Advertisement

Factors associated with serious bacterial infections in infants ≤60 days with hypothermia in the emergency department

  • Sriram Ramgopal
    Correspondence
    Corresponding author at: Division of Emergency Medicine, Children's Hospital of Pittsburgh, AOB 2400, 4401 Penn Avenue, Pittsburgh, PA 15224, United States of America.
    Affiliations
    Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
    Search for articles by this author
  • Lorne W. Walker
    Affiliations
    Division of Infectious Disease, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
    Search for articles by this author
  • Melissa A. Vitale
    Affiliations
    Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
    Search for articles by this author
  • Andrew J. Nowalk
    Affiliations
    Division of Infectious Disease, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
    Search for articles by this author
Published:April 11, 2019DOI:https://doi.org/10.1016/j.ajem.2019.04.015

      Abstract

      Background

      We sought to investigate risk factors for serious bacterial infection (SBI: bacterial meningitis, bacteremia, and urinary tract infection [UTI]) among infants ≤60 days of age presenting to the emergency department (ED) with hypothermia (temperature < 36 °C).

      Methods

      We performed a single center study over a 12-year period including all patients ≤60 days old with hypothermia, excluding patients who did not receive a blood culture and patients who received antibiotics prior to culture acquisition. The primary outcome was SBI. Secondary outcomes were mortality and herpes simplex infection. We performed multivariable logistic regression to identify risk factors for primary outcomes reporting adjusted odds ratios with 95% confidence intervals (aOR, 95% CI).

      Results

      360 infants were identified. 10/360 (2.8%) had an SBI. All episodes of SBI occurred in infants ≤28 days of age. Two patients had meningitis, two had meningitis with bacteremia, one had isolated bacteremia, and five had UTI. Associated diagnoses included prematurity (46.9%), hyperbilirubinemia (28.3%) and dehydration (14.7%). In multivariable analysis, presentation at 15–28 days (7.60, 1.81–31.86; p = 0.005) compared to 0–14 days, higher absolute neutrophil count (1.25, 1.04–1.50; p = 0.015) and lower platelet count (0.99, 0.99–1.00; p = 0.046) were associated with SBI. Three patients without SBI died during or soon after their hospitalization. One patient had positive testing for herpes simplex.

      Conclusion

      In this cohort of hypothermic infants, 2.8% had a SBI. Age of presentation, ANC, and lower platelet count were associated with serious infections. Hypothermic infants presenting to the ED carry significant morbidity and require prospective study to better risk-stratify this population.

