Children with fever without apparent source: diagnosis and dilemmas

Tills thesis describes the results of diagnostic research in young children presenting with fever without apparent source at the emergency department. The study was conducted at the Sophia Children's University Hospital in Rotterdam and the Juliana Children's Hospital in The Hague, both large inner-city paediatric teaching hospitals in the Netherlands. The specific aims of the studies are: 1. To describe trends in the management of children visiting the emergency department with fever without apparent source. 2. To develop a diagnostic prediction rule for referred patients presenting with fever without apparent source, including readily obtainable parameters from the patient's history, physical examination and laboratory tests in order to distinguish the patients with a serious bacterial infection from those without a serious bacterial infection. 3. To externally validate this developed diagnostic prediction rule for referred patients. 4. To obtain a diagnostic prediction rule for self-referred patients presenting with fever without apparent source, including the determination of the generalisability of the previously developed prediction rule for referred patients. 5. To deal with pitfalls with regard to diagnostic research on routine care data. 6. To compare results of internal and external validation of the developed diagnostic prediction rule for referred patients. 7. To develop a computer-based patient record for structured data entry for paediatric practice, in particular for recording data from the patient's history and physical exarnination

Clinical Decision Support in Pediatric Care

The overall aim of the studies described in this thesis was to investigate and optimize the diagnostic process of (febrile) children presenting to the hospital emergency department (ed), and to study aspects of this process as a base for clinical decision support systems. We discussed the use of an electronic medical record with structured data entry, the development of clinical prediction rules for specific diagnostic problems in febrile children attending the hospital ed, the validity of a triage system used for pediatric patients, and the evaluation of a clinical decision support system for diagnostic management of children with fever without apparent source

Diagnosing serious infections in acutely ill children in ambulatory care (ERNIE 2 study protocol, part A): diagnostic accuracy of a clinical decision tree and added value of a point-of-care C-reactive protein test and oxygen saturation

Background: Acute illness is the most common presentation of children to ambulatory care. In contrast, serious infections are rare and often present at an early stage. To avoid complications or death, early recognition and adequate referral are essential. In a recent large study children were included prospectively to construct a symptom-based decision tree with a sensitivity and negative predictive value of nearly 100%. To reduce the number of false positives, point-of-care tests might be useful, providing an immediate result at bedside. The most probable candidate is C-reactive protein, as well as a pulse oximetry. Methods: This is a diagnostic accuracy study of signs, symptoms and point-of-care tests for serious infections. Acutely ill children presenting to a family physician or paediatrician will be included consecutively in Flanders, Belgium. Children testing positive on the decision tree will get a point-of-care C-reactive protein test. Children testing negative will randomly either receive a point-of-care C-reactive protein test or usual care. The outcome of interest is hospital admission more than 24 hours with a serious infection within 10 days. Aiming to include over 6500 children, we will report the diagnostic accuracy of the decision tree (+/- the point-of-care C-reactive protein test or pulse oximetry) in sensitivity, specificity, positive and negative likelihood ratios, and positive and negative predictive values. New diagnostic algorithms will be constructed through classification and regression tree and multiple logistic regression analysis. Discussion: We aim to improve detection of serious infections, and present a practical tool for diagnostic triage of acutely ill children in primary care. We also aim to reduce the number of investigations and admissions in children with non-serious infections

Alarming signs of serious infections in febrile children: Studies in primary care and hospital emergency care

__Abstract__ Children constitute a substantial part of the workload of physicians in primary care and hospital emergency care. In the Netherlands, about 70% of the 3.9 million inhabitants less than 20 years of age had one or more contacts with their general practitioner (GP) in 2011. Primary out-ofhours care is annually visited by approximately 600,000 children younger than 14 years of age and hospital emergency departments (EDs) by nearly 400,000 children in this age group. Fever is one of the most common reasons for children to consult a physician. The incidence of fever as a reason for contacting primary care is approximately 430 per 1,000 patients/year under the age of 5 years. The overall incidence rate of the diagnosis of fever (without apparent source) in primary care is 19.2 per 1,000 patients/year, with the highest rate for children less than one year (100 per 1,000 patients/year) and the lowest rate for children aged 10 to 17 years (2.7 per 1,000 patients/year). At the ED, fever is also one of the main presenting problems and accounts for about 10% to 30% of all visits by children. Most acute febrile illnesses are caused by self-limiting viral infections, which do not require antibiotic treatment, diagnostic procedures, or hospitalization. However, a minority of febrile children develop a serious infection, such as meningitis, sepsis, pneumonia or urinary tract infection, for which timely diagnosis and targeted therapy are necessary to prevent harm. In primary care, the annual incidence of serious infections is about 1%, with a peak incidence rate among the youngest children (0 to 4 years: 21.1 per 1,000 patients/year). At the hospital ED about 15% to 20% of febrile children are diagnosed with a serious infection. Serious infections are an important cause of morbidity and mortality, especially in young children. Infections accounted for about 15% to 20% of all childhood deaths by natural cause in the Netherlands and the United Kingdom

