Pneumococcal Bacteremia in Febrile Infants Presenting to the Emergency Department Before

Peter Dayan, M.D., M.Sc. & Martin Pusic, M.D., M.A.

The following are 10 manuscripts, mainly from 2007 forward, we hope will challenge your practice and have potentially immediate clinical implications.

Pneumococcal Bacteremia in Febrile Infants Presenting to the Emergency Department Before and After the Introduction of the Heptavalent Pneumococcal Vaccine.Carstairs KL, Tanen DA, Johnson AS, Kailes SB, Riffenburgh RH. Annals of Emergency Medicine. 2007;49:772-777.

Background

Fever is among the most common presenting complaints of infants and children younger than 3 years who present to the emergency department (ED). The evaluation and management of the febrile child is evolving rapidly. We compare the proportion of pneumococcal bacteremia between febrile infants and children younger than 3 years who had and had not received the heptavalent pneumococcal vaccine and who had received blood culture tests in our ED.

Methods

We performed a non-concurrent prospective observational cohort study, with a standardized medical record review to collect data of patients treated in the ED of a tertiary care military hospital during 24 months. Patients were eligible if they were younger than 36 months and had a temperature greater than or equal to 100.4°F (38°C). A data collection sheet was used to abstract age, temperature, and whether CBC count and blood cultures were obtained. Heptavalent pneumococcal vaccine status and blood culture results were obtained through review of the computerized medical record. Descriptive analysis was used for comparing the 2 groups. Group size analysis was based on the prevalence of occult bacteremia caused by Pneumococcus before the introduction of heptavalent pneumococcal vaccine. Interobserver variation was assessed by independent review of 10% of abstracted records. The main outcome measure was the proportion of positive pneumococcal blood cultures in infants and children younger than 3 years who had received at least 1 vaccination of heptavalent pneumococcal vaccine versus those who had not.

Results

Three thousand five hundred seventy-one patients met entry criteria; 1,428 had blood cultures obtained, and 833 of them received at least 1 immunization of heptavalent pneumococcal vaccine. All groups were similar in age, sex, and temperature. Positive blood culture results, including probable contaminants, were obtained for 4.2% (58/1,383) of the patients. In the heptavalent pneumococcal vaccine group, there were 0 of 833 (0%) positive pneumococcal blood cultures compared with 13 of 550 (2.4%) in the unimmunized group (P<.001; 95% confidence interval 1.4% to 3.3%).

Conclusion

Pneumococcal bacteremia was found to be lower in our patients who had received the heptavalent pneumococcal vaccine than in the patients who had not.

Martin Comments: You will have heard this at Peter’s talk this morning but it bears repeating – if a child has been immunized against Pneumococcus and HIB, the risk of these diseases is VERY low. Follow the algorithm and do fewer blood tests. Urine, on the other hand…

Oral Ondansetron for Gastroenteritis in a Pediatric Emergency Department.

Freedman SB, Adler M, Seshadri R, Powell EC. New England Journal of Medicine. 2006;354:1698.

Background: Vomiting limits the success of oral rehydration in children with gastroenteritis. We conducted a double-blind trial to determine whether a single oral dose of ondansetron, an antiemetic, would improve outcomes in children with gastroenteritis.

Background: We enrolled 215 children 6 months through 10 years of age who were treated in a pediatric emergency department for gastroenteritis and dehydration. After being randomly assigned to treatment with orally disintegrating ondansetron tablets or placebo, the children received oral-rehydration therapy according to a standardized protocol. The primary outcome was the proportion who vomited while receiving oral rehydration. The secondary outcomes were the number of episodes of vomiting and the proportions who were treated with intravenous rehydration or hospitalized.

Results: As compared with children who received placebo, children who received ondansetron were less likely to vomit (14 percent vs. 35 percent; relative risk, 0.40; 95 percent confidence interval, 0.26 to 0.61), vomited less often (mean number of episodes per child, 0.18 vs. 0.65; P<0.001), had greater oral intake (239 ml vs. 196 ml, P=0.001), and were less likely to be treated by intravenous rehydration (14 percent vs. 31 percent; relative risk, 0.46; 95 percent confidence interval, 0.26 to 0.79). Although the mean length of stay in the emergency department was reduced by 12 percent in the ondansetron group, as compared with the placebo group (P=0.02), the rates of hospitalization (4 percent and 5 percent, respectively; P=1.00) and of return visits to the emergency department (19 percent and 22 percent, P=0.73) did not differ significantly between groups.

