Febrile infants and children in the Paediatric Emergency Department: How to recognize serious bacterial infection? Prof. Jean-Christophe Mercier Service d’Urgences pédiatriques Hôpital Robert Debré, Paris, France  . . . .. .     . . . . .  . France 2013  .   . 33 Level-3 Hosp • 97 Level-2 Hosp. 500 Level-1 Hosp. 656 Dpts of EM Including 280 PEM    . .. .    . . . . .   203,000 physicians including 53,010 GPs 7,000 paediatricians 2,799 private practice     ~822,000 deliveries   . 65.8 million people 16.2 million children  .          . . . .      18 million ED visits 5 million PED visits 6.5 million GP visits 3 million Paed visits Arch. Pédiatr. 2012; 19:1132-9. Most frequent diagnoses in the Paediatric Emergency Department Robert Debré Hospital in Paris (78,599 visits in 2012) >500 codes CIM-10 2 bacterial vs. 78 enterovirus meningitis 57 imported malaria, 4 Dengue fever 4516 2234 1901 1747 1741 1546 1337 1241 1122 793 670 633 563 524 513 R on G vu O ls io ns G ri p pe 2361 R C 4719 hi no ph ar yn gi te G E D A ou le ur Br Ot on ite ch io l it As e th m e Fi è C on vre st ip at io An n g Br ine Vo on ch Pn m i i s eu se te m m op e at nts hi e ba La ct. ry n In gite qu ié tu de 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Chasing potentially severe bacterial infection is as finding a needle in a haystack! Major role of triage in the PED Goals: 1. To rapidly identify patients with urgent or life-threatening conditions. 2. To determine the most appropriate treatment area for patients presenting to the ED. 3. To decrease congestion in ED treatment areas. 4. To provide a logical mechanism for ongoing patient assessment. 5. To provide information to patients and families regarding expected care and waiting times. 6. To provide reliable information defining department acuity. The Canadian Triage and Acuity Scale for Children: A prospective multicenter evaluation. Ann Emerg Med 2012; 60:71-7. http://caep.ca/resources/ctas The importance of vital signs General Cardiovascular Respiratory Neurology Body Weight HR RR GCS Temperature BP (S/D,M) SpO2 Pain scale Study population • 30% had >1 alarming sign at triage • 23% were hospitalized Van Ierland Y et al. J Ped 2013; 162(4):862-6. Some alarming signs (eg, abnormal vital signs) strongly associated with Urgency-1 and Hospitalisation Clinical recognition of meningococcal disease in children Thompson M et al. Lancet 2006; 367:397-403 Sepsis is a dynamic process, if recognised early can we stop it? Clinical recognition of meningococcal disease in children Lancet 2006; 367:397-403 Extremity pain and refusal to walk in children with meningococcal disease. Pediatrics 2002; 110:e3 ACTIV Surveillance network of bacterial meningitis in French children: 3,376 cases 2001-2009 Corinne Levy, Emmanuelle Varon, Aurélie Lécuyer, Muhamed-Keir Taha, Daniel Floret, Henri Dabernat, Michel Boucherat, Dominique Gendrel, Yannick Aujard, Robert Cohen, Edouard Bingen and the Group of Pediatricians and Microbiologists. ESPID 2010 Bacteria N (%) Case fatality Rate (%) <1 mo N=515 (15%) >1 <12 mos N=121(36%) >12 <24 mos N=369 (11%) >2 <5 yrs N=563 (17%) >5 yrs N=714 (21%) 6.6% 16 (3%) 13 (2%) 1 (.2%) 437 (36%) 294 (24%) 97 (8%) 213 (58%) 125 (34%) 64 (17%) 371 (66%) 222 (39%) 64 (17%) 485 (68%) 266 (37%) 159 (22%) S. Pneumoniae N=957 (28%) 11.5% 9 (2%) 474 (39%) 127 (34%) 162 (29%) 185 (26% H. Influenzae N=89 (14%) 2.3% 0 40 (3%) 23 (6%) 16 (3%) 10 (1%) Strept. B N=479 (14%) 13.7%) 304 (59%) 175 (15%) 0 0 0 E. coli N=192 (6%) 10.1% 143 (28%) 49 (4%) 0 0 0 M. tuberculosis N=10 (.3%) 13.7% 0 5 (.4%) 1 (.3%) 1 (.2%) 3 (.4%) Others N=127 (4%) 8.7% 43 (8.4%) 36 (3%) 4 (1%) 13 (2%) 31 (4%) N. meningitis N=1522 (45%) • Men B N=920 • Men C N=426 Arch. Pédiatr. 2012; 19:S49-S54. Global assessment and behavioural features 12 Van den Bruel A et al. Lancet 2010; 375:834-45. Circulatory and respiratory features 13 Van den Bruel A et al. Lancet 2010; 375:834-45. Miscellaneous Van den Bruel A et al. Lancet 2010; 375:834-45. 