Outpatient management of children at low risk for bacterial meningitis

2018 ◽  
Vol 35 (6) ◽  
pp. 361-366 ◽  
Author(s):  
Silvia Garcia ◽  
Janire Echevarri ◽  
Eunate Arana-Arri ◽  
Mercedes Sota ◽  
Javier Benito ◽  
...  
Keyword(s):  
Bacterial Meningitis ◽  
Prospective Observational Study ◽  
Final Diagnosis ◽  
Low Risk ◽  
Clinical Deterioration ◽  
Outpatient Management ◽  
Predictive Values ◽  
Risk Criteria ◽  
Csf Pleocytosis ◽  
Primary Composite Outcome

ObjectiveTo determine the outcome of children aged 2–14 years with cerebrospinal fluid (CSF) pleocytosis and at very low risk for bacterial meningitis managed as outpatients without antibiotics.MethodsMulticentre, prospective, observational study conducted at nine Spanish paediatric EDs. Patients were diagnosed with meningitis based on clinical suspicion of meningitis and CSF pleocytosis when evaluated in the ED. Children between 2 and 14 years of age with pleocytosis and very low-risk criteria for bacterial meningitis (well appearing, Bacterial Meningitis Score (BMS)=0, procalcitonin (PCT)<0.5 ng/mL and observation without deterioration for less than 24 hours in the ED) were treated as outpatients without antibiotics pending CSF cultures. The primary composite outcome was a final diagnosis of bacterial meningitis or return to the ED for clinical deterioration.ResultsOf 182 children between 2 and 14 years old diagnosed with meningitis, 56 met the very low-risk criteria and 45 were managed as outpatients. None was diagnosed with bacterial meningitis or returned due to clinical deterioration. Another 31 patients with BMS=1 (due to a peripheral absolute neutrophil count (ANC)>10 000/mm3) and PCT <0.5 ng/mL were managed as outpatients, diagnosed with aseptic meningitis and did well. BMS using PCT had the same sensitivity but greater specificity than classic BMS.ConclusionsThis set of low-risk criteria appears safe for the outpatient management without antibiotics of children with CSF pleocytosis. Larger studies are needed to evaluate the predictive values of replacing peripheral ANC with PCT in the BMS.

Outpatient management of selected young febrile infants without antibiotics

2016 ◽  
Vol 102 (3) ◽  
pp. 244-249 ◽  
Author(s):  
Santiago Mintegi ◽  
Borja Gomez ◽  
Lidia Martinez-Virumbrales ◽  
Oihane Morientes ◽  
Javier Benito
Keyword(s):  
Lumbar Puncture ◽  
Low Risk ◽  
Clinical Deterioration ◽  
Short Stay ◽  
Outpatient Management ◽  
C Reactive Protein ◽  
Reactive Protein ◽  
Risk Criteria ◽  
Bacterial Gastroenteritis

ObjectiveTo analyse the outpatient management of selected febrile infants younger than 90 days without systematic lumbar puncture and antibiotics.MethodsA prospective registry-based cohort study including all the infants ≤90 days with fever without a source (FWS) who were evaluated in a paediatric emergency department (ED) over a 7-year period (September 2007–August 2014). We analysed the outcome of those infants with low-risk criteria for serious bacterial infection (SBI) managed as outpatients without antibiotics and without undergoing a lumbar puncture. Low-risk criteria: Well appearing, older than 21 days of age, no leucocyturia, absolute neutrophil count ≤10 000, serum C reactive protein ≤20 mg/L, procalcitonin <0.5 ng/mL and no clinical deterioration during the stay in the ED (always <24 hours).Results1472 infants with FWS attended the ED. Of these, 676 were classified to be at low risk for SBI without performing a lumbar puncture. After staying <24 hours in the short-stay unit of the ED, 586 (86.6%) were managed as outpatients without antibiotics. Two patients were diagnosed with SBI: one occult bacteraemia and one bacterial gastroenteritis. Both were afebrile when evaluated again and did well. No patient returned to the ED due to clinical deterioration. Fifty-one infants (8.7%) returned to the ED mainly due to persistence of fever or irritability. None was diagnosed with definite SBI or non-bacterial meningitis.ConclusionsOutpatient management without antibiotics and systematic lumbar puncture is appropriate for selected febrile infants younger than 3 months of age with close follow-up.

