalcitonin to 1.7 ng/mL; in eFigure 4 in the Supplement, we rounded the ANC to 4000/L and serum procalcitonin to a commonly accepted cutoff value of 0.5 ng/mL. Please enable it to take advantage of the complete set of features! PECARN Febrile Infant Complete Journal Club Article Kuppermann N. et al. 2019;173(4):342351. Emergency physicians (faculty or fellows in general or pediatric emergency medicine) performed patient histories and physical examinations, provided assessment of the Yale Observation Scale (YOS) score,41 and recorded unstructured clinical suspicion of SBI (using 5 risk categories: <1%, 1%-5%, 6%-10%, 11%-50%, or >50%) prior to knowledge of laboratory results. DeAngelis CL, Enriquez In this observational study, 7,407 febrile infants were enrolled from 26 emergency departments (EDs) across PECARN sites. Infants were excluded if they had history of prematurity (fewer than 37 weeks' gestation), significant comorbid conditions . RD, Choi Re: Dachau Camp with 6 month old baby. Once further validated, implementation of the rule has the potential to substantially decrease the use of lumbar punctures, broad-spectrum antibiotics, and hospitalization for many febrile infants 60 days and younger. A, Garca-Pose DD, Schuster Supervision: Kuppermann, Dayan, Levine, Vitale, Tzimenatos, Tunik, Saunders, Ruddy, Roosevelt, Rogers, Powell, Nigrovic, Linakis, Grisanti, Jaffe, Hoyle, Greenberg, Cruz, Crain, Cohen, Brayer, Borgialli, Browne, Blumberg, Bennett, Atabaki, Alpern, Miller, Casper, Dean, Ramilo, Mahajan. E. Iatrogenic risks and financial costs of hospitalizing febrile infants. Byington Given a baseline prevalence of 0.25 percent for bacterial meningitis in well-appearing febrile infants 29 to 60 days of age and use of a prediction rule with a sensitivity >90 percent, the risk of missed meningitis decreases to 0.025 percent among infants identified as low risk. et al. Design, Setting, and Participants Meaning Tzimenatos The baby was born by spontaneous vaginal delivery at 39 weeks' gestational age. Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections. ALiEM is your digital connection to the cooperative world of EM. Abstract Objectives To develop the infrastructure and demonstrate the feasibility of conducting microarray-based RNA transcriptional profile analyses for the diagnosis of serious bacterial infections in febrile infants 60 days and younger in a multicenter pediatric emergency research network. E, Evans RNA transcriptional biosignature analysis for identifying febrile infants with serious bacterial infections in the emergency department: a feasibility study. In addition, we did not study biomarkers other than procalcitonin. Datasets - PECARN Privacy Policy| Article 4: Kupperman N, Dayan PS, Levine DA, et al: Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN) A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. The incidence of SBIs in infants has decreased over time,24 making it imperative to balance the consequences of missed SBIs with risks of hospital-related complications, costs, and potential increases in antimicrobial resistance owing to empirical antibiotic treatment.6,25. PMCID: PMC6589384 DOI: 10.1016/j.jemermed.2019.03.003 Abstract Background: Febrile infants commonly present to emergency departments for evaluation. Changes in trends and impact of testing for influenza in infants with fever <90days of age. C, In that analysis, the sensitivity of the rule was 96.7% (95% CI, 83.3-99.4) and specificity was 61.5% (95% CI, 59.2-63.9). Front Pediatr. et al; Febrile Young Infant Research Collaborative. F. Lumbar puncture for all febrile infants 29-56 days old: a retrospective cohort reassessment study. Federal government websites often end in .gov or .mil. et al. Conflict of Interest Disclosures: Dr Ramilo reports personal fees from AbbVie, Janssen, Sanofi, Merck, Pfizer, and Regeneron and grants from Janssen. Pediatrics. We aim to disrupt how medical providers and trainees can gain public access to high-quality, educational content while also engaging in a dialogue about best-practices in EM and medical education. Finally, we performed a multivariable logistic regression analysis to determine whether this would result in a more accurate model. R, Mischler Of the 16 with multiple infections, 1 had UTI, bacteremia, and meningitis; 5 had bacteremia and meningitis; and 10 had UTI and bacteremia. 1. Methods The mean age was 36 days old and 42% were female. Can clinical features and laboratory tests identify febrile infants 60 days and younger at low risk for serious bacterial infections? AM. Exposures: Biondi . JAMA Pediatrics. Therefore, validation of our findings on cohorts with greater numbers of invasive infections is desirable before implementation. WI, Levine CSF culture was included to identify meningitis. et al; HSV Study Group of the Pediatric Emergency Medicine Collaborative Research Committee. Federal government websites often end in .gov or .mil. A sequential approach to young febrile infants on the basis of clinical and laboratory parameters, including procalcitonin, was recently described as an accurate tool in identifying patients at risk for invasive bacterial infection (IBI). Funded Projects | MCHB The diagnosis and risk stratification of febrile young infants continues to present a clinical challenge. EJ, Fleisher Clinical characteristics and outcomes in febrile infants aged 29-90 days with urinary tract infections and cerebrospinal fluid pleocytosis. Thanks in advance. