1. Develop strategies into practice to identify recently immunized febrile infants at risk for serious bacterial infection
2. Incorporate into clinical practice the current recommendations for steroid use in meningitis
Are steroids necessary for bacterial meningitis? When do urine cultures become positive in relation to duration of fever? This journal club will review some key articles on fever in children and will help us with the management of febrile infants who present shortly after immunizations.
Q. What is the prevalence of serious bacterial infection (SBI) in febrile infants without a source aged 6-12 weeks who have received immunizations in the preceding 72 hours?
A. Among febrile infants, the prevalence of SBI is less in the initial 24 hours following immunizations. However, there is still a substantial risk of UTI. Therefore, urine testing should be considered in febrile infants who present within 24 hours of immunization. Infants who present greater than 24 hours after immunizations with fever should be managed similarly to infants without RIs.
Wolff M, Bachur R. Serious bacterial infection in recently immunized young febrile infants. Acad Emerg Med. 2009 Dec;16(12):1284-9.
Methodology: The authors conducted a medical record review of infants aged 6-12 weeks with a fever of > or = 38.0 degrees C presenting to the pediatric emergency department (ED) over 88 months. Infants were classified either as having received immunizations within the 72 hours preceding the ED visit (recent immunization [RI]) or as not having received immunizations during this time period (no recent immunization [NRI]). Primary outcome of an SBI was based on culture results; only patients with a minimum of blood and urine cultures were studied.
Findings: A total of 1,978 febrile infants were studied, of whom 213 (10.8%) had received RIs. The overall prevalence of definite SBI was 6.6% (95% confidence interval [CI] = 5.5 to 7.7). The prevalence of definite SBI in NRI infants was 7.0% (95% CI = 5.9 to 8.3) compared to 2.8% (95% CI = 0.6 to 5.1) in the RI infants. The prevalence of definite SBI in febrile infants vaccinated in the preceding 24 hours decreased to 0.6% (95% CI = 0 to 1.9). The prevalence of definite SBI in febrile infants vaccinated greater than 24 hours prior to presentation was 8.9% (95 CI = 1.5 to 16.4). The relative risk of SBI with RI was 0.41 (95% CI = 0.19 to 0.90). All SBIs in the RI infants were urinary tract infections (UTI).
Q. Are steroids necessary for bacterial meningitis? How might treatment differ regionally?
A. Overall, adjuvant corticosteroid treatment for acute bacterial meningitis is associated with significantly reduced mortality, hearing loss, and neurologic sequelae. In high-income countries with good access to medical services, all adult and pediatric patients should receive adjuvant corticosteroids with their first dose of antibiotics. These benefits were not statistically significant in patients from low-income countries.
Upadhye S. Corticosteroids for acute bacterial meningitis . Ann Emerg Med. 2008;52:291-293.
Methodology: The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to June 2006), Current Contents (2001 to June 2006), and reference lists of all articles. They also contacted manufacturers and researchers in the relevant fields. Studies were selected if they were published and unpublished randomized controlled trials on corticosteroids as an adjuvant therapy for acute bacterial meningitis. Studies included all patient ages, clinical conditions, and treatment with antibiotics. Patients had to be randomized to corticosteroid therapy or placebo. At least 1 case fatality or episode of hearing loss had to be recorded for inclusion. Studies were independently reviewed by 2 review authors for trial quality and data extraction. Information was collected for the primary efficacy outcomes and adverse effects of adjuvant corticosteroid treatment. Planned subgroup analyses included adults versus children, causative organisms, and low- versus high-income countries. Income categorization of countries was defined by the United Nations Human Development Index: “high” defined by an index of 0.7 or higher, “lower” defined by index less than 0.7.
Findings: Twenty studies with 2,750 patients were included. The overall mortality benefit with adjuvant corticosteroid was favorable (RR=0.83; 95% confidence interval [CI] 0.71 to 0.99). There were lower rates of severe hearing loss (relative risk [RR]=0.65; 95% CI 0.47 to 0.91) and other long-term sequelae (RR=0.67; 95% CI 0.45 to 1.00). In children, there was significantly less hearing loss (RR=0.61; 95% CI 0.44 to 0.86). In adults, there was a significant reduction in mortality (RR=0.57; 95% CI 0.40 to 0.99), as well as short-term neurologic sequelae (RR=0.42; 95% CI 0.22 to 0.87).
For causative organisms, there was a mortality reduction in meningitis caused by S pneumoniae (RR=0.59; 95% CI 0.45 to 0.77) and reduced hearing loss in children with H influenzae (RR=0.37; 95% CI 0.20 to 0.68). There was a nonsignificant trend to mortality reduction with N meningitidis (RR=0.71; 95% CI 0.31 to 1.62).
For patients from high-income countries, the observed benefits were as follows: overall mortality reduction RR=0.83 (95% CI 0.51 to 1.05), short-term neurologic sequelae RR=0.56 (95% CI 0.03 to 0.84), and severe pediatric hearing loss RR=0.61 (95% CI 0.41 to 0.91). There were favorable trends to reduced pediatric severe hearing loss with non–H influenzae meningitis (RR=0.51; 95% CI 0.23 to 1.13) and short-term neurologic sequelae (RR=0.72; 95% CI 0.23 to 1.13). For all patients, and specifically children in low-income countries, there were no statistically significant benefits or adverse sequelae observed with corticosteroid use.
Q. How does the duration of fever affect the likelihood of a positive bag urinalysis or catheter culture in young children?
A. The yield of positive bag urinalyses and catheter cultures increased significantly in children with fever of 3 days or longer duration
Hashim Bin Salleeh, MDa, David McGillivray, MD, Mitch Martin, BAb, Hema Patel, MDc. Duration of Fever Affects the Likelihood of a Positive Bag Urinalysis or Catheter Culture in Young Children. J Peds 156: 629-633
Methodology: This was a prospective cohort study of 818 infants and children age 3-36 months presenting to a tertiary care emergency department with documented fever without source. Following the documentation of fever from < 1 to ≥ 5 days, bag specimens were collected for urinalysis. The primary outcome was the yield of positive bag dipsticks by day, defined as positive for nitrates or more than trace leukocyte esterase. The secondary outcome was positive catheter cultures on each day of fever.
Findings: Positive bag urinalyses increased with duration of fever: 14.8% (35/237) on day 1 versus 26.4% (43/163) on day 3 (relative risk [RR] = 1.8; 95% confidence interval [CI] = 1.2-2.7; P = .004). Positive catheter cultures increased in the same fashion: 4.8% (11/229) on day 1 versus 12.6% (20/159) on day 3 (RR = 2.6; 95% CI = 1.3-5.3; P = .005).