Marc N. Baskin

Oral Versus Initial Intravenous Therapy for Urinary Tract Infections in Young Febrile Children

Background. The standard recommendation for treatment of young, febrile children with urinary tract infection has been hospitalization for intravenous antimicrobials. The availability of potent, oral, third-generation cephalosporins as well as interest in cost containment and avoidance of nosocomial risks prompted evaluation of the safety and efficacy of outpatient therapy. Methods. In a multicenter, randomized clinical trial, we evaluated the efficacy of oral versus initial intravenous therapy in 306 children 1 to 24 months old with fever and urinary tract infection, in terms of short-term clinical outcomes (sterilization of the urine and defervescence) and long-term morbidity (incidence of reinfection and incidence and extent of renal scarring documented at 6 months by99mTc-dimercaptosuccinic acid renal scans). Children received either oral cefixime for 14 days (double dose on day 1) or initial intravenous cefotaxime for 3 days followed by oral cefixime for 11 days. Results. Treatment groups were comparable regarding demographic, clinical, and laboratory characteristics. Bacteremia was present in 3.4% of children treated orally and 5.3% of children treated intravenously. Of the short-term outcomes, 1) repeat urine cultures were sterile within 24 hours in all children, and 2) mean time to defervescence was 25 and 24 hours for children treated orally and intravenously, respectively. Of the long-term outcomes, 1) symptomatic reinfections occurred in 4.6% of children treated orally and 7.2% of children treated intravenously, 2) renal scarring at 6 months was noted in 9.8% children treated orally versus 7.2% of children treated intravenously, and 3) mean extent of scarring was ∼8% in both treatment groups. Mean costs were at least twofold higher for children treated intravenously (

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

3577 vs

Acute Pediatric Rhabdomyolysis: Causes and Rates of Renal Failure

1473) compared with those treated orally. Conclusions. Oral cefixime can be recommended as a safe and effective treatment for children with fever and urinary tract infection. Use of cefixime will result in substantial reductions of health care expenditures.

A Randomized Clinical Trial of the Management of Esophageal Coins in Children

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.

Intravenous Versus Oral Corticosteroids in the Management of Acute Asthma in Children

OBJECTIVES. The goals were to (1) compare the causes, clinical presentation, and prevalence of acute renal failure in pediatric rhabdomyolysis with the published data for adults; (2) determine predictors of acute renal failure in pediatric patients with rhabdomyolysis; and (3) explore the relationship of acute renal failure with treatment modalities such as fluid and bicarbonate administration. METHODS. We performed a retrospective chart review to identify patients with creatinine kinase levels of >1000 IU/L who were treated in the emergency department of a tertiary pediatric hospital between 1993 and 2003, and we constructed regression models. RESULTS. Two hundred ten patients were studied. One hundred ninety-one patients met study eligibility (128 male and 63 female), with a median age of 11 years. The most common documented symptoms were muscle pain (45%), fever (40%), and symptoms of viral infection (39%). The most common causes of pediatric rhabdomyolysis were viral myositis (38%), trauma (26%), and connective tissue disease (5%). Six of 37 patients with creatinine kinase levels of ≥6000 IU/L had previously undiagnosed dermatomyositis or hereditary metabolic disease, compared with 10 of 154 patients with creatinine kinase levels of 1000 to 5999 IU/L. Nine of 191 patients developed acute renal failure. None of 99 patients with initial urinary heme dipstick results of <2+ developed acute renal failure, compared with 9 of 44 patients with urinary heme dipstick results of ≥2+. Higher initial creatinine kinase levels and higher fluid administration rates were associated with higher maximal creatinine levels. CONCLUSIONS. The cause of acute pediatric rhabdomyolysis is different from that of adult rhabdomyolysis. The risk of acute renal failure in children is much less than the risk reported for adults.