Accuracy of the "traffic light" clinical decision rule for serious bacterial infections in young children with fever: A retrospective cohort study

Objectives To determine the accuracy of a clinical decision rule (the traffic light system developed by the National Institute for Health and Clinical Excellence (NICE)) for detecting three common serious bacterial infections (urinary tract infection, pneumonia, and bacteraemia) in young febrile children. Design Retrospective analysis of data from a two year prospective cohort study Setting A paediatric emergency department. Participants 15 781 cases of children under 5 years of age presenting with a febrile illness. Main outcome measures Clinical features were used to categorise each febrile episodes as low, intermediate, or high probability of serious bacterial infection (green, amber, and red zones of the traffic light system); these results were checked (using standard radiological and microbiological tests) for each of the infections of interest and for any serious bacterial infection. Results After combination of the intermediate and high risk categories, the NICE traffic light system had a test sensitivity of 85.8% (95% confidence interval 83.6% to 87.7%) and specificity of 28.5% (27.8% to 29.3%) for the detection of any serious bacterial infection. Of the 1140 cases of serious bacterial infection, 157 (13.8%) were test negative (in the green zone), and, of these, 108 (68.8%) were urinary tract infections. Adding urine analysis (leucocyte esterase or nitrite positive), reported in 3653 (23.1%) episodes, to the traffic light system improved the test performance: sensitivity 92.1% (89.3% to 94.1%), specificity 22.3% (20.9% to 23.8%), and relative positive likelihood ratio 1.10 (1.06 to 1.14). Conclusion The NICE traffic light system failed to identify a substantial proportion of serious bacterial infections, particularly urinary tract infections. The addition of urine analysis significantly improved test sensitivity, making the traffic light system a more useful triage tool for the detection of serious bacterial infections in young febrile children

Signs and symptoms in children with a serious infection: a qualitative study

BACKGROUND: Early diagnosis of serious infections in children is difficult in general practice, as incidence is low, patients present themselves at an early stage of the disease and diagnostic tools are limited to signs and symptoms from observation, clinical history and physical examination. Little is known which signs and symptoms are important in general practice. With this qualitative study, we aimed to identify possible new important diagnostic variables. METHODS: Semi-structured interviews with parents and physicians of children with a serious infection. We investigated all signs and symptoms that were related to or preceded the diagnosis. The analysis was done according to the grounded theory approach. Participants were recruited in general practice and at the hospital. RESULTS: 18 children who were hospitalised because of a serious infection were included. On average, parents and paediatricians were interviewed 3 days after admittance of the child to hospital, general practitioners between 5 and 8 days after the initial contact. The most prominent diagnostic signs in seriously ill children were changed behaviour, crying characteristics and the parents' opinion. Children either behaved drowsy or irritable and cried differently, either moaning or an inconsolable, loud crying. The parents found this illness different from previous illnesses, because of the seriousness or duration of the symptoms, or the occurrence of a critical incident. Classical signs, like high fever, petechiae or abnormalities at auscultation were helpful for the diagnosis when they were present, but not helpful when they were absent. CONCLUSION: behavioural signs and symptoms were very prominent in children with a serious infection. They will be further assessed for diagnostic accuracy in a subsequent, quantitative diagnostic study