Febrile Infants at Low Risk for Serious Bacterial Infection—An Appraisal of the Rochester Criteria and Implications for Management

PEDIATRICS ◽  
1994 ◽  
Vol 94 (3) ◽  
pp. 390-396 ◽  
Author(s):  
Julie A. Jaskiewicz ◽  
Carol A. McCarthy ◽  
Amy C. Richardson ◽  
Kathleen C. White ◽  
Donna J. Fisher ◽  
...  
Keyword(s):  
Confidence Interval ◽  
High Power ◽  
Microscopic Examination ◽  
Bacterial Infections ◽  
Antimicrobial Agents ◽  
Low Risk ◽  
High Power Field ◽  
Urine Sediment ◽  
Predictive Values ◽  
Risk Criteria

Objective. Prospective studies were conducted to test the hypothesis that infants unlikely to have serious bacterial infections (SBI) can be accurately identified by low risk criteria. Methods. Febrile infants (rectal T ≥ 38°C) ≤60 days of age were considered at low risk for SBI if they met the following criteria: 1) appear well; 2) were previously healthy; 3) have no focal infection; 4) have WBC count 5.0-15.0 x 109 cells/L (5000-15 000/mm3), band form count≤ 1.5 x 109 cells/L (≤1500/mm3), ≤10 WBC per high power field on microscopic examination of spun urine sediment, and ≤5 WBC per high power field on microscopic examination of a stool smear (if diarrhea). The recommended evaluation included the culture of specimens of blood, cerebrospinal fluid, and urine for bacteria. Outcomes were determined. The negative predictive values of the low risk criteria for SBI and bacteremia were calculated. Results. Of 1057 eligible infants, 931 were well appearing, and, of these, 437 met the remaining low risk criteria. Five low risk infants had SBI including two infants with bacteremia. The negative predictive value of the low risk criteria was 98.9% (95% confidence interval, 97.2% to 99.6%) for SBI, and 99.5% (95% confidence interval, 98.2% to 99.9%) for bacteremia. Conclusions. These data confirm the ability of the low risk criteria to identify infants unlikely to have SBI. Infants who meet the low risk criteria can be carefully observed without administering antimicrobial agents.

Analysis of emergency department prediction tools in evaluating febrile young infants at risk for serious infections

2019 ◽  
pp. emermed-2018-208210 ◽  
Author(s):  
Sarah Hui Wen Yao ◽  
Gene Yong-Kwang Ong ◽  
Ian K Maconochie ◽  
Khai Pin Lee ◽  
Shu-Ling Chong
Keyword(s):  
At Risk ◽  
Emergency Department ◽  
Clinical Assessment ◽  
Low Risk ◽  
Assessment Tools ◽  
Predictive Values ◽  
Nice Guideline ◽  
Risk Criteria ◽  
Young Infants ◽  
Serious Infections