14 Clinical decision rules to rule in or rule out SBI 15 Lancet 2010; 375:834-45. BMJ 2013;346:f1706 www.erasmusmc.nl/feverkidstool Making diagnosis in the PED is probabilist The critical role of prevalence of the disease Pre-test probability of the disease No treatment Uncertainty Dx level Required treatment Rx level 0% 100% NPV PPV NPV PPV Test useful if negative Useful if positive NPV PPV Useless Thus, any test is useful when it allows medical decision to switch from the ‘uncertainty zone’ to ‘treatment decision’ 18 Van den Bruel A et al. BMJ 2011;342:d3082 To rule in SBI, CRP >80mg/L (LR 8.3 [95%CI 5.1-14.1]) & PCT>2µg/L (LR 13.7 [7.4-25.3]) To rule out SBI, CRP<20mg/L & PCT<0.5µg/L Van den Bruel A et al. BMJ 2011;342:d3082 Urinary Tract Infections prevalence in children according to the age and sex Baby boy <3mos not circumcised: prevalence 8-9% Infant girl 3-24mos: prevalence ~7% Dubos F, Raymond J. Arch Pédiatr 2012;19:S101-8. 20 Urine sampling in infants: to bag or not? • Cleaning with soap and water • Disinfection using Dakin® or Amukine® solution • Wearing sterile gloves, gown and masks Catheter (Fr) Newborn 1-11 mos 12-23mos 2-6 yrs 7-12 yrs >12 yrs Straight 4.0-6.0 6.0-8.0 8.0 10.0 10.0-12.0 14.0 Balloon 6.0 6.0-8.0 8.0 8.0-10.0 12.0-14.0 14.0-16.0 Lacroix LE et al. Catheterization of the urethra in male children. N Engl J Med 2010; 363:e19. 21 Point of care methods at Robert Debré PED Urinary dipstick ~3min CRP-test ~5 min. PCT may be obtained on demand from the Lab within one hour, even at night Validation of a laboratory risk index score for the identification of SBI in children with fever without source PIDJ 2008; 27:654-6. 408 children (7d-36mos) with FWS Lab-score >3 Se 86% (95%CI 77-92%) Sp 83% (95%CI 79-87%) Lab-score ROC=0.91 Galetto-Lacour A et al. ADC 2010;95:968-73. Diagnostic value of the Lab-score in predicting SBI and IBI in well-apearing young febrile infants SBI • 7 Children’s hospitals in Spain & Italy • Among 533,133 visits • 1,388 infants <3 mos with fever w/o source • 1,098 included in the study • SBI= isolation of a bacterial pathogen from the blood, CSF, urine or stools in 287 (28%) • IBI= isolation of a bacterial pathogen from the blood or CSF in 23 (2%) of 1,098 IBI Bressan S et al. PIDJ 2012; 31:1239-44. Febrile infants with UTI at very low risk for adverse events and bacteremia: should we perform a LP in every febrile infant? A US 20-center retrospective study of 1,895 29-60d infants with UTI Thus a LP was performed in 1,609/1,842 (87%) for only two bacterial meningitis Schnadower D et al. Pediatrics 2010; 126:1074-83. Retrospective analysis of all (4,255) BCs collected at Kaiser Permanente Norther California on 160,818 full-term infants (1wk-3mos old) from 2005 to 2009. 7/10 with bacterial meningitis were Ill-appearing at presentation. Greenhow TL et al. Pediatrics 2012; 129:e590-6. Pediatrics 2013; 132:990-6. Two infants who had E.coli bacteremia and E.coli UTI had concurrent E.coli meningitis (2/68, 3%) SBI in febrile infants 1 to 90 days old with and without viral infections 1,779 infants Utah Children’s 1996-2002 Byington CL et al. Pediatrics 2004;113:1662-6. FWS SBI Afebrile Pediatrics 2012;130:e1455-e1462 The crucial role of epidemiology Winter epidemics in Paris area <2 yrs old www.grog.fr Flu epidemics in Paris area <15 yrs old Rapid testing for Influenza A & B is largely used at Robert Debré PED Ann Emerg Med 2013; 61:573-6. Management of febrile neonates in 36 US Pediatric Emergency Departments Blood, urine & CSF cultures Antibiotic prescription Cultures + Antibiotics + Hospitalization Jain S et al. Pediatrics 2014; 133(2):187-95. Conclusions • Recent clinical studies have improved our knowledge of SBI epidemiology in febrile infants and children. • In the PED, clinical appearance, abnormal vital signs and physical findings should alert the Clinician about SBI risk. • The Laboratory Score which combines CRP, PCT, and urinary dipstick is of tremendous help for the Clinician. • To perform or not a LP in febrile infants <3-mo old and start a probabilist antibiotic treatment is still debated, but clinical appearance should guide the Clinician. • Although viral testing using Rapid tests or multiplex PCR may help, it hasn’t decreased antibiotic treatment but may help decide discharge home without further testing. • New consensus on the management of febrile infants and children should be sought on the basis of those recent findings.