Marie Wang, MD

Abstract

To determine the frequency and predictors of temperature measurement at well-child visits in the US and report rates of interventions associated with visits at which temperature is measured and fever is detected.In this cross-sectional study, we analyzed 22,518 sampled well-child visits from the National Ambulatory Medical Care Survey (NAMCS) between 2003 and 2015. We estimated the frequency of temperature measurement and performed multivariable regression to identify patient, provider/clinic and seasonal factors associated with the practice. We described rates of interventions (complete blood count, x-ray, urinalysis, antibiotic prescription, and emergency department/hospital referral) by measurement and fever (temperature 100.4F, 38.0C) status.Temperature was measured in 48.5% (95% CI 45.6-51.4) of well-child visits. Measurement was more common during visits by non-pediatric providers (adjusted odds ratio [aOR] 2.0, 95% CI 1.6-2.5; ref: pediatricians), in Hispanic (aOR 1.9, 95% CI 1.6-2.3) and Black (aOR 1.5, 95% CI 1.2-1.9; ref: non-Hispanic White) patients, and in patients with government (aOR 2.0, 95% CI 1.7-2.4; ref: private) insurance. Interventions were more commonly pursued when temperature was measured (aOR 1.3, 95% CI 1.1-1.6) and fever was detected (aOR 3.8, 95% CI 1.5-9.4).Temperature was measured in nearly half of all well-child visits. Interventions were more common when temperature was measured and fever was detected. The value of routine temperature measurement during well-child visits warrants further evaluation.

View details for DOI 10.1016/j.jpeds.2021.01.045

View details for PubMedID 33508277

Abstract

OBJECTIVES: To describe the characteristics and outcomes of afebrile infants 60 days old with invasive bacterial infection (IBI).METHODS: We conducted a secondary analysis of a cross-sectional study of infants 60 days old with IBI presenting to the emergency departments (EDs) of 11 children's hospitals from 2011 to 2016. We classified infants as afebrile if there was absence of a temperature 38C at home, at the referring clinic, or in the ED. Bacteremia and bacterial meningitis were defined as pathogenic bacterial growth from a blood and/or cerebrospinal fluid culture.RESULTS: Of 440 infants with IBI, 78 (18%) were afebrile. Among afebrile infants, 62 (79%) had bacteremia without meningitis and 16 (20%) had bacterial meningitis (10 with concomitant bacteremia). Five infants (6%) died, all with bacteremia. The most common pathogens were Streptococcus agalactiae (35%), Escherichia coli (16%), and Staphylococcus aureus (16%). Sixty infants (77%) had an abnormal triage vital sign (temperature <36C, heart rate 181 beats per minute, or respiratory rate 66 breaths per minute) or a physical examination abnormality (ill appearance, full or depressed fontanelle, increased work of breathing, or signs of focal infection). Forty-three infants (55%) had 1 of the following laboratory abnormalities: white blood cell count <5000 or >15000 cells per muL, absolute band count >1500 cells per mul, or positive urinalysis. Presence of an abnormal vital sign, examination finding, or laboratory test result had a sensitivity of 91% (95% confidence interval 82%-96%) for IBI.CONCLUSIONS: Most afebrile young infants with an IBI had vital sign, examination, or laboratory abnormalities. Future studies should evaluate the predictive ability of these criteria in afebrile infants undergoing evaluation for IBI.