ObjectiveFebrile infants≤3 months old constitute a vulnerable group at risk of serious infections (SI). We aimed to (1) study the test performance of two clinical assessment tools—the National Institute for Health and Care Excellence (NICE) Traffic Light System and Severity Index Score (SIS) in predicting SI among all febrile young infants and (2) evaluate the performance of three low-risk criteria—the Rochester Criteria (RC), Philadelphia Criteria (PC) and Boston Criteria (BC) among well-looking febrile infants.MethodsA retrospective validation study was conducted. Serious illness included both bacterial and serious viral illness such as meningitis and encephalitis. We included febrile infants≤3 months old presenting to a paediatric emergency department in Singapore between March 2015 and February 2016. Infants were assigned to high-risk and low-risk groups for SI according to each of the five tools. We compared the performance of the NICE guideline and SIS at initial clinical assessment for all infants and the low-risk criteria—RC, PC and BC—among well-looking infants. We presented their performance using sensitivity, specificity, positive, negative predictive values and likelihood ratios.ResultsOf 1057 infants analysed, 326 (30.8%) were diagnosed with SI. The NICE guideline had an overall sensitivity of 93.3% (95% CI 90.0 to 95.7), while the SIS had a sensitivity of 79.1% (95% CI 74.3 to 83.4). The incidence of SI was similar among infants who were well-looking and those who were not. Among the low-risk criteria, the RC performed with the highest sensitivity in infants aged 0–28 days (98.2%, 95% CI 90.3% to 100.0%) and 29–60 days (92.4%, 95% CI 86.0% to 96.5%), while the PC performed best in infants aged 61–90 days (100.0%, 95% CI 95.4% to 100.0%).ConclusionsThe NICE guideline achieved high sensitivity in our study population, and the RC had the highest sensitivity in predicting for SI among well-appearing febrile infants. Prospective validation is required.

Implementation of a Clinical Pathway to Avoid Lumbar Puncture in Febrile Young Infants Aged 29-56 Days Meeting a Set of Low Risk Criteria

PEDIATRICS ◽  
2016 ◽  
Vol 137 (Supplement 3) ◽  
pp. 282A-282A
Author(s):  
Payal K. Gala ◽  
Ashlee L Murray ◽  
Aileen P. Schast ◽  
Christian Minich ◽  
Ashley L. Woodford ◽  
...  
Keyword(s):  
Lumbar Puncture ◽  
Clinical Pathway ◽  
Low Risk ◽  
Risk Criteria ◽  
Young Infants

scholarly journals A safe protocol to identify low-risk patients with COVID-19 pneumonia for outpatient management

2021 ◽  
Author(s):  
Francisco Javier Teigell Muñoz ◽  
Elena García-Guijarro ◽  
Paula García-Domingo ◽  
Guadalupe Pérez-Nieto ◽  
Fernando Roque Rojas ◽  
...  
Keyword(s):  
Low Risk ◽  
Outpatient Management ◽  
Risk Patients

Outcomes and Cost of Outpatient or Inpatient Management of 712 Patients With Febrile Neutropenia

2008 ◽  
Vol 26 (4) ◽  
pp. 606-611 ◽  
Author(s):  
Linda S. Elting ◽  
Charles Lu ◽  
Carmelita P. Escalante ◽  
Sharon H. Giordano ◽  
Jonathan C. Trent ◽  
...  
Keyword(s):  
Febrile Neutropenia ◽  
Statistical Tests ◽  
Signs And Symptoms ◽  
Low Risk ◽  
Outpatient Management ◽  
Single Episode ◽  
Risk Patients ◽  
Inpatient Management ◽  
The Mean ◽  
Mean Cost

Purpose We retrospectively compared the outcomes and costs of outpatient and inpatient management of low-risk outpatients who presented to an emergency department with febrile neutropenia (FN). Patients and Methods A single episode of FN was randomly chosen from each of 712 consecutive, low-risk solid tumor outpatients who had been treated prospectively on a clinical pathway (1997-2003). Their medical records were reviewed retrospectively for overall success (resolution of all signs and symptoms of infection without modification of antibiotics, major medical complications, or intensive care unit admission) and nine secondary outcomes. Outcomes were assessed by physician investigators who were blinded to management strategy. Outcomes and costs (payer's perspective) in 529 low-risk outpatients were compared with 123 low-risk patients who were psychosocially ineligible for outpatient management (no access to caregiver, telephone, or transportation; residence > 30 minutes from treating center; poor compliance with previous outpatient therapy) using univariate statistical tests. Results Overall success was 80% among low-risk outpatients and 79% among low-risk inpatients. Response to initial antibiotics was 81% among outpatients and 80% among inpatients (P = .94); 21% of those initially treated as outpatients subsequently required hospitalization. All patients ultimately responded to antibiotics; there were no deaths. Serious complications were rare (1%) and equally frequent between the groups. The mean cost of therapy among inpatients was double that of outpatients ($15,231 v $7,772; P < .001). Conclusion Outpatient management of low-risk patients with FN is as safe and effective as inpatient management of low-risk patients and is significantly less costly.

scholarly journals Mo1093 Outpatient Management of Low-Risk Patients With Upper GI Bleeding: Can We Safely Extend the Glasgow Blatchford Score in Clinical Practice?