Conclusions: In children with gastroenteritis and dehydration, a single dose of oral ondansetron reduces vomiting and facilitates oral rehydration and may thus be well suited for use in the emergency department.

Martin’s comments: So it doesn’t change the admission rate BUT does make the patients’ stay in the ED shorter and less noxious. There is a sub-lingual form of Ondansetron (Zofran) that may make it even easier to administer to a nauseous child. The next step might be to give it at Triage.Internet health information use and e-mail access by parents attending a paediatric emergency department.

Goldman RD, Macpherson A. Emergency Medicine Journal. 2006;23:345-348.

Objectives: To document internet access and health related usage patterns by families of children in a large paediatric emergency department (ED), and to discover if parents want the internet to become a tool for transferring medical test results.

Methods: This was a pre-tested, 21 item, interview conducted with parents at the paediatric ED in Toronto over 3 months. Descriptive statistics and frequency distributions were calculated and variables associated with parents wishing to access results electronically were examined.

Results: In total, 950 parents completed the interview (93%), of whom 87% reported routine internet access, 75% reported having an e-mail account, and 60% accessed their e-mail once or more a day. Over half (56%) reported searching the internet for health related information, with 8.5% of these searching immediately preceding their visit. Nearly three quarters (73%) indicated they would like to receive an e-mail containing the results of tests conducted in the ED; 66% of all respondents and 89% of those with e-mail indicated that they would like their child’s primary care provider to receive information electronically.

Conclusion: The majority of families have internet access and most want to receive medical information electronically and to send it to the primary provider. The vast use of internet for health related information emphasises the need to guide parents regarding reliable resources online, possibly as part of their ED visit.

Martin’s comments: We VASTLY underestimate the capacity for our patients to use online health knowledge. As we state in our workshop, use MEDLINEPLUS and familydoctor.org regularly. Hand the patient a handout, and you’ve fed them for a day. Teach them how to search the Internet themselves and you can change their health management forever.Effect of Ondansetron on the Incidence of Vomiting Associated with Ketamine Sedation in Children: A Double-Blind, Randomized, Placebo-Controlled Trial.

Langston W, Wathen J, Roback M, Bajaj L. Annals of Emergency Medicine. In press.
Abstract: Comparison of nebulized epinephrine to albuterol in bronchiolitis.
Walsh P, Caldwell J, McQuillan KK, Friese S, Robbins D, Rothenberg SJ.

Study Objective: We investigate the effect of ondansetron on the incidence of vomiting in children who receive intravenous (IV) ketamine for procedural sedation and analgesia in the emergency department (ED).

Methods: In this double-blind, randomized, placebo-controlled trial in a children's hospital ED, patients receiving IV ketamine (1 mg/kg) for ED procedures were randomized to receive either IV ondansetron (0.15 mg/kg; maximum 4 mg) or identical placebo. We recorded whether vomiting occurred in the ED postsedation or up to 12 hours after discharge with telephone follow-up and compared ED length of stay and parental satisfaction.

Results: One hundred twenty-seven children were randomized to placebo and 128 to ondansetron. The groups were similar in age, sex, and fasting duration. ED vomiting was less common with ondansetron: 6 of 128 (4.7%) versus 16 of 127 (12.6%), P=.02, difference 7.9% (95% confidence interval 1.1% to 14.7%), number needed to treat 13. Follow-up was successful in 82.7%, with vomiting in the ED or after discharge less frequent with ondansetron: 10 of 128 (7.8%) versus 24 of 127 (18.9%), P=.01, difference 11.1% (95% confidence interval 2.7% to 19.5%), number needed to treat 9. ED length of stay and parental satisfaction were similar between groups.

Conclusion: IV ondansetron significantly reduces the incidence of vomiting associated with IV ketamine procedural sedation in children.

Martin’s comments: Zofran everywhere. The one problem I have with this study is the seemingly high number of patients vomiting at baseline. I can’t remember the last kid who vomited after Ketamine in our hands. Maybe the culprit is the glycopyrrolate anticholinergic they gave with the study meds?

