Lise E. Nigrovic

Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis

OBJECTIVE. The goal of this study was to evaluate the effect of antibiotic administration before lumbar puncture on cerebrospinal fluid profiles in children with bacterial meningitis. METHODS. We reviewed the medical records of all children (1 month to 18 years of age) with bacterial meningitis who presented to 20 pediatric emergency departments between 2001 and 2004. Bacterial meningitis was defined by positive cerebrospinal fluid culture results for a bacterial pathogen or cerebrospinal fluid pleocytosis with positive blood culture and/or cerebrospinal fluid latex agglutination results. Probable bacterial meningitis was defined as positive cerebrospinal fluid Gram stain results with negative results of bacterial cultures of blood and cerebrospinal fluid. Antibiotic pretreatment was defined as any antibiotic administered within 72 hours before the lumbar puncture. RESULTS. We identified 231 patients with bacterial meningitis and another 14 with probable bacterial meningitis. Of those 245 patients, 85 (35%) had received antibiotic pretreatment. After adjustment for patient age, duration and severity of illness at presentation, and bacterial pathogen, longer duration of antibiotic pretreatment was not significantly associated with cerebrospinal fluid white blood cell count, cerebrospinal fluid absolute neutrophil count. However, antibiotic pretreatment was significantly associated with higher cerebrospinal fluid glucose and lower cerebrospinal fluid protein levels. Although these effects became apparent earlier, patients with ≥12 hours of pretreatment, compared with patients who either were not pretreated or were pretreated for <12 hours, had significantly higher median cerebrospinal fluid glucose levels (48 mg/dL vs 29 mg/dL) and lower median cerebrospinal fluid protein levels (121 vs 178 mg/dL). CONCLUSIONS. In patients with bacterial meningitis, antibiotic pretreatment is associated with higher cerebrospinal fluid glucose levels and lower cerebrospinal fluid protein levels, although pretreatment does not modify cerebrospinal fluid white blood cell count or absolute neutrophil count results.

Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review

STUDY OBJECTIVE Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED). METHODS We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success. RESULTS We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined. CONCLUSION Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.

The Effect of Observation on Cranial Computed Tomography Utilization for Children After Blunt Head Trauma

OBJECTIVE: Children with minor blunt head trauma often are observed in the emergency department before a decision is made regarding computed tomography use. We studied the impact of this clinical strategy on computed tomography use and outcomes. METHODS: We performed a subanalysis of a prospective multicenter observational study of children with minor blunt head trauma. Clinicians completed case report forms indicating whether the child was observed before making a decision regarding computed tomography. We defined clinically important traumatic brain injury as an intracranial injury resulting in death, neurosurgical intervention, intubation for longer than 24 hours, or hospital admission for 2 nights or longer. To compare computed tomography rates between children observed and those not observed before a decision was made regarding computed tomography use, we used a generalized estimating equation model to control for hospital clustering and patient characteristics. RESULTS: Of 42 412 children enrolled in the study, clinicians noted if the patient was observed before making a decision on computed tomography in 40 113 (95%). Of these, 5433 (14%) children were observed. The computed tomography use rate was lower in those observed than in those not observed (31.1% vs 35.0%; difference: −3.9% [95% confidence interval: −5.3 to −2.6]), but the rate of clinically important traumatic brain injury was similar (0.75% vs 0.87%; difference: −0.1% [95% confidence interval: −0.4 to 0.1]). After adjustment for hospital and patient characteristics, the difference in the computed tomography use rate remained significant (adjusted odds ratio for obtaining a computed tomography in the observed group: 0.53 [95% confidence interval: 0.43–0.66]). CONCLUSIONS: Clinical observation was associated with reduced computed tomography use among children with minor blunt head trauma and may be an effective strategy to reduce computed tomography use.

The Lyme vaccine: a cautionary tale

People living in endemic areas acquire Lyme disease from the bite of an infected tick. This infection, when diagnosed and treated early in its course, usually responds well to antibiotic therapy. A minority of patients develops more serious disease, particularly after a delay in diagnosis or therapy, and sometimes chronic neurological, cardiac, or rheumatological manifestations. In 1998, the FDA approved a new recombinant Lyme vaccine, LYMErix, which reduced new infections in vaccinated adults by nearly 80%. Just 3 years later, the manufacturer voluntarily withdrew its product from the market amidst media coverage, fears of vaccine side-effects, and declining sales. This paper reviews these events in detail and focuses on the public communication of risks and benefits of the Lyme vaccine and important lessons learned.