Febrile Infants With Urinary Tract Infections at Very Low Risk for Adverse Events and Bacteremia

Context. Children frequently ingest coins. When lodged in the esophagus, the coin may cause complications and must either be removed or observed to pass spontaneously. Objectives. (1) To compare relatively immediate endoscopic removal to a period of observation followed by removal when necessary and (2) to evaluate the relationship between select clinical features and spontaneous passage. Design/Setting. Randomized, prospective study of children <21 years old who presented to an emergency department with esophageal coins in the esophagus. Exclusion criteria were (1) history of tracheal or esophageal surgery, (2) showing symptoms, or (3) swallowing the coin >24 hours earlier. Children were randomized to either endoscopic removal (surgery) or admission for observation, with repeat radiographs ∼16 hours after the initial image. Outcome Measures. Proportion of patients requiring endoscopic removal, length of hospital stay, and the number of complications observed. Results. Among 168 children who presented with esophageal coins lodged in the esophagus, 81 were eligible. Of those eligible, 60 enrolled, 20 refused consent, and 1 was not approached. In the observation group, 23 of 30 (77%) children required endoscopy compared with 21 of 30 (70%) in the surgical group. Total hospital length of stay was longer in the randomized-to-observation group compared with the randomized-to-surgery group (mean: 19.4 [SD: ±8.0] hours vs 10.7 [SD: ±7.1] hours, respectively). There were no complications in either group. Spontaneous passage occurred at similar rates in both groups (23% vs 30%). Spontaneous passage was more likely in older patients (66 vs 46 months) and male patients (odds ratio: 3.7; 95% confidence interval: 0.98–13.99) and more likely to occur when the coin was in the distal one third of the esophagus (56% vs 27% [95% confidence interval: 1.07–5.57]). Conclusions. Because 25% to 30% of esophageal coins in children will pass spontaneously without complications, treatment of these patients may reasonably include a period of observation, in the range of 8 to 16 hours, particularly among older children and those with distally located coins.

Uses and complications of central venous catheters inserted in a pediatric emergency department.

STUDY OBJECTIVE To determine whether oral corticosteroids are significantly better at preventing the need for hospital admission than i.v. corticosteroids in children with moderate to severe asthma exacerbation. METHODS We carried out a randomized, double-blind, controlled trial of patients in the emergency department of a tertiary urban childrens hospital. Patients who presented to the ED with moderate to severe asthma (defined as forced expiratory volume in 1 second [FEV1] < 60% predicted for height in patients aged 7 to 18 years and as Pulmonary Index Score [PIS] between 6 and 11 for patients aged 18 months through 6 years). Patients were randomized to receive 2 mg/kg oral methylprednisolone or 2 mg/kg i.v. methylprednisolone 30 minutes after the initial treatment with nebulized albuterol. Each patient was otherwise treated with an identical regimen of frequent nebulized albuterol and i.v. theophylline for a total of 4 hours. RESULTS Forty-nine patients were enrolled. Four hours after treatment, both groups had similar respiratory rates, oxygen saturation, PISs, and FEV1 values. Eleven of 23 patients in the oral group (48%) and 13 of 26 patients in the i.v group (50%) were admitted to the hospital (P = .88). The 90% confidence interval for the 2% cifference in admission rate to the hospital (favoring oral methylprednisolone) ranged from 21% (favoring i.v. methylpredinisolone) to 25% (favoring oral methylprednisolone). Patients discharged home demonstrated greater improvement from baseline with regard to PIS and FEV1 than patients who were admitted. Two patients in each group failed to complete the standard treatment or returned to the hospital within 48 hours of ED discharge. CONCLUSION These data suggest that for children with moderate to severe asthma exacerbation, hospital admission rates are similar in children given oral methylprednisolone and those given i.v. methylprednisolone.

Failure of oxygen saturation and clinical assessment to predict which patients with bronchiolitis discharged from the emergency department will return requiring admission