Antibiotics for acute otitis media: a meta-analysis with individual patient data.

Rovers MM, Glasziou P, Appelman CL et al. The Lancet. 2006;368:1429-1435.

Background: Individual trials to test effectiveness of antibiotics in children with acute otitis media have been too small for valid subgroup analyses. We aimed to identify subgroups of children who would and would not benefit more than others from treatment with antibiotics.

Methods: We did a meta-analysis of data from six randomised trials of the effects of antibiotics in children with acute otitis media. Individual patient data from 1643 children aged from 6 months to 12 years were validated and re-analysed. We defined the primary outcome as an extended course of acute otitis media, consisting of pain, fever, or both at 3-7 days.

Findings: Significant effect modifications were noted for otorrhoea, and for age and bilateral acute otitis media. In children younger than 2 years of age with bilateral acute otitis media, 55% of controls and 30% on antibiotics still had pain, fever, or both at 3-7 days, with a rate difference between these groups of -25% (95% CI -36% to -14%), resulting in a number-needed-to-treat (NNT) of four children. We identified no significant differences for age alone. In children with otorrhoea the rate difference and NNT, respectively, were -36% (-53% to -19%) and three, whereas in children without otorrhoea the equivalent values were -14% (-23% to -5%) and eight.

Interpretation: Antibiotics seem to be most beneficial in children younger than 2 years of age with bilateral acute otitis media, and in children with both acute otitis media and otorrhoea. For most other children with mild disease an observational policy seems justified.

Martin’s comments: This is a landmark study out of Europe where they actively look for excuses NOT to treat Otitis Media. The six studies had balanced numbers of kids on antibiotics versus placebo. It seems antibiotics only reliably make a difference in kids with either 1) bilateral findings or 2) otorrhea. Most of us know about the latter but it will be interesting to see how we use bilateral v. unilateral to decide whether someone would benefit. Note that even with the best clinical acumen, only 1 in 4 benefits from antibiotics.

A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis.

Corneli HM, Zorc JJ, Majahan P, Shaw KN, Holubkov R, Reeves SD, Ruddy RM, Malik B, Nelson KA, Bregstein JS, Brown KM, Denenberg MN, Lillis KA, Cimpello LB, Tsung JW, Borgialli DA, Baskin MN, Teshome G, Goldstein MA, Monroe D, Dean JM, Kuppermann N; Bronchiolitis Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). New England Journal of Medicine. 2007 Jul 26;357(4):331-9.

Background: Bronchiolitis, the most common infection of the lower respiratory tract in infants, is a leading cause of hospitalization in childhood. Corticosteroids are commonly used to treat bronchiolitis, but evidence of their effectiveness is limited.

Methods: We conducted a double-blind, randomized trial comparing a single dose of oral dexamethasone (1 mg per kilogram of body weight) with placebo in 600 children (age range, 2 to 12 months) with a first episode of wheezing diagnosed in the emergency department as moderate-to-severe bronchiolitis (defined by a Respiratory Distress Assessment Instrument score > or =6). We enrolled patients at 20 emergency departments during the months of November through April over a 3-year period. The primary outcome was hospital admission after 4 hours of emergency department observation. The secondary outcome was the Respiratory Assessment Change Score (RACS). We also evaluated later outcomes: length of hospital stay, later medical visits or admissions, and adverse events.

Results: Baseline characteristics were similar in the two groups. The admission rate was 39.7% for children assigned to dexamethasone, as compared with 41.0% for those assigned to placebo (absolute difference, -1.3%; 95% confidence interval [CI], -9.2 to 6.5). Both groups had respiratory improvement during observation; the mean 4-hour RACS was -5.3 for dexamethasone, as compared with -4.8 for placebo (absolute difference, -0.5; 95% CI, -1.3 to 0.3). Multivariate adjustment did not significantly alter the results, nor were differences detected in later outcomes.

Conclusions: In infants with acute moderate-to-severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes.

Peter’s comments: So that 9 month old with no past history and now with bronchiolitis and in no distress? Reassure the parents and go see the next patient. Save the oral dexamethasone for croup.