View details for DOI 10.1542/hpeds.2020-002204

View details for PubMedID 33318052

Abstract

OBJECTIVES: We aimed to describe the clinical and laboratory characteristics of febrile infants 60 days old with positive urinalysis results and invasive bacterial infections (IBI).METHODS: We performed a planned secondary analysis of a retrospective cohort study of febrile infants 60 days old with IBI who presented to 11 emergency departments from July 1, 2011, to June 30, 2016. For this subanalysis, we included infants with IBI and positive urinalysis results. We analyzed the sensitivity of high-risk past medical history (PMH) (prematurity, chronic medical condition, or recent antimicrobial receipt), ill appearance, and/or abnormal white blood cell (WBC) count (<5000 or >15000 cells/muL) for identification of IBI.RESULTS: Of 148 febrile infants with positive urinalysis results and IBI, 134 (90.5%) had bacteremia without meningitis and 14 (9.5%) had bacterial meningitis (11 with concomitant bacteremia). Thirty-five infants (23.6%) with positive urinalysis results and IBI did not have urinary tract infections. The presence of high-risk PMH, ill appearance, and/or abnormal WBC count had a sensitivity of 53.4% (95% confidence interval: 45.0-61.6) for identification of IBI. Of the 14 infants with positive urinalysis results and concomitant bacterial meningitis, 7 were 29 to 60 days old. Six of these 7 infants were ill-appearing or had an abnormal WBC count. The other infant had bacteremia with cerebrospinal fluid pleocytosis after antimicrobial pretreatment and was treated for meningitis.CONCLUSIONS: The sensitivity of high-risk PMH, ill appearance, and/or abnormal WBC count is suboptimal for identifying febrile infants with positive urinalysis results at low risk for IBI. Most infants with positive urinalysis results and bacterial meningitis are 28 days old, ill-appearing, or have an abnormal WBC count.

View details for DOI 10.1542/hpeds.2020-000638

View details for PubMedID 33239319

View details for DOI 10.12788/jhm.3496

View details for PubMedID 32924930

View details for Web of Science ID 000538159300010

Abstract

Urinary tract infections (UTIs) are the most common bacterial infection in young infants. The American Academy of Pediatrics' (AAP) clinical practice guideline for UTIs focuses on febrile children age 2-24 months, with no guideline for infants <2 months of age, an age group commonly encountered by pediatric hospitalists. In this review, we assess the applicability of the AAP UTI Guideline's action statements for previously healthy, febrile infants <2 months of age. We also discuss additional considerations in this age group, including concurrent bacteremia and routine testing for meningitis.

View details for DOI 10.12788/jhm.3349

View details for PubMedID 32118563

View details for DOI 10.12788/jhm.3451

View details for PubMedID 33147137

View details for DOI 10.1542/hpeds.2020-001685

View details for PubMedID 32817063

Abstract

We aimed to evaluate the association of height of fever with invasive bacterial infection (IBI) among febrile infants <=60 days of age.In a secondary analysis of a multicentre case-control study of non-ill-appearing febrile infants <=60 days of age, we compared the maximum temperature (at home or in the emergency department) for infants with and without IBI. We then computed interval likelihood ratios (iLRs) for the diagnosis of IBI at each half-degree Celsius interval.The median temperature was higher for infants with IBI (38.8C; IQR 38.4-39.2) compared with those without IBI (38.4C; IQR 38.2-38.9) (p<0.001). Temperatures 39C-39.4Cand 39.5C-39.9C were associated with a higher likelihood of IBI (iLR 2.49 and 3.40, respectively), although 30.4% of febrile infants with IBI had maximum temperatures <38.5C.Although IBI is more likely with higher temperatures, height of fever alone should not be used for risk stratification of febrile infants.

View details for DOI 10.1136/archdischild-2019-318548

View details for PubMedID 32819913

Abstract

GUIDELINE TITLE: (1) Measles (Rubeola): For Healthcare Professionals and (2) Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings RELEASE DATE: (1) February 5, 2018, and (2) July 2019 PRIOR VERSION(S): n/a DEVELOPER: Centers for Disease Control and Prevention (CDC) FUNDING SOURCE: CDC TARGET POPULATION: Children and adults with suspected or confirmed measles.