2014 ◽  
Vol 146 (5) ◽  
pp. S-555
Author(s):  
Zia Mustafa ◽  
Elaine Clark ◽  
Neil Campbell ◽  
Allan Cameron ◽  
Adrian J. Stanley
Keyword(s):  
Clinical Practice ◽  
Low Risk ◽  
Gi Bleeding ◽  
Outpatient Management ◽  
Upper Gi Bleeding ◽  
Upper Gi ◽  
Risk Patients

Lumbar Puncture in Pediatric Bacterial Meningitis: Defining the Time Interval for Recovery of Cerebrospinal Fluid Pathogens After Parenteral Antibiotic Pretreatment

PEDIATRICS ◽  
2001 ◽  
Vol 108 (5) ◽  
pp. 1169-1174 ◽  
Author(s):  
John T. Kanegaye ◽  
Peyman Soliemanzadeh ◽  
John S. Bradley
Keyword(s):  
Cerebrospinal Fluid ◽  
Bacterial Meningitis ◽  
Laboratory Data ◽  
Final Diagnosis ◽  
Prolonged Treatment ◽  
Time Interval ◽  
Antibiotic Administration ◽  
Parenteral Antibiotic ◽  
Culture Material ◽  
Before And After

Objective. Despite the lack of evidence defining a time interval during which cerebrospinal fluid (CSF) culture yield will not be affected by previous antibiotic therapy, recent publications cite a “minimum window” of 2 to 3 hours for recovery of bacterial pathogens after parenteral antibiotic administration. We conducted a retrospective review of children with bacterial meningitis to describe the rate at which parenteral antibiotic pretreatment sterilizes CSF cultures. Methods. The medical records of pediatric patients who were discharged from a tertiary children's hospital during a 5-year period with the final diagnosis of bacterial meningitis or suspected bacterial meningitis were reviewed. The decay in yield of CSF cultures over time was evaluated in patients with lumbar punctures (LP) delayed until after initiation of parenteral antibiotics and in patients with serial LPs before and after initiation of parenteral antibiotics. Results. The pathogens that infected the 128 study patients were Streptococcus pneumoniae (49),Neisseria meningitidis (37), group BStreptococcus (21), Haemophilus influenzae (8), other organisms (11), and undetermined (3). Thirty-nine patients (30%) had first LPs after initiation of parenteral antibiotics, and 55 (43%) had serial LPs before and after initiation of parenteral antibiotics. After ≥50 mg/kg of a third-generation cephalosporin, 3 of 9 LPs in meningococcal meningitis were sterile within 1 hour, occurring as early as 15 minutes, and all were sterile by 2 hours. With pneumococcal disease, the first negative CSF culture occurred at 4.3 hours, with 5 of 7 cultures negative from 4 to 10 hours after initiation of parenteral antibiotics. Reduced susceptibility to β-lactam antibiotics occurred in 11 of 46 pneumococcal isolates. Group B streptococcal cultures were positive through the first 8 hours after parenteral antibiotics. Blood cultures were positive in 74% of cases without pretreatment and in 57% to 68% of cases with negative CSF cultures. Conclusions. The temptation to initiate antimicrobial therapy may override the principle of obtaining adequate pretreatment culture material. The present study demonstrates that CSF sterilization may occur more rapidly after initiation of parenteral antibiotics than previously suggested, with complete sterilization of meningococcus within 2 hours and the beginning of sterilization of pneumococcus by 4 hours into therapy. Lack of adequate culture material may result in inability to tailor therapy to antimicrobial susceptibility or in unnecessarily prolonged treatment if the clinical presentation and laboratory data cannot exclude the possibility of bacterial meningitis.

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