Paola Berlese

Bacteremia in feverish children presenting to the emergency department: a retrospective study and literature review

Aim:  To evaluate the incidence of bacteremia, and the isolated pathogens, in well‐appearing children with fever without source (FWS) presenting to the pediatric emergency department (PED), after pneumococcal conjucate vaccine ‐ 7 valent (PCV‐7) widespread introduction in the Veneto region of north‐eastern Italy, and to review the main literature contributions on the subject.

Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection

Introduction Much effort has been put in the past years to create and assess accurate tools for the management of febrile infants. However, no optimal strategy has been so far identified. A sequential approach evaluating, first, the appearance of the infant, second, the age and result of the urinanalysis and, finally, the results of the blood biomarkers, including procalcitonin, may better identify low risk febrile infants suitable for outpatient management. Objective To assess the value of a sequential approach (‘step by step’) to febrile young infants in order to identify patients at a low risk for invasive bacterial infections (IBI) who are suitable for outpatient management and compare it with other previously described strategies such as the Rochester criteria and the Lab-score. Methods A retrospective comparison of three different approaches (step by step, Lab-score and Rochester criteria) was carried out in 1123 febrile infants less than 3 months of age attended in seven European paediatric emergency departments. IBI was defined as isolation of a bacterial pathogen from the blood or cerebrospinal fluid. Results Of the 1123 infants (IBI 48; 4.2%), 488 (43.4%) were classified as low-risk criteria according to the step by step approach (vs 693 (61.7%) with the Lab-score and 458 (40.7%) with the Rochester criteria). The prevalence of IBI in the low-risk criteria patients was 0.2% (95% CI 0% to 0.6%) using the step by step approach; 0.7% (95% CI 0.1% to 1.3%) using the Lab-score; and 1.1% (95% CI 0.1% to 2%) using the Rochester criteria. Using the step by step approach, one patient with IBI was not correctly classified (2.0%, 95% CI 0% to 6.12%) versus five using the Lab-score or Rochester criteria (10.4%, 95% CI 1.76% to 19.04%). Conclusions A sequential approach to young febrile infants based on clinical and laboratory parameters, including procalcitonin, identifies better patients more suitable for outpatient management.

Association between functional gastrointestinal disorders and migraine in children and adolescents: a case-control study

BACKGROUND Functional gastrointestinal disorders and migraine are both common causes of medical attention. We have previously shown an association between migraine and infant colic. In this case-control study, we aimed to establish whether there is an association between migraine and other functional gastrointestinal disorders in children and adolescents. METHODS We included children and adolescents aged 6-17 years presenting to the emergency department of four tertiary hospitals in France and Italy. Patients diagnosed with either migraine or tension-type headache by the hospitals paediatric neurologist were enrolled as cases. Patients presenting to the emergency department with minor trauma and no history of recurrent headache were enrolled as controls. Investigators masked to a patients group allocation diagnosed functional gastrointestinal disorders using the Rome III diagnostic criteria. Univariable and multivariable analyses were done to identify specific disorders and baseline factors associated with migraines and tension-type headache. FINDINGS Between Nov 1, 2014, and Jan 31, 2015, we enrolled 648 controls and 424 cases (257 patients with migraine and 167 with tension-type headache). 83 (32%) children and adolescents in the migraine group were diagnosed with functional gastrointestinal disorders compared with 118 (18%) in the control group (p<0·0001). Multivariable logistic regression showed a significant association between migraine and three gastrointestinal disorders: functional dyspepsia (odds ratio 10·76, 95% CI 3·52-32·85; p<0·0001), irritable bowel syndrome (3·47, 1·81-6·62; p=0·0002), and abdominal migraine (5·87, 1·95-17·69; p=0·002). By contrast, there was an inverse association between migraine and functional constipation (0·34, 0·14-0·84, p=0·02). 41 (25%) participants with tension-type headache had functional gastrointestinal disorders, which did not significantly differ from the prevalence of these disorders in the control group (p=0·07); no significant association was noted between any functional gastrointestinal disease and tension-type headaches. INTERPRETATION Three abdominal-pain-related functional gastrointestinal disorders were associated with migraine in children and adolescents. These findings are of value to the diagnosis and management of these common diseases. Future studies should investigate whether antimigraine drugs are of benefit in functional gastrointestinal disorders. FUNDING None.

The Pediatric Emergency Care Applied Research Network intermediate-risk predictors were not associated with scanning decisions for minor head injuries

This study determined the predictors associated with the decision to perform a computed tomography (CT) scan in children with a minor head injury (MHI). We focused on those facing an intermediate risk of clinically important traumatic brain injury (ciTBI), according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rule.