Easy Diagnosis of Invasive Pneumococcal Disease

Invasive pneumococcal disease (IPD) causes many cases of severe disease and death among children <5 years of age, mostly in developing countries. Before conjugate vaccines can be introduced in developing countries, information about disease epidemiology is urgently needed. The lack of laboratories equipped to perform pneumococcal serotyping leads to the need to send isolates to reference laboratories. Good sample preservation is necessary to prevent samples from arriving at the laboratory in poor condition. We evaluated the usefulness of multiplex real-time PCR from strains and blood samples kept at room temperature on dried blood spot (DBS) filter paper for detecting and serotyping Streptococcus pneumoniae. DBS screening is a reliable method that requires only a small amount of blood; it is used for the diagnosis of several human disease

Can computerized clinical decision support systems improve practitioners' diagnostic test ordering behavior? A decision-maker-researcher partnership systematic review

<p>Abstract</p> <p>Background</p> <p>Underuse and overuse of diagnostic tests have important implications for health outcomes and costs. Decision support technology purports to optimize the use of diagnostic tests in clinical practice. The objective of this review was to assess whether computerized clinical decision support systems (CCDSSs) are effective at improving ordering of tests for diagnosis, monitoring of disease, or monitoring of treatment. The outcome of interest was effect on the diagnostic test-ordering behavior of practitioners.</p> <p>Methods</p> <p>We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for eligible articles published up to January 2010. We included randomized controlled trials comparing the use of CCDSSs to usual practice or non-CCDSS controls in clinical care settings. Trials were eligible if at least one component of the CCDSS gave suggestions for ordering or performing a diagnostic procedure. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of test ordering outcomes.</p> <p>Results</p> <p>Thirty-five studies were identified, with significantly higher methodological quality in those published after the year 2000 (<it>p </it>= 0.002). Thirty-three trials reported evaluable data on diagnostic test ordering, and 55% (18/33) of CCDSSs improved testing behavior overall, including 83% (5/6) for diagnosis, 63% (5/8) for treatment monitoring, 35% (6/17) for disease monitoring, and 100% (3/3) for other purposes. Four of the systems explicitly attempted to reduce test ordering rates and all succeeded. Factors of particular interest to decision makers include costs, user satisfaction, and impact on workflow but were rarely investigated or reported.</p> <p>Conclusions</p> <p>Some CCDSSs can modify practitioner test-ordering behavior. To better inform development and implementation efforts, studies should describe in more detail potentially important factors such as system design, user interface, local context, implementation strategy, and evaluate impact on user satisfaction and workflow, costs, and unintended consequences.</p

Computerized clinical decision support systems for acute care management: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes

<p>Abstract</p> <p>Background</p> <p>Acute medical care often demands timely, accurate decisions in complex situations. Computerized clinical decision support systems (CCDSSs) have many features that could help. However, as for any medical intervention, claims that CCDSSs improve care processes and patient outcomes need to be rigorously assessed. The objective of this review was to systematically review the effects of CCDSSs on process of care and patient outcomes for acute medical care.</p> <p>Methods</p> <p>We conducted a decision-maker-researcher partnership systematic review. MEDLINE, EMBASE, Evidence-Based Medicine Reviews databases (Cochrane Database of Systematic Reviews, DARE, ACP Journal Club, and others), and the Inspec bibliographic database were searched to January 2010, in all languages, for randomized controlled trials (RCTs) of CCDSSs in all clinical areas. We included RCTs that evaluated the effect on process of care or patient outcomes of a CCDSS used for acute medical care compared with care provided without a CCDSS. A study was considered to have a positive effect (<it>i.e.</it>, CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive.</p> <p>Results</p> <p>Thirty-six studies met our inclusion criteria for acute medical care. The CCDSS improved process of care in 63% (22/35) of studies, including 64% (9/14) of medication dosing assistants, 82% (9/11) of management assistants using alerts/reminders, 38% (3/8) of management assistants using guidelines/algorithms, and 67% (2/3) of diagnostic assistants. Twenty studies evaluated patient outcomes, of which three (15%) reported improvements, all of which were medication dosing assistants.</p> <p>Conclusion</p> <p>The majority of CCDSSs demonstrated improvements in process of care, but patient outcomes were less likely to be evaluated and far less likely to show positive results.</p

Utilitat d'una prova ràpida per determinar la proteïna C reactiva (QuikRead go® CRP) en el maneig del lactant amb febre sense focus a urgències

The C-reactive protein (CRP) is useful in the management of infants with fever without source (FWS) as it may help identify those at high risk of potentially serious bacterial infection SBI). Methods for bedside CRP testing are now available