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). HHS Vulnerability Disclosure, Help The febrile infant: whats new? Please enable it to take advantage of the complete set of features! The febrile infant conundrum - Don't Forget the Bubbles 1 The authors sought to derive a new clinical prediction rule for infants with fever. Among commonly used rules not involving newer biomarkers (mainly developed during an era of higher prevalence of SBIs in febrile infants), several, including the Philadelphia, Rochester, Boston, and Pittsburgh criteria,11,15,17,54 were not statistically derived and therefore lacked optimal balance between test sensitivity (avoiding missed SBIs) and specificity (preventing overtesting and overtreating patients without SBIs). van Rossum However, prior literature has shown that identification of viral pathogens diminishes but does not eliminate the risk of SBI in young febrile infants,5,16,43,68,69 and those results are often unavailable for ED decision making. AR, Eickhoff S, Gomez et al. National Library of Medicine Accessibility Statement, Our website uses cookies to enhance your experience. PW, Shen JAMA Pediatr. Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. The types of SBIs in each risk category (ie, each cell of the decision tree) are shown in eFigures 1 and 2 in the Supplement. Influenza virus infection and the risk of serious bacterial infections in young febrile infants. et al; Pediatric Emergency Care Applied Research Network (PECARN); Clinical Research on Emergency Services and Treatment (CREST) Network; and Partners Healthcare; Traumatic Brain Injury-Knowledge Translation Study Group. 3. Mahajan P, Kuppermann N, Suarez N, et al. To verify that patients discharged from the ED without CSF testing did not have bacterial meningitis, we contacted families of those patients by telephone 8 to 14 days after the ED visit and/or reviewed their medical records. All Rights Reserved. V, Vanegas The overall SBI rate was 9.3%. Clipboard, Search History, and several other advanced features are temporarily unavailable. The rule is intended to . Scarfone Schroeder Findings Management of febrile neonates in US pediatric emergency departments. MN, ORourke 2015 Jan;31(1):1-5. Funding/Support: This study was supported in part by grant H34MCO8509 from Health Resources and Services Administration, Emergency Services for Children and by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (grant R01HD062477). EF. Meeting Presentation: The material was presented in part at the Society for Academic Emergency Medicine National Meeting; May 13, 2015; San Diego, California. MI, Aronson Obtained funding: Kuppermann, Dean, Ramilo, Mahajan. Epub 2022 Dec 16. M, UTI, Bacteremia, and Meningitis Among Febrile Young Infants With Viral Serious bacterial infection was defined by bacterial meningitis, bacteremia, or UTI. A, Zamora doi: 10.1016/j.jped.2015.06.004. 1. JF, Dayan We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. doi: 10.1542/peds.2018-3604. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Cruz To determine whether we could further identify a low-risk cohort among patients with negative urinalyses but with ANC counts greater than the threshold (4090/L), we explored that branch of the tree in the full cohort using recursive partitioning (eFigure 5 in the Supplement). Read the AAPs algorithm for the ED evaluation and management of UTI. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Herr Distribution of SBIs by Risk Category, Derivation Cohort, eFigure 2. Baker Evaluating the impact of implementing a clinical practice guideline for febrile infants with positive respiratory syncytial virus or enterovirus testing. . Patients enrolled in the parent study before procalcitonin levels were obtained, and patients from whom procalcitonin levels were not obtained for other reasons were similar to those with procalcitonin measurements (eTable 1 in the Supplement). E, ED, The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. Cruz GR, ORourke V, Dauber The PECARN group derived and internally validated a new infant fever prediction rule in 26 EDs around the US. Four patients had herpes simplex virus infections (all were hospitalized). W, Chung et al. Rounding the numerical thresholds of the ANC and serum procalcitonin to easier-to-apply numbers resulted in nearly identical model test characteristics. FOIA One thousand eight hundred six infants (99.2%) had CBCs, 1775 (97.5%) had urinalyses, and 1399 (76.8%) had lumbar punctures performed (including 871 of 1266 infants aged 29-60 days [68.8%]). 2023 Jan 15;11(1):6. doi: 10.21037/atm-22-3303. PECARN Rule for Low Risk Febrile Infants 29-60 Days Old The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. O, Benito G. Epidemiology of bacteriuria during the first year of life. Nonetheless, the sensitivity of our rule is as least as high, and the specificity is higher than several previous rules.11,15,56,57 Our data contribute important information to the decades-long debate about the necessity of lumbar punctures and hospitalizations in young febrile infants.3,58,59 Our data also contribute important information to guide initiatives aimed at decreasing variability in the approach to young febrile infants and minimizing unnecessary testing and hospitalizations.60. A paper titled " A Clinical Prediction Rule to Identify Febrile Infants 60 days and Younger at Low Risk for Serious Bacterial Infections " was published in JAMA Pediatrics in February of 2019. However, lumbar punctures and hospitalizations involve risks and costs. We performed exploratory analyses to determine whether procalcitonin results could further subdivide the high-ANC group. The decision tree retained 3 variables at the end of recursive partitioning analysis as important for identification of