Variation in Care of the Febrile Young Infant <90 Days in US Pediatric Emergency Departments

BACKGROUND AND OBJECTIVES: Variation in patient care or outcomes may indicate an opportunity to improve quality of care. We evaluated the variation in testing, treatment, hospitalization rates, and outcomes of febrile young infants in US pediatric emergency departments (EDs). METHODS: Retrospective cohort study of infants <90 days of age with a diagnosis code of fever who were evaluated in 1 of 37 pediatric EDs between July 1, 2011 and June 30, 2013. We assessed patient- and hospital-level variation in testing, treatment, and disposition for patients in 3 distinct age groups: ≤28, 29 to 56, and 57 to 89 days. We also compared interhospital variation for 3-day revisits and revisits resulting in hospitalization. RESULTS: We identified 35 070 ED visits that met inclusion criteria. The proportion of patients who underwent comprehensive evaluation, defined as urine, serum, and cerebrospinal fluid testing, decreased with increasing patient age: 72.0% (95% confidence interval [CI], 71.0–73.0) of neonates ≤28 days, 49.0% (95% CI, 48.2–49.8) of infants 29 to 56 days, and 13.1% (95% CI, 12.5–13.6) of infants 57 to 89 days. Significant interhospital variation was demonstrated in testing, treatment, and hospitalization rates overall and across all 3 age groups, with little interhospital variation in outcomes. Hospitalization rate in the overall cohort did not correlate with 3-day revisits (R2 = 0.10, P = .06) or revisits resulting in hospitalization (R2 = 0.08, P = .09). CONCLUSIONS: Substantial patient- and hospital-level variation was observed in the ED management of the febrile young infant, without concomitant differences in outcomes. Strategies to understand and address the modifiable sources of variation are needed.

The effect of recommending cognitive rest on recovery from sport-related concussion

Abstract Objective: To determine whether recommending cognitive rest to athletes after a sport-related concussion affects time to symptom resolution. Methods: A retrospective cohort study was conducted of 184 patients who presented to a sports concussion clinic in an academic medical centre between 1 November 2007 and 31 July 2009. The effect of recommending cognitive rest on symptom duration (days) was measured after adjusting for age, gender, initial PCSS score, history of amnesia, history of loss of consciousness and number of previous concussions. Using multivariate logistic regression, independent predictors of prolonged symptoms were identified, defined as >30 days. Results: Of the 135 study patients with complete medical records, 85 (63%) had cognitive rest recommended. Of those, 79 (59%) had prolonged symptoms. In the multivariate analysis, only initial PCSS score was associated with the duration of concussion symptoms (adjusted odds ratio (AOR) = 1.03; 95% CI = 1.01–1.05). The recommendation for cognitive rest was not significantly associated with time to concussion symptom resolution (AOR = 0.5; 95% CI = 0.18–1.37). Conclusions: Given the limited evidence regarding the effects of cognitive rest on recovery from concussion, recommendations of prolonged periods of cognitive rest, particularly absences from school, should be approached cautiously.

Factors Associated With Cervical Spine Injury in Children After Blunt Trauma

STUDY OBJECTIVE Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma. METHODS We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the models sensitivity and specificity. RESULTS We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses. CONCLUSION We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.

Children with bacterial meningitis presenting to the emergency department during the pneumococcal conjugate vaccine era.