Over-the-counter medications for acute cough in children and adults in ambulatory settings.Smith SM, Schroeder K, Fahey T.Cochrane Database Syst Rev.2008 Jan 23;(1):CD001831.

Background: Acute cough due to upper respiratory tract infection (URTI) is a common symptom. Non-prescription over-the-counter (OTC) medicines are frequently recommended as a first-line treatment, but there is little evidence as to whether these drugs are effective.

Objectives: To assess the effects of oral OTC cough preparations for acute cough. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4); MEDLINE (January 1966 to January Week 1, 2007); EMBASE (January 1974 to January 2007); and the UK Department of Health National Research Register (June 2007). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing oral OTC cough preparations with placebo in children and adults suffering from acute cough in ambulatory settings. We considered all cough outcomes and second outcomes of interest were adverse effects. DATA COLLECTION AND ANALYSIS: Two review authors independently screened potentially relevant citations and independently extracted data and assessed study quality. Quantitative analysis was performed where appropriate.

Main Results: RESULTS OF STUDIES IN CHILDREN: Antitussives (two studies), antihistamines (two studies), antihistamine decongestants (two studies) and antitussive/bronchodilator combinations (one study) were no more effective than placebo. No studies using expectorants met our inclusion criteria. The results of one trial favoured active treatment with mucolytics over placebo. One trial tested two paediatric cough syrups and both preparations showed a 'satisfactory response' in 46% and 56% of children compared to 21% of children in the placebo group.

Authors’ conclusions: There is no good evidence for or against the effectiveness of OTC medicines in acute cough. The results of this review have to be interpreted with caution due differences in study characteristics and quality. Studies often showed conflicting results with uncertainty regarding clinical relevance. Higher quality evidence is needed to determine the effectiveness of self-care treatments for acute cough.

Peter’s comments: As you know, the FDA now recommends that over-the-counter (OTC) cough and cold products not be used for infants and children under 2 years of age. Very worth knowing the data.I recommend reading (both short):

Sharfstein JM, North M, Serwint JR.N Engl J Med. 2007 Dec 6;357(23):2321-4. Over the counter but no longer under the radar--pediatric cough and cold medications.

Morbidity and Mortality Weekly Report - January 12, 2007 / 56(01);1-4

Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children.Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K; Children's head injury algorithm for the prediction of important clinical events study group.Archives Diseases Children. 2006 Nov;91(11):885-91.

Background: A quarter of all patients presenting to emergency departments are children. Although there are several large, well-conducted studies on adults enabling accurate selection of patients with head injury at high risk for computed tomography scanning, no such study has derived a rule for children.

Aim: To conduct a prospective multicentre diagnostic cohort study to provide a rule for selection of high-risk children with head injury for computed tomography scanning.

Design: All children presenting to the emergency departments of 10 hospitals in the northwest of England with any severity of head injury were recruited. A tailor-made proforma was used to collect data on around 40 clinical variables for each child. These variables were defined from a literature review, and a pilot study was conducted before the children's head injury algorithm for the prediction of important clinical events (CHALICE) study. All children who had a clinically significant head injury (death, need for neurosurgical intervention or abnormality on a computed tomography scan) were identified. Recursive partitioning was used to create a highly sensitive rule for the prediction of significant intracranial pathology.

Results: 22,772 children were recruited over 2 1/2 years. 65% of these were boys and 56% were <5 years old. 281 children showed an abnormality on the computed tomography scan, 137 had a neurosurgical operation and 15 died. The CHALICE rule was derived with a sensitivity of 98% (95% confidence interval (CI) 96% to 100%) and a specificity of 87% (95% CI 86% to 87%) for the prediction of clinically significant head injury, and requires a computed tomography scan rate of 14%.

Conclusion: A highly sensitive clinical decision rule is derived for the identification of children who should undergo computed tomography scanning after head injury. This rule has the potential to improve and standardise the care of children presenting with head injuries. Validation of this rule in new cohorts of patients should now be undertaken.

Peter’s comments: The prediction rule is complex but makes some sense and is worth looking at to challenge your present practice. Some predictors in the model are difficult to assess in young patients. As for all newly derived prediction models, validation must occur prior to widespread clinical use