      Keywords

      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • de Jonge R.C.
        • van Furth A.M.
        • Wassenaar M.
        • Gemke R.J.
        • Terwee C.B.
        Predicting sequelae and death after bacterial meningitis in childhood: a systematic review of prognostic studies.
        BMC Infect Dis. 2010; 10: 232https://doi.org/10.1186/1471-2334-10-232
        • Gomez B.
        • Mintegi S.
        • Bressan S.
        • Da Dalt L.
        • Gervaix A.
        • Lacroix L.
        • et al.
        Validation of the “step-by-step” approach in the management of young febrile infants.
        Pediatrics. 2016; 138e20154381https://doi.org/10.1542/peds.2015-4381
        • Kuppermann N.
        • Dayan P.S.
        • Levine D.A.
        • Vitale M.
        • Tzimenatos L.
        • Tunik M.G.
        • et al.
        A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections.
        JAMA Pediatr. 2019; https://doi.org/10.1001/jamapediatrics.2018.5501
        • Drewry A.M.
        • Fuller B.M.
        • Skrupky L.P.
        • Hotchkiss R.S.
        The presence of hypothermia within 24 hours of sepsis diagnosis predicts persistent lymphopenia.
        Crit Care Med. 2015; 43: 1165-1169https://doi.org/10.1097/CCM.0000000000000940
        • Leon L.R.
        Hypothermia in systemic inflammation: role of cytokines.
        Front Biosci. 2004; 9: 1877-1888
        • Azab A.
        • Kobal S.
        • Rubin M.
        • Kaplanski J.
        Inhibition of prostaglandins does not reduce the cardiovascular changes during endotoxemia in rats.
        Prostaglandins Leukot Essent Fatty Acids. 2006; 74: 135-142https://doi.org/10.1016/j.plefa.2005.10.004
        • Marik P.E.
        • Zaloga G.P.
        Hypothermia and cytokines in septic shock. Norasept II Study Investigators. North American study of the safety and efficacy of murine monoclonal antibody to tumor necrosis factor for the treatment of septic shock.
        Intensive Care Med. 2000; 26: 716-721
        • Dagan R.
        • Gorodischer R.
        Infections in hypothermic infants younger than 3 months old.
        Arch Pediatr Adolesc Med. 1984; 138: 483https://doi.org/10.1001/archpedi.1984.02140430059015
        • Bower B.
        • Jones L.
        • Weeks M.
        Cold injury in the newborn. A study of 70 cases.
        Br Med J. 1960; 1: 303-309
        • El-Radhi A.S.
        • Jawad M.H.
        • Mansor N.
        • Ibrahim M.
        • Jamil I.I.
        Infection in neonatal hypothermia.
        Arch Dis Child. 1983; 58: 143-145
        • Arneil G.
        • Kerr M.
        Severe hypothermia in Glasgow infants in winter.
        Lancet (London, England). 1963; 2: 756-759
        • Perry M.C.
        • Yaeger S.K.
        • Noorbakhsh K.
        • Cruz A.T.
        • Hickey R.W.
        Hypothermia in young infants.
        Pediatr Emerg Care. 2018; : 1https://doi.org/10.1097/PEC.0000000000001674
        • Kasmire K.E.
        • Vega C.
        • Bennett N.J.
        • Laurich V.M.
        Hypothermia: a sign of sepsis in young infants in the emergency department?.
        Pediatr Emerg Care. 2018; : 1https://doi.org/10.1097/PEC.0000000000001539
        • Wood J.K.
        • Halvorson E.E.
        • Auriemma J.R.
        • Ervin S.E.
        • Thurtle D.P.
        • Keskinyan V.S.
        • et al.
        Clinical characteristics and health outcomes of neonates reporting to the emergency department with hypothermia.
        Hosp Pediatr. 2018; 8: 458-464https://doi.org/10.1542/hpeds.2017-0176
        • Goldstein B.
        • Giroir B.
        • Randolph A.
        International consensus conference on pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics.
        Pediatr Crit Care Med. 2005; 6: 2-8https://doi.org/10.1097/01.PCC.0000149131.72248.E6
        • Hofer N.
        • Müller W.
        • Resch B.
        Neonates presenting with temperature symptoms: role in the diagnosis of early onset sepsis.
        Pediatr Int. 2012; 54: 486-490https://doi.org/10.1111/j.1442-200X.2012.03570.x
        • de Almeida M.F.B.
        • Guinsburg R.
        • Sancho G.A.
        • Rosa I.R.M.
        • Lamy Z.C.
        • Martinez F.E.
        • et al.
        Hypothermia and early neonatal mortality in preterm infants.
        J Pediatr. 2014; 164: 271-275.e1https://doi.org/10.1016/J.JPEDS.2013.09.049
        • Schnadower D.
        • Kuppermann N.
        • Macias C.G.
        • Freedman S.B.
        • Baskin M.N.
        • Ishimine P.
        • et al.
        Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia.
        Pediatrics. 2010; 126: 1074-1083https://doi.org/10.1542/peds.2010-0479
        • Venebles W.N.
        • Ripley B.D.
        Modern applied statistics with S.
        4th ed. Springer, New York2002
        • Aronson P.L.
        • Thurm C.
        • Alpern E.R.
        • Alessandrini E.A.
        • Williams D.J.
        • Shah S.S.
        • et al.
        Variation in care of the febrile young infant <90 days in US pediatric emergency departments.
        Pediatrics. 2014; 134: 667-677https://doi.org/10.1542/peds.2014-1382
        • Greenhow T.L.
        • Hung Y.-Y.
        • Herz A.M.
        • Losada E.
        • Pantell R.H.
        The changing epidemiology of serious bacterial infections in young infants.
        Pediatr Infect Dis J. 2014; 33: 595-599https://doi.org/10.1097/INF.0000000000000225
        • Kuppermann N.
        • Dayan P.S.
        • Levine D.A.
        • Vitale M.
        • Tzimenatos L.
        • Tunik M.G.
        • et al.
        A clinical prediction rule for stratifying febrile infants 60 days and younger at risk for serious bacterial infections.
        JAMA Pediatr. 2019; 297: 52-60
        • Ramgopal S.
        • Janofsky S.
        • Zuckerbraun N.S.
        • Ramilo O.
        • Mahajan P.
        • Kuppermann N.
        • et al.
        Risk of serious bacterial infection in infants aged ≤60 days presenting to emergency departments with a history of fever only.
        J Pediatr. 2018; https://doi.org/10.1016/j.jpeds.2018.08.043
        • Carmon L.
        • Goldbart A.
        • Greenberg D.
        • Ben-Shimol S.
        Serious bacterial infections in hospitalized febrile infants in the first and second months of life.
        Pediatr Infect Dis J. 2017; 36: 924-929https://doi.org/10.1097/INF.0000000000001632
        • Miller S.S.
        • Lee H.C.
        • Gould J.B.
        Hypothermia in very low birth weight infants: distribution, risk factors and outcomes.
        J Perinatol. 2011; 31: S49-S56https://doi.org/10.1038/jp.2010.177
        • Cruz A.T.
        • Mahajan P.
        • Bonsu B.K.
        • Bennett J.E.
        • Levine D.A.
        • Alpern E.R.
        • et al.
        Accuracy of complete blood cell counts to identify febrile infants 60 days or younger with invasive bacterial infections.
        JAMA Pediatr. 2017; 171e172927https://doi.org/10.1001/jamapediatrics.2017.2927
        • Venkata C.
        • Kashyap R.
        • Farmer J.C.
        • Afessa B.
        Thrombocytopenia in adult patients with sepsis: incidence, risk factors, and its association with clinical outcome.
        J Intensive Care. 2013; 19https://doi.org/10.1186/2052-0492-1-9
        • Ree I.M.C.
        • Fustolo-Gunnink S.F.
        • Bekker V.
        • Fijnvandraat K.J.
        • Steggerda S.J.
        • Lopriore E.
        Thrombocytopenia in neonatal sepsis: incidence, severity and risk factors.
        PLoS One. 2017; 12e0185581https://doi.org/10.1371/journal.pone.0185581
        • Stoll B.J.
        Infectious of the neonatal infant.
        in: Kliegman R. Stanton B. St. Geme III, J. Schor N. Behrman R. Nelson textbook of pediatrics. Elsevier Saunders, Philadelphia2011: 629-647 (19th ed.)