A. Chantal Caviness

Retrospective review of serious bacterial infections in infants who are 0 to 36 months of age and have influenza A infection.

Objective. Previous studies of febrile children who were 3 to 36 months of age and had clinically recognizable viral syndromes have shown low rates of concurrent bacteremia. We sought to determine the prevalence of serious bacterial infections (SBIs) among children with influenza A, a viral syndrome that can be established definitively by specific tests. Methods. We performed a retrospective cross-sectional study of patients who were 0 to 36 months of age and presented with fever to the emergency department (ED) over 4 consecutive influenza seasons. Chest radiographs and urine and cerebrospinal fluid cultures also were reviewed. Results. Of 705 included patients, 163 (23%) were influenza positive (IP) and 542 (77%) were influenza negative (IN). Only 1 IP patient was bacteremic (0.6%) versus 23 of the 542 IN control subjects (4.2%). Two (1.8%) of 110 IP cases had urinary tract infections versus 38 (9.9%) of the 382 IN control subjects. Thirteen (25.4%) of 51 IP patients had radiographic evidence of pneumonia versus 99 (41.9%) of 236 IN control subjects. There were no cases of meningitis in 41 cerebrospinal fluid samples obtained from IP patients versus 4 (2.2%) cases of culture-positive meningitis in 179 IN control subjects. A total of 16 (9.8%) SBIs were identified in the IP cases versus 153 (28.2%) in the IN control subjects. Conclusions. Febrile children with influenza A had a lower prevalence of bacteremia, urinary tract infections, consolidative pneumonia, or any SBI compared with those without influenza A infection in this study.

The Prevalence of Neonatal Herpes Simplex Virus Infection Compared with Serious Bacterial Illness in Hospitalized Neonates

OBJECTIVE To determine the prevalence of herpes simplex virus (HSV) relative to other viral infections and serious bacterial illnesses (SBIs) in hospitalized neonates admitted from a pediatric emergency department over a 5-year period. STUDY DESIGN Retrospective prevalence study of laboratory-confirmed viral infections and culture-proven SBIs, with electronic databases and medical record review. RESULTS A total 5817 neonates were included: 8.4% with viral infection, 4.6% with SBIs. Of 960 neonates with documented fever, 17.2% had viral infections (0.3% HSV infection) and 14.2% had SBIs (1.3% bacterial meningitis). Of 204 neonates with fever and cerebrospinal fluid (CSF) pleocytosis, 1.0% had HSV infection and 5.4% had bacterial meningitis. Of 124 neonates with fever and mononuclear CSF pleocytosis, 1.6% had HSV and 0.8% had bacterial meningitis. Of 187 neonates with hypothermia, 1.1% had HSV infection presenting as a sepsis-like syndrome. CONCLUSIONS In febrile neonates admitted to the hospital from the emergency department, the prevalence of HSV infection was similar to that of bacterial meningitis, suggesting that HSV infection be considered in the differential diagnosis of neonatal fever, especially in the presence of mononuclear CSF pleocytosis. HSV infection should also be considered in neonates with hypothermia and a sepsis-like syndrome.

Delivering Tailored Asthma Family Education in a Pediatric Emergency Department Setting: A Pilot Study

OBJECTIVE. Many children are brought to the pediatric emergency department (ED) with acute asthma symptoms. Emergency asthma care is costly, and many ED visits may be preventable. Families often do not have written asthma action plans and lack asthma self-managment skills. This study tests a tailored self-managment intervention delivered in the ED for families of children with asthma. The primary hypotheses were that the intervention group would have greater confidence to manage asthma 14 days postintervention and more well-asthma visits and fewer urgent care/ED visits at 9 and 12 months. METHODS. This randomized intervention/usual-care study was part of a larger ED asthma surveillance project in 4 urban pediatric ED sites. Asthma educators used a computer-based resource to tailor the intervention messages and provide a customized asthma action plan and educational summary. Children with acute asthma were enrolled during an ED visit, and follow-up telephone interviews were conducted during the next 9 months. The ED clinician classified the child’s acute and chronic severity. RESULTS. To date, 464 subjects aged 1 to 18 years have been enrolled. The ED clinicians reported that 46% had intermittent and 54% had persistent chronic severity with 51% having mild acute severity episodes. The confidence level to prevent asthma episodes and keep them from getting worse was significantly higher in the intervention group at 14 days postintervention. More subjects in the intervention group reported well-asthma visits by 9 months. Return ED visits were significantly lower in the intervention group in those with intermittent asthma. Twelve-month follow-up is in process. CONCLUSIONS. The tailored ED self-management intervention demonstrates significant effects on caregiver self-confidence and well-visit follow-up. Additional evaluation is needed to determine what impact this intervention has long-term.