BACKGROUND The epidemiology of bacterial meningitis in children in the era of widespread heptavalent conjugate pneumococcal vaccination (PCV7) is unknown. OBJECTIVES The objective was to describe the epidemiology of bacterial meningitis in children presenting to the emergency department (ED) during the era of widespread PCV7 vaccination. METHODS The authors retrospectively reviewed the medical records of all children aged 1 month to 19 years with bacterial meningitis who presented to the EDs of 20 U.S. pediatric centers (2001-2004). Bacterial meningitis was defined by a positive cerebrospinal fluid (CSF) culture for a bacterial pathogen or CSF pleocytosis (CSF white blood cell [WBC] count >or=10 cells/mm(3)) in association with either a positive blood culture or a CSF latex agglutination study. RESULTS A total of 231 children with bacterial meningitis were identified. The median age was 0.6 years (interquartile range [IQR] = 0.2-4.2). Eight patients (3% of all patients) died. The following bacterial pathogens were identified: Streptococcus pneumoniae (n = 77; 33.3%), Neisseria meningitidis (67; 29.0%), Group B Streptococcus (42; 18.2%), Escherichia coli (17; 7.4%), nontypeable Haemophilus influenzae (10; 4.3%), other Gram-negative bacilli (7; 3.0%), Listeria monocytogenes (5; 2.2%), Group A Streptococcus (5; 2.2%), and Moraxella catarrhalis (1; 0.4%). S. pneumoniae serotypes were determined in 37 of 77 patients; of these, 62% were due to nonvaccine serotypes (including 19A). CONCLUSIONS Although now a rare infectious disease in United States, bacterial meningitis still causes substantial morbidity in affected children. Despite the introduction of PCV7, S. pneumoniae remains the most common cause of bacterial meningitis in U.S. children, with approximately half of cases due to nonvaccine serotypes.

Prevalence of Clinically Important Traumatic Brain Injuries in Children With Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms

OBJECTIVE To determine the prevalence of clinically important traumatic brain injuries (TBIs) with severe injury mechanisms in children with minor blunt head trauma but with no other risk factors from the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules (defined as isolated severe injury mechanisms). DESIGN Secondary analysis of a large prospective observational cohort study. SETTING Twenty-five emergency departments participating in the PECARN. PATIENTS Children with minor blunt head trauma and Glasgow Coma Scale scores of at least 14. INTERVENTION Treating clinicians completed a structured data form that included injury mechanism (severity categories defined a priori). MAIN OUTCOME MEASURES Clinically important TBIs were defined as intracranial injuries resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for at least 2 nights. We investigated the rate of clinically important TBIs in children with either severe injury mechanisms or isolated severe injury mechanisms. RESULTS Of the 42,412 patients enrolled in the overall study, 42,099 (99%) had injury mechanisms recorded, and their data were included for analysis. Of all study patients, 5869 (14%) had severe injury mechanisms, and 3302 (8%) had isolated severe injury mechanisms. Overall, 367 children had clinically important TBIs (0.9%; 95% CI, 0.8%-1.0%). Of the 1327 children younger than 2 years with isolated severe injury mechanisms, 4 (0.3%; 95% CI, 0.1%-0.8%) had clinically important TBIs, as did 12 of the 1975 children 2 years or older (0.6%; 95% CI, 0.3%-1.1%). CONCLUSION Children with isolated severe injury mechanisms are at low risk of clinically important TBI, and many do not require emergent neuroimaging.

Clinical Predictors of Lyme Disease Among Children With a Peripheral Facial Palsy at an Emergency Department in a Lyme Disease–Endemic Area

INTRODUCTION. Although Lyme disease can cause peripheral facial palsy in Lyme disease–endemic areas, diagnostic predictors in children have not been described. OBJECTIVE. Our goal was to determine clinical predictors of Lyme disease as the etiology of peripheral facial palsy in children presenting to an emergency department in a Lyme disease–endemic area. METHODS. We reviewed all available electronic medical charts of children ≤20 years old with peripheral facial palsy who were evaluated in the emergency department of a tertiary care pediatric center from 1995 to 2007. We used the Centers for Disease Control Lyme disease definition: presence of erythema migrans lesion or serologic evidence of infection with Borrelia burgdorferi. We performed binary logistic regression with bootstrapping validation to determine independent clinical predictors of Lyme disease. RESULTS. We identified 313 patients with peripheral facial palsy evaluated for Lyme disease. The mean age was 10.7 years, and 52% were male. Of these, 106 (34%) had Lyme disease facial palsy. After adjusting for year of study, the following were independently associated with Lyme disease facial palsy: onset of symptoms during peak Lyme disease season (June to October), absence of previous herpetic lesions, presence of fever, and history of headache. In the subset of patients without meningitis, both onset of symptoms during Lyme disease season and presence of headache remained significant independent predictors. CONCLUSIONS. Lyme disease is a frequent cause of facial palsy in children living in an endemic region. Serologic testing and empiric antibiotics should be strongly considered, especially when children present during peak Lyme disease season or with a headache.