BACKGROUND: There is limited evidence from which to derive guidelines for the management of febrile infants aged 29 to 60 days with urinary tract infections (UTIs). Most such infants are hospitalized for ≥48 hours. Our objective was to derive clinical prediction models to identify febrile infants with UTIs at very low risk of adverse events and bacteremia in a large sample of patients. METHODS: This study was a 20-center retrospective review of infants aged 29 to 60 days with temperatures of ≥38°C and culture-proven UTIs. We defined UTI by growth of ≥50 000 colony-forming units (CFU)/mL of a single pathogen or ≥10 000 CFU/mL in association with positive urinalyses. We defined adverse events as death, shock, bacterial meningitis, ICU admission need for ventilator support, or other substantial complications. We performed binary recursive partitioning analyses to derive prediction models. RESULTS: We analyzed 1895 patients. Adverse events occurred in 51 of 1842 (2.8% [95% confidence interval (CI): 2.1%–3.6%)] and bacteremia in 123 of 1877 (6.5% [95% CI: 5.5%–7.7%]). Patients were at very low risk for adverse events if not clinically ill on emergency department (ED) examination and did not have a high-risk past medical history (prediction model sensitivity: 98.0% [95% CI: 88.2%–99.9%]). Patients were at lower risk for bacteremia if they were not clinically ill on ED examination, did not have a high-risk past medical history, had a peripheral band count of <1250 cells per μL, and had a peripheral absolute neutrophil count of ≥1500 cells per μL (sensitivity 77.2% [95% CI: 68.6%–84.1%]). CONCLUSION: Brief hospitalization or outpatient management with close follow-up may be considered for infants with UTIs at very low risk of adverse events.

Impact of a Bronchiolitis Guideline on ED Resource Use and Cost: A Segmented Time-Series Analysis

Objective To describe the incidence, indications, insertion sites, duration, and complications of central venous catheter (CVC) insertion in patients in a pediatric emergency department (ED). Methods: Design Retrospective chart review. Setting ED of an urban pediatric teaching hospital. Subjects Patients who had a CVC inserted in the ED from January 1992 to July 1997. Results During the 5.5-year study period, 121 patients were identified. Indications for insertion were cardiac/respiratory arrest in 20 patients (17%), lack of peripheral vascular access in 78 (64%), and inadequate peripheral vascular access in 23 (19%). Presenting diagnoses included cardiac/respiratory arrest (20), dehydration (19), lower respiratory tract disease (15), seizure (15), sepsis (13), trauma (10), and other (29). Prior to the CVC insertion, 80 (66%) patients had no venous access, 28 (23%) had a peripheral intravenous catheter, and 13 (11%) had an intraosseous needle. One hundred one (83%) CVCs were inserted into the femoral vein, 12 (10%) into the subclavian, 7 (6%) into the internal jugular, and 1 (1%) into an axillary vein. There were four reported complications requiring the CVC to be removed, and all occurred with femoral line placement. There were no long-term sequelae or life-threatening or limb-threatening complications (95% CI = 0–2.5%). Conclusions Central venous catheterization, particularly using the femoral approach, appears to a safe method of obtaining central venous access in the critically ill infant, child, or young adult.

Bacteremia Risk and Outpatient Management of Febrile Patients With Sickle Cell Disease

Objective. To determine if there is a difference between patients with bronchiolitis who are discharged from the emergency department (ED) but return requiring admission and those who do not return. Design. Retrospective, case control study. Setting. Tertiary care childrens hospital emergency department Participants. Fifty-seven study patients under one year of age with bronchiolitis seen from November 1991 to April 1993 who were discharged but returned requiring admission within 96 hours, and 124 controls, matched by diagnosis, who did not return. Results No differences were found between cases and controls in duration of illness (3.0 vs 3.7 days, P = 0.08), gestational age (39.3 vs 38.8 weeks, P = 0.32), chronologic age (20.9 vs 22.9 weeks, P = 0.31), respiratory rate (49.9 vs 48.0 respirations/ min, P = 0.18), presence of retractions (54.8 vs 54.4%, P = 0.97), oxygen saturation (SaO2; 97.6 vs 98.0%, P = 0.29), or number of nebulized β-agonists administered in the ED (1.4 vs 1.2 P = 0.35). Cases had higher mean heart rates (HR) than controls (154.8 vs 148.8, P = 0.006). Patients with HR >150 were more likely to return requiring admission (odds ratio = 2.45, 95% confidence intervals 1.2–4.9). However, only 36 of 57 patients who returned requiring admission had HR >150 (sensitivity = 0.63), and 73 of 124 who did not return had HR ≥