View details for DOI 10.12788/jhm.3346

View details for PubMedID 31869297

Abstract

We aimed to describe the cerebrospinal fluid (CSF) profiles of infants 60 days old with bacterial meningitis and the characteristics of infants with bacterial meningitis who did not have CSF abnormalities.We included infants 60 days old with culture-positive bacterial meningitis who were evaluated in the emergency departments of 11 children's hospitals between July 1, 2011, and June 30, 2016. From medical records, we abstracted clinical and laboratory data. For infants with traumatic lumbar punctures (CSF red blood cell count of 10000 cells per mm3), we used a red blood cell count/white blood cell (WBC) count correction factor of 1000:1 to determine the corrected CSF WBC count. We calculated the sensitivity for bacterial meningitis of a CSF Gram-stain and corrected CSF pleocytosis (16 WBCs per mm3 for infants 28 days old and 10 WBCs per mm3 for infants 29-60 days old).Among 66 infants with bacterial meningitis, the sensitivity of a CSF Gram-stain was 71.9% (95% confidence interval [CI]: 59.2-82.4), and the sensitivity of corrected CSF pleocytosis was 80.3% (95% CI: 68.7-89.1). The sensitivity of combining positive Gram-stain results with corrected CSF pleocytosis was 86.4% (95% CI: 75.7-93.6). Of 9 infants with meningitis who had a negative Gram-stain result and no corrected CSF pleocytosis, 8 (88.9%) had either an abnormal peripheral WBC count (>15000 or <5000 cells per L) or bandemia >10%.Most infants 60 days old with bacterial meningitis have CSF pleocytosis or a positive Gram-stain result. Infants with no CSF pleocytosis and a negative Gram-stain result are unlikely to have bacterial meningitis in the absence of other laboratory abnormalities.

View details for DOI 10.1542/hpeds.2019-0202

View details for PubMedID 31690569

Abstract

To determine the association between parenteral antibiotic duration and outcomes in infants 60 days old with bacteremic urinary tract infection (UTI).This multicenter retrospective cohort study included infants 60 days old who had concomitant growth of a pathogen in blood and urine cultures at 11 children's hospitals between 2011 and 2016. Short-course parenteral antibiotic duration was defined as 7 days, and long-course parenteral antibiotic duration was defined as >7 days. Propensity scores, calculated using patient characteristics, were used to determine the likelihood of receiving long-course parenteral antibiotics. We conducted inverse probability weighting to achieve covariate balance and applied marginal structural models to the weighted population to examine the association between parenteral antibiotic duration and outcomes (30-day UTI recurrence, 30-day all-cause reutilization, and length of stay).Among 115 infants with bacteremic UTI, 58 (50%) infants received short-course parenteral antibiotics. Infants who received long-course parenteral antibiotics were more likely to be ill appearing and have growth of a non-Escherichia coli organism. There was no difference in adjusted 30-day UTI recurrence between the long- and short-course groups (adjusted risk difference: 3%; 95% confidence interval: -5.8 to 12.7) or 30-day all-cause reutilization (risk difference: 3%; 95% confidence interval: -14.5 to 20.6).Young infants with bacteremic UTI who received 7 days of parenteral antibiotics did not have more frequent recurrent UTIs or hospital reutilization compared with infants who received long-course therapy. Short-course parenteral therapy with early conversion to oral antibiotics may be considered in this population.

View details for DOI 10.1542/peds.2018-3844

View details for PubMedID 31431480

Abstract

To derive and internally validate a prediction model for the identification of febrile infants 60 days old at low probability of invasive bacterial infection (IBI).We conducted a case-control study of febrile infants 60 days old who presented to the emergency departments of 11 hospitals between July 1, 2011 and June 30, 2016. Infants with IBI, defined by growth of a pathogen in blood (bacteremia) and/or cerebrospinal fluid (bacterial meningitis), were matched by hospital and date of visit to 2 control patients without IBI. Ill-appearing infants and those with complex chronic conditions were excluded. Predictors of IBI were identified with multiple logistic regression and internally validated with 10-fold cross-validation, and an IBI score was calculated.We included 181 infants with IBI (155 [85.6%] with bacteremia without meningitis and 26 [14.4%] with bacterial meningitis) and 362 control patients. Twenty-three infants with IBI (12.7%) and 138 control patients (38.1%) had fever by history only. Four predictors of IBI were identified (area under the curve 0.83 [95% confidence interval (CI): 0.79-0.86]) and incorporated into an IBI score: age <21 days (1 point), highest temperature recorded in the emergency department 38.0-38.4C (2 points) or 38.5C (4 points), absolute neutrophil count 5185 cells per L (2 points), and abnormal urinalysis results (3 points). The sensitivity and specificity of a score 2 were 98.8% (95% CI: 95.7%-99.9%) and 31.3% (95% CI: 26.3%-36.6%), respectively. All 26 infants with meningitis had scores 2.Infants 60 days old with fever by history only, a normal urinalysis result, and an absolute neutrophil count <5185 cells per L have a low probability of IBI.