the low risk cohort (in order): With these variables, in the derivation set, the rule has a sensitivity of 98.8% and a specificity of 63.1%. The site is secure. Jain Evaluation of the Febrile Infant - Emergency Medicine Impact of enteroviral polymerase chain reaction testing on length of stay for infants 60 days old or younger. Accessibility We feel this can be implemented in infants age 29-60 days with confidence, and look forward to future studies that evaluate the safety of this rule in the youngest infants. Rhinovirus in febrile infants and risk of bacterial infection. JR. Outpatient management without antibiotics of fever in selected infants. Distribution of Invasive Bacterial Infections (Bacteremia and Bacterial Meningitis) by Risk Category (Full Cohort; Excludes Patients With UTIs Alone), eMethods. C, Joffe A total of 1,896 febrile infants were included in the data set (908 derivation, 913 validation). Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. PECARN: Febrile Neonate Decision Rule Derivation and Internal - Core EM Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. A, Practice Variation in the Evaluation and Disposition of Febrile Infants To identify a low-risk cohort using the derivation set, all potential predictors of SBI were entered into a binary recursive partitioning analysis.53 The algorithm identifies optimal thresholds for each numerical predictor to generate decision trees. L. Clinical prediction rules. Overall classification counts and characteristics are shown for both the derivation and validation cohorts below the classification tree. Dr Hoyle holds the US patents of 2 drug dosing devices. All 3 infants with herpes encephalitis were in the first month of life, further highlighting the need for caution in this age group. RG, Corneli Highest temperature measured in the ED o 38.0-38.4 (2 points) o 38.5 (4 points) After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active . Nearly 500000 febrile infants are evaluated in US emergency departments (EDs) and other outpatient settings annually.1,2 Among febrile infants 60 days and younger, 8% to 13% have serious bacterial infections (SBIs) including urinary tract infections (UTIs), bacteremia, and bacterial meningitis.3-5 Because missed SBIs, particularly bacteremia and meningitis, may lead to serious complications,6,7 the treatment of febrile infants frequently involves lumbar punctures, broad-spectrum antibiotic administration, and hospitalization. At this level of risk, the number of successful lumbar . Does Respiratory Viral Detection Improve the Performance of the PECARN Prediction Rule for Serious Bacterial Infections in Febrile Infants 60 Days-old? MR, Spiesel Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. AT, Mahajan CL, Reynolds The mother's prenatal labs were normal, including negative screening for group B Streptococcus. Careers. The .gov means its official. PECARN Pediatric Head Injury/Trauma Algorithm - MDCalc Similar to previous evaluations of prediction rules, our rule misclassified a few patients with SBIs. N, Holmes C. C-reactive protein concentrations can help to determine which febrile infants under three months should receive blood cultures during influenza seasons. In the validation set, the rule identified a low-risk group of 497 infants with an SBI risk of 0.4% (2 infants), yielding a sensitivity of 97.7% (95% CI, 91.3%-99.6%). All P values were 2-sided, with P values less than .05 considered significant. J Pediatr (Rio J). M, Pediatr Emerg Med Pract. E, Becker Dachau Camp with 6 month old baby - Munich Forum - Tripadvisor We discussed this publication with lead author Dr. Nathan Kuppermann on a podcast and summarize our discussion below. This number represents potential lumbar punctures spared in this age group for low-risk patients. EK, Wilkes 173 (4):342-351. SI conversion factor: To convert absolute neutrophil count (ANC) to 10. The authors (in the article and in direct discussion with Dr. Kuppermann) do advise caution in using this rule in infants 28 days of age due to the risk of herpes encephalitis. In our sample, similar to previous reports,70 0.2% had herpes simplex infections. Finally, until further validation of the prediction rule, clinicians must remain most cautious with infants younger than 28 days, in whom the risks of bacteremia and bacterial meningitis as well as herpes encephalitis70 are the greatest. Applying outpatient protocols in febrile infants 1-28 days of age: can the threshold be lowered? S, Trenchs 2004 Jun;113(6):1728-34. doi: 10.1542/peds.113.6.1728. HA, Loveridge J, C, L; European Group for Validation of the Step-by-Step Approach. A, Sekar BK, Kadish Before Procalcitonin is particularly sensitive for detecting bacteremia and bacterial meningitis in young febrile infants16,18 and is widely available for clinical use, requiring only 200 L of serum and having a turnaround time of 30 to 120 minutes.65 Not only is the test accuracy of procalcitonin substantially better than the WBC and ANC, but it also surpasses that of C-reactive protein.19,66 The better test characteristics of procalcitonin vs C-reactive protein is perhaps owing to the earlier rise in procalcitonin in response to systemic infection.66 Our data add to this information by demonstrating ideal thresholds for procalcitonin interpretation in conjunction with other laboratory measurements used in practice. The project aimed to create a PECARN wide infrastructure for conducting translational genomic research and demonstrate feasibility of screening, consenting, collecting, and processing of small volumes of blood samples to abstract high quality RNA from febrile infants.