368 Markers for Invasive Bacterial Infection in Well-Appearing Young Febrile Infants. The Value of Procalcitonin

Background In the last decade, the procalcitonin (PCT) has been introduced in many protocols for the management of the febrile child. However, its value among young well-appearing infants is not completely defined. Objective To assess the value of PCT in diagnosing serious bacterial infections and specifically invasive bacterial infections (IBIs) in well-appearing infants under 3 months of age with fever without source (FWS). Design and Methods Retrospective study including well-appearing infants under 3 months of age with FWS attended in seven European Paediatric Emergency Departments. An IBI was defined when a bacterial pathogen was isolated in blood or cerebrospinal fluid culture. Results A total of 1,531 infants under 3 months of age with FWS were attended. There were 1,112 well-appearing infants in whom PCT and a blood culture were performed. Among them, 23 (2.1%) were diagnosed with an IBI. A multivariate analysis showed that, among different epidemicological data and blood tests, PCT was the only independent risk factor for having an IBI (OR 21.69 if PCT 0.5 ng/mL). Comparing with C-Reactive Protein, PCT showed a better performance to rule-in an IBI. Among patients with normal urine dipstick and short-evolution fever (less than 6 hours), areas under the ROC curve were 0.819 and 0.563, respectively for detecting IBIs. Conclusions Among young infants with FWS, PCT showed a better performance than C-Reactive Protein in identifying patients with IBIs and, mainly in those patients with normal urine dipstick and short-evolution fever, PCT seems to be also the best marker to rule out an IBI.

PO-0308 Dural Sinus And Internal Jugular Vein Thrombosis After Blunt Head Injury In A Paediatric Patient: Good Outcome After Prompt Anticoagulation Therapy

Introduction Paediatric cerebral venous sinus thrombosis (CVST) is a rare condition (3 cases/million population), usually idiopathic. Traumatic head injury is a rare cause of this severe disease and no consensus exists regarding diagnosis and management of post-traumatic CVST. We describe the case of a patient with blunt head injury who developed sigmoid sinus and Internal Jugular Vein Thrombosis (IJVT), successfully treated with anticoagulation therapy (ACT). Case-Report A 14 years old boy, previously healthy, was brought to our ED because of an head trauma and transient loss of consciousness after a road traffic accident. On arrival he was conscious and irritated and needed sedation and oro-tracheal intubation. Immediate CT showed right temporo-parietal fracture with left fronto-parietal subarachoid hematoma. A 48 h CT revealed a worsening of right temporal hematoma and an hyperdensity area at the right sigmoid sinus suggestive of CVST, confirmed by CT venography as venous thrombosis of sigmoid sinus and IJV. His coagulation profile was normal. The patient started immediately Low Molecular Weight Heparin therapy, continued for three months. The MRI after two weeks of ACT was normal. He was discharged after 27 days without any neurological deficit. Conclusion Our report demonstrates importance of suspicion for CVST in head trauma, especially in those with high energy trauma or focal lesion, in which the neurological status cannot be monitored. The early diagnosis may permit to start an appropriated ACT, that is probably effective in reducing the risk of death and sequelae, if started early, during the acute phase.

1484 Accuracy of a Sequential Approach to Identify Young Febrile Infants at Low Risk for Invasive Bacterial Infection

Introduction Nowadays it is possible to manage as outpatients selected young febrile infants with low risk criteria for serious bacterial infection. A sequential approach, evaluating, firstly, the appearance of the infant, secondly, the urinanalysis, and, finally, the results of the blood biomarkers, including procalcitonin, may identify better low risk febrile infants suitable for outpatient management. Objective To assess the value of a sequential approach (“step by step”) to febrile young infants in order to identify low risk patients suitable for outpatient management and compare it with other ones previously described (Rochester criteria and Lab-score). Methods A retrospective comparison of three different approaches (“step by step”, Lab-score and Rochester criteria) was made in 1123 febrile infants less than 3 months of age attended in seven European Pediatric Emergency Departments. Results Of the 1123 infants (Invasive Bacterial Infection - IBI-, 48; 4.2%), 488 (43.4%) were classified as low risk criteria for IBI according to the “step by step” approach (vs 693–61.7%- with the Labscore and 458–40.7%- with the Rochester criteria). The prevalence of IBI in the low-risk criteria patients was 0.2% (95% CI 0–0.6%) using the “step by step” approach (vs 0.7%–95% CI 0.1–1.3% with the Labscore and 1.1%–95% CI 0.1–2%- with Rochester). Using the “step by step” approach, 1 patient with IBI was not correctly classified (2.0%, CI95% 0–6.12) vs 5 using the Labscore or Rochester (10.4%, CI95% 1.76–19.04%). Conclusions A sequential approach to young febrile infants including procalcitonin identifies better patients more suitable for outpatient management.