View details for DOI 10.1542/peds.2018-3604

View details for PubMedID 31167938

Abstract

To help guide empiric treatment of infants 60 days old with suspected invasive bacterial infection by describing pathogens and their antimicrobial susceptibilities.Cross-sectional study of infants 60 days old with invasive bacterial infection (bacteremia and/or bacterial meningitis) evaluated in the emergency departments of 11 children's hospitals between July 1, 2011 and June 30, 2016. Each site's microbiology laboratory database or electronic medical record system was queried to identify infants from whom a bacterial pathogen was isolated from either blood or cerebrospinal fluid. Medical records of these infants were reviewed to confirm the presence of a pathogen and to obtain demographic, clinical, and laboratory data.Of the 442 infants with invasive bacterial infection, 353 (79.9%) had bacteremia without meningitis, 64 (14.5%) had bacterial meningitis with bacteremia, and 25 (5.7%) had bacterial meningitis without bacteremia. The peak number of cases of invasive bacterial infection occurred in the second week of life; 364 (82.4%) infants were febrile. Group B streptococcus was the most common pathogen identified (36.7%), followed by Escherichia coli (30.8%), Staphylococcus aureus (9.7%), and Enterococcus spp (6.6%). Overall, 96.8% of pathogens were susceptible to ampicillin plus a third-generation cephalosporin, 96.0% to ampicillin plus gentamicin, and 89.2% to third-generation cephalosporins alone.For most infants 60 days old evaluated in a pediatric emergency department for suspected invasive bacterial infection, the combination of ampicillin plus either gentamicin or a third-generation cephalosporin is an appropriate empiric antimicrobial treatment regimen. Of the pathogens isolated from infants with invasive bacterial infection, 11% were resistant to third-generation cephalosporins alone.

View details for PubMedID 29784512

Abstract

: media-1vid110.1542/5840460609001PEDS-VA_2018-1879Video Abstract OBJECTIVES: To evaluate the Rochester and modified Philadelphia criteria for the risk stratification of febrile infants with invasive bacterial infection (IBI) who do not appear ill without routine cerebrospinal fluid (CSF) testing.We performed a case-control study of febrile infants 60 days old presenting to 1 of 9 emergency departments from 2011 to 2016. For each infant with IBI (defined as a blood [bacteremia] and/or CSF [bacterial meningitis] culture with growth of a pathogen), controls without IBI were matched by site and date of visit. Infants were excluded if they appeared ill or had a complex chronic condition or if data for any component of the Rochester or modified Philadelphia criteria were missing.Overall, 135 infants with IBI (118 [87.4%] with bacteremia without meningitis and 17 [12.6%] with bacterial meningitis) and 249 controls were included. The sensitivity of the modified Philadelphia criteria was higher than that of the Rochester criteria (91.9% vs 81.5%; P = .01), but the specificity was lower (34.5% vs 59.8%; P < .001). Among 67 infants >28 days old with IBI, the sensitivity of both criteria was 83.6%; none of the 11 low-risk infants had bacterial meningitis. Of 68 infants 28 days old with IBI, 14 (20.6%) were low risk per the Rochester criteria, and 2 had meningitis.The modified Philadelphia criteria had high sensitivity for IBI without routine CSF testing, and all infants >28 days old with bacterial meningitis were classified as high risk. Because some infants with bacteremia were classified as low risk, infants discharged from the emergency department without CSF testing require close follow-up.