Prospective Evaluation of the Risk of Serious Bacterial Infection in Children Who Present to the Emergency Department With Hyperpyrexia (Temperature of 106°F or Higher)

BACKGROUND. Previous studies of children with temperatures ≥106°F (hyperpyrexia) disagree as to whether hyperpyrexia confers a high risk of serious bacterial infection. OBJECTIVES. The purpose of this study was to determine (1) the risk of serious bacterial infection in children with hyperpyrexia and (2) whether clinical presentation can identify hyperpyrexic patients at risk for serious bacterial infection. METHODS. Data were collected prospectively on all children <18 years of age presenting to a pediatric emergency department during a 2-year period with rectal temperatures of ≥106°F. History, physical examination, complete blood cell counts, blood cultures, and nasopharyngeal viral cultures were obtained on all of the patients. RESULTS. Of 130828 visits, 103 children had hyperpyrexia (1 per 1270 patient visits). Of the 103 subjects, 20 had serious bacterial infection, and 22 had laboratory-proven viral illness (including 1 subject with bacterial/viral coinfection). The presence of a chronic underlying illness was associated with an increased risk of serious bacterial infection. The presence of rhinorrhea or any viral symptom was associated with a decreased risk of serious bacterial infection, although diarrhea itself was associated with an increased risk of serious bacterial infection. Age, maximum temperature, and total white blood cell count were not predictive of either bacterial or viral illness. CONCLUSIONS. Children with hyperpyrexia are at equally high risk for serious bacterial infection and for viral illness. Bacterial and viral coinfection also occurs. No aspect of the clinical presentation reliably distinguishes between bacterial and viral illness. We recommend consideration of antibiotic treatment for all children presenting to the emergency department with hyperpyrexia without confirmed viral illness.

Clinical and laboratory features of neonatal herpes simplex virus infection: a case-control study.

Background: Neonatal herpes simplex virus (HSV) infection can cause significant morbidity and mortality but can be difficult to identify, particularly in neonates without vesicular rash. Objective: To determine the unique clinical and laboratory features of neonates with and without HSV infection admitted to Texas Childrens Hospital during a 14-year period. Methods: An historic case-control study of all hospitalized neonates with laboratory-confirmed HSV infection and a restricted sample (ratio 1:4) of HSV test-negative hospitalized neonates. Univariate and multivariate analyses were performed to identify clinical and laboratory factors associated with neonatal HSV infection. Results: Forty cases and 160 comparison subjects were identified. The following factors were associated with neonatal HSV infection by univariate analysis: maternal primary HSV infection, maternal fever, vaginal delivery, prematurity, postnatal HSV contact, vesicular rash, hypothermia, lethargy, seizures, severe respiratory distress, hepatosplenomegaly, thrombocytopenia, elevated hepatic enzymes, and cerebrospinal fluid (CSF) pleocyosis and proteinosis. Factors not associated with neonatal HSV infection were fever, total peripheral white blood cell count, and red blood cells in the CSF. For neonates presenting without vesicular rash, maternal fever, respiratory distress requiring mechanical ventilation, and CSF pleocytosis were independently associated with HSV infection. Conclusions: Inclusion of the newly appreciated features of maternal fever, respiratory distress, and thrombocytopenia might improve the detection of neonatal HSV infection. Clinical and laboratory factors typically associated with neonatal HSV infection were confirmed to be maternal primary HSV infection, vaginal delivery, prematurity, neonatal seizures, vesicular rash, elevated hepatic enzymes, and CSF pleocytosis.

Cost-effectiveness Analysis of Herpes Simplex Virus Testing and Treatment Strategies in Febrile Neonates

OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of testing for and empirically treating herpes simplex virus (HSV) infection in neonates with fever aged from birth to 28 days. DESIGN Cost-effectiveness analysis. SETTING Decision model. PATIENTS Neonates with fever with no other symptoms and neonates with fever with cerebrospinal fluid (CSF) pleocytosis. INTERVENTIONS Four clinical strategies: (1) HSV testing and empirical treatment while awaiting test results; (2) HSV testing and treatment if test results were positive for HSV or the patient had symptoms of HSV; (3) treatment alone without testing; or (4) no HSV testing or treatment unless the patient exhibited symptoms. The 2 HSV testing methods used were CSF HSV polymerase chain reaction (PCR) and comprehensive evaluation with blood HSV PCR, CSF HSV PCR, and multiple viral cultures. MAIN OUTCOME MEASURES Twelve-month survival and quality-adjusted life expectancy with a cost-effectiveness threshold of

Hearing Loss in Children With Asymptomatic Congenital Cytomegalovirus Infection

100,000 per quality-adjusted life year (QALY) gained. RESULTS Clinical strategy 1, when applied in febrile neonates with CSF pleocytosis, saved 17 lives per 10,000 neonates and was cost-effective using CSF HSV PCR testing (

Urinary nitrate might be an early biomarker for pediatric acute kidney injury in the emergency department.

55,652/QALY gained). The cost-effectiveness of applying clinical strategy 1 in all febrile neonates depended on the cost of the CSF HSV PCR, prevalence of disease, and parental preferences for neurodevelopmental outcomes. Clinical strategies using comprehensive HSV testing were not cost-effective in febrile neonates (

The effect of acute and chronic asthma severity on pediatric emergency department utilization.

368,411/QALY gained) or febrile neonates with CSF pleocytosis (

Direct immunofluorescence assay compared to cell culture for the diagnosis of mucocutaneous herpes simplex virus infections in children

110,190/QALY gained). CONCLUSIONS Testing with CSF HSV PCR and empirically treating with acyclovir sodium saves lives and is cost-effective in febrile neonates with CSF pleocytosis. It is not a cost-effective use of health care resources in all febrile neonates.