View details for PubMedID 30425130

Abstract

To determine factors associated with adverse outcomes among febrile young infants with invasive bacterial infections (IBIs) (ie, bacteremia and/or bacterial meningitis).Multicenter, retrospective cohort study (July 2011-June 2016) of febrile infants 60 days of age with pathogenic bacterial growth in blood and/or cerebrospinal fluid. Subjects were identified by query of local microbiology laboratory and/or electronic medical record systems, and clinical data were extracted by medical record review. Mixed-effect logistic regression was employed to determine clinical factors associated with 30-day adverse outcomes, which were defined as death, neurologic sequelae, mechanical ventilation, or vasoactive medication receipt.Three hundred fifty infants met inclusion criteria; 279 (79.7%) with bacteremia without meningitis and 71 (20.3%) with bacterial meningitis. Forty-two (12.0%) infants had a 30-day adverse outcome: 29 of 71 (40.8%) with bacterial meningitis vs 13 of 279 (4.7%) with bacteremia without meningitis (36.2% difference, 95% CI 25.1%-48.0%; P<.001). On adjusted analysis, bacterial meningitis (aOR 16.3, 95% CI 6.5-41.0; P<.001), prematurity (aOR 7.1, 95% CI 2.6-19.7; P<.001), and ill appearance (aOR 3.8, 95% CI 1.6-9.1; P=.002) were associated with adverse outcomes. Among infants who were born at term, not ill appearing, and had bacteremia without meningitis, only 2 of 184 (1.1%) had adverse outcomes, and there were no deaths.Among febrile infants 60 days old with IBI, prematurity, ill appearance, and bacterial meningitis (vs bacteremia without meningitis) were associated with adverse outcomes. These factors can inform clinical decision-making for febrile young infants with IBI.

View details for PubMedID 30297292

Abstract

We sought to determine the time to pathogen detection in blood and cerebrospinal fluid (CSF) for infants 60 days old with bacteremia and/or bacterial meningitis and to explore whether time to pathogen detection differed for non-ill-appearing and ill-appearing infants.We included infants 60 days old with bacteremia and/or bacterial meningitis evaluated in the emergency departments of 10 children's hospitals between July 1, 2011, and June 30, 2016. The microbiology laboratories at each site were queried to identify infants in whom a bacterial pathogen was isolated from blood and/or CSF. Medical records were then reviewed to confirm the presence of a pathogen and to extract demographic characteristics, clinical appearance, and the time to pathogen detection.Among 360 infants with bacteremia, 316 (87.8%) pathogens were detected within 24 hours and 343 (95.3%) within 36 hours. A lower proportion of non-ill-appearing infants with bacteremia had a pathogen detected on blood culture within 24 hours compared with ill-appearing infants (85.0% vs 92.9%, respectively; P = .03). Among 62 infants with bacterial meningitis, 55 (88.7%) pathogens were detected within 24 hours and 59 (95.2%) were detected within 36 hours, with no difference based on ill appearance.Among infants 60 days old with bacteremia and/or bacterial meningitis, pathogens were commonly identified from blood or CSF within 24 and 36 hours. However, clinicians must weigh the potential for missed bacteremia in non-ill-appearing infants discharged within 24 hours against the overall low prevalence of infection.

View details for PubMedID 29954839

Abstract

Possible severe bacterial infections (pSBI) continue to be a leading cause of global neonatal mortality annually. With the recent publications of simplified antibiotic regimens for treatment of pSBI where referral is not possible, it is important to know how and where to target these regimens, but data on the incidence and outcomes of pSBI are limited.We used data prospectively collected at 7 rural community-based sites in 6 low and middle income countries participating in the NICHD Global Network's Maternal and Newborn Health Registry, between January 1, 2010 and December 31, 2013. Participants included pregnant women and their live born neonates followed for 6weeks after delivery and assessed for maternal and infant outcomes.In a cohort of 248,539 infants born alive between 2010 and 2013, 32,088 (13%) neonates met symptomatic criteria for pSBI. The incidence of pSBI during the first 6weeks of life varied 10 fold from 3% (Zambia) to 36% (Pakistan), and overall case fatality rates varied 8 fold from 5% (Kenya) to 42% (Zambia). Significant variations in incidence of pSBI during the study period, with proportions decreasing in 3 sites (Argentina, Kenya and Nagpur, India), remaining stable in 3 sites (Zambia, Guatemala, Belgaum, India) and increasing in 1 site (Pakistan), cannot be explained solely by changing rates of facility deliveries. Case fatality rates did not vary over time.In a prospective population based registry with trained data collectors, there were wide variations in the incidence and case fatality of pSBI in rural communities and in trends over time. Regardless of these variations, the burden of pSBI is still high and strategies to implement timely diagnosis and treatment are still urgently needed to reduce neonatal mortality.The study was registered at ClinicalTrials.gov ( NCT01073475 ).

View details for DOI 10.1186/s12978-016-0177-1

View details for PubMedID 27221099

Abstract

Possible serious bacterial infection (PBSI) is a major cause of neonatal mortality worldwide. We studied risk factors for PSBI in a large rural population in central India where facility deliveries have increased as a result of a government financial assistance program.We studied 37,379 pregnant women and their singleton live born infants with birth weight1.5kg from 20 rural primary health centers around Nagpur, India, using data from the 2010-13 population-based Maternal and Newborn Health Registry supported by NICHD's Global Network for Women's and Children's Health Research. Factors associated with PSBI were identified using multivariable Poisson regression.Two thousand one hundred twenty-three infants (6%) had PSBI. Risk factors for PSBI included nulliparity (RR 1.13, 95% CI 1.03-1.23), parity>2 (RR 1.30, 95% CI 1.07-1.57) compared to parity 1-2, first antenatal care visit in the 2(nd)/3(rd) trimester (RR 1.46, 95% CI 1.08-1.98) compared to 1(st) trimester, administration of antenatal corticosteroids (RR 2.04, 95% CI 1.60-2.61), low birth weight (RR 3.10, 95% CI 2.17-4.42), male sex (RR 1.20, 95% CI 1.10-1.31) and lack of early initiation of breastfeeding (RR 3.87, 95% CI 2.69-5.58).Infants who are low birth weight, born to mothers who present late to antenatal care or receive antenatal corticosteroids, or born to nulliparous women or those with a parity>2, could be targeted for interventions before and after delivery to improve early recognition of signs and symptoms of PSBI and prompt referral. There also appears to be a need for a renewed focus on promoting early initiation of breastfeeding following delivery in facilities.This trial is registered at ClinicalTrials.gov ( NCT01073475 ).

View details for DOI 10.1186/s12889-016-3688-3

View details for PubMedID 27760543

Abstract

Immune reconstitution inflammatory syndrome (IRIS) after initiating highly active antiretroviral therapy (HAART) has not been widely studied in children, especially in resource-poor settings.Retrospective cohort study of HIV-infected children initiating HAART between 2001 and 2006 at a tertiary pediatric hospital in Lima, Peru. Charts were reviewed for 1 year after HAART initiation. IRIS was defined as a HAART-associated adverse event caused by an infectious or inflammatory condition in patients with documented virologic or immunologic success.Ninety-one children (52% female) received HAART for at least 1 year. Median age at initiation was 5.7 years; 91% were ART naive and 73% had CDC stage C disease. The incidence of IRIS was 19.8 events per 100 person years (95% CI: 11.5-28.0). Median time to IRIS was 6.6 weeks after HAART initiation (range: 2-32 weeks). There were 18 IRIS events, 11 unmasking and 7 paradoxical. These included associations with Mycobacterium tuberculosis in 4 cases, Bacillus Calmette Guerin lymphadenitis in 1 case, varicella zoster virus in 6 cases and herpes simplex labialis in 6 cases. Children who developed IRIS had a higher baseline HIV viral load (P = 0.02) and an indicator of malnutrition (P = 0.007) before HAART initiation.IRIS occurred in 20% of HIV-infected children starting HAART in Peru and was associated with more advanced disease and malnutrition. Future research is needed to examine specific risk factors associated with pediatric IRIS to allow prompt identification and treatment of IRIS.

View details for DOI 10.1097/INF.0b013e3181a4b7fa

View details for Web of Science ID 000270407800009

View details for PubMedID 19687769

View details for PubMedCentralID PMC3514443

Abstract

Using Current Population Survey data from 2000-2002, this paper documents the changes that led the uninsured population to grow by 3.8 million during that time period. All of the increase in the uninsured occurred among adults, and two-thirds was among low-income adults. The extent to which the loss of employer coverage resulted in people becoming uninsured depended on their access to public programs: Children were more likely than adults to gain public coverage; women more likely than men; and parents more likely than nonparents. Middle- and higher-income Americans were also affected because many lost income and because rates of employer coverage were lower.

View details for PubMedID 15451962