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To Test or Not to Test – that is the question … Kevin Chan, MD, MPH, FRCPC, FAAP Clinical Chief, Children’s Health Division Head, Pediatric Emergency,

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Presentation on theme: "To Test or Not to Test – that is the question … Kevin Chan, MD, MPH, FRCPC, FAAP Clinical Chief, Children’s Health Division Head, Pediatric Emergency,"— Presentation transcript:

1 To Test or Not to Test – that is the question … Kevin Chan, MD, MPH, FRCPC, FAAP Clinical Chief, Children’s Health Division Head, Pediatric Emergency, Janeway Children’s Hospital

2  To indicate when should investigations be conducted for fever: bloodwork, urine, chest X-rays, and LP  To look at what the value of clinical and ultrasound is on predicting acute appendicitis  Identify current risk factors for the need for CT in head injury  Identify the various rules for ankles and knees and their requirements for X-rays Objectives

3  A 6 week old baby comes in with a 1 day history of fever. Besides the temperature, his vitals signs are stable and his examination is normal?  How many of you would: a.Do a full septic workup including LP? b.Do a partial septic workup without a LP? c.Do a urine test? d.Do no testing? Case #1

4  A 6 week old baby comes in with a 1 day history of fever. Besides the temperature, his vitals signs are stable and his examination is normal?  How many of you would: a.Do a full septic workup including LP? b.Do a partial septic workup without a LP? c.Do a urine test? d.Do no testing? * All of the answers may be right … Case #1

5 In the Pre-Hib and Pre-Prevenar eras Prior to Hib and Prevenar vaccines:  20% of children had a fever with no identifiable source of infection, or a self-limited viral infection  10% of all children with fever without focus had occult bacteremia or serious bacterial illness  3% of well appearing children had bacteremia Source: Baraff LJ. “Management of fever without source in infants and children.” Annals of Emergency Medicine. 2000; 36:

6 In the 1980s, pre-Hib and pre- Prevenar vaccines Risk of bacteremia 5%5% 1% 15,00030,000 WBC

7 Why Are We Interested? After Hib:  1.5-2% rate of occult bacteremia  90% of bacteremia was Streptococcus pneumoniae Source: Lee GM, Harper MB. “Risk of bacteremia for febrile young children in the post-Haemophilus influenzae type b era.” Archives of Pediatrics and Adolescent Medicine. 1998; 152:

8 Traditional Work-up  Toxic children: Septic work-up with iv antibiotics  < 28 days: Full septic-workup until culture results are obtained, or source of fever is identified  days: Screening blood work, and Ceftriaxone given (50 mg/kg)  3-36 months, non-toxic, < 39°C: Observation unless other diagnoses considered  3-36 months, non-toxic, > 39°C, and WBC > 15,000: Treat with antibiotics until culture results obtained Source: Baraff LJ, Bass JW, Fleisher GR, et al. “Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research.” Annals of Emergency Medicine July; 22 (7):

9 Diagnostic Criteria CriteriaBostonPhiladelphiaRochester Age28-90 days < 60 days AppearanceWell-looking CSF WBC< 10 / mm 3 < 8 / mm 3 Urinalysis< 10 WBC/hpf WBC count< 20 x 10 9 < 15 x x 10 9 Band:Neutrophil Ratio < 0.2 Band count< 1.5 x 10 9 CXR (if obtained)Normal StoolNegative for blood; Few or no WBC < 5 WBC/hpf Prior historyPreviously healthy

10 Stoll and Rubin (2004)  Retrospective Chart Review over 15 months  2-36 months of age  Occult Bacteremia: 0.91% (0-1.9%)  PPV of WBC Count > 15,000 = 3.2%  PPV of WBC Count > 20,000 = 7.1%  Caveat: only 28% of infants < 6 months had 3 vaccinations; only 66% of infants < 12 months had received 3 vaccinations Stoll ML, Rubin LG. “Incidence of Occult Bacteremia Among Highly Febrile Young Children in the Era of the Pneumococcal Conjugate Vaccine.” Archive of Pediatrics and Adolescent Medicine. July 2004; 158:

11 Herz et al. (2006)  Retrospective case series,  3 months to 3 years  Prevenar introduced: April 2000  84% reduction in S. pneumoniae bactermia (1.3 to 0.2%)  56% reduction in overall bacteremia (1.6 to 0.7%)  E.coli dominating < 1 year (2.5 time more frequent than S. pneumoniae), all 27 patient had UTIs as well Source: Herz AM, Greenhow TL, Alcantara J, et al. “Changing Epidemiology of Outpatient Bacteremia in 3- to 36- Month-Old Children After the Introduction of Heptavalent-Conjugated Pneumococcal Vaccine.” Pediatric Infectious Disease Journal. April 2006; 25 (4):

12 Blood Cultures Obtained

13 Important Change  WBC count > 15,000:  74% sensitivity, 54.5% specificity in predicting bacteremia  Positive Predictive Value: 1.5%  Negative Predictive Value: 99.5%  Treating a child with WBC > 15,000 has little value in the post-Prevenar era

14 Sard et al. (2006)  Retrospective chart review, community setting US  1-36 months  January 1997 – January 2005  Significant decline of S. pneumoniae from 1% to 0.2% in patients with blood cultures drawn  If WBC 24 hours, and Gram stain negative  predictive of contaminant Source: Sard B, Bailey MC, Vinci R. “An Analysis of Pediatric Blood Cultures in the Postpneumococcal Conjugate Vaccine Era in a Community Hospital Emergency Department.” Pediatric Emergency Care. May 2006; 22 (5):

15 Carstairs et al. (2007)  Noncurrent prospective observational cohort study  < 36 months  Compared vaccinated vs. unvaccinated children for pneumococcal bacteremia  0% vs. 2.4% positive pneumococcal blood cultures (vac. vs. unvac) Carstairs KL, et al. “Pneumococcal Bacteremia in Febrile Infants Presenting to the Emergency Department Before and After the Introduction of the Heptavalent Pneumococcal Vaccine.” Annals of Emergency Medicine. June 2007; 49 (6):

16 Waddle and Jhaveri (2009)  Retrospective review: microbiology laboratory database and chart review  3-36 months  Significant drop in occult bacteremia from 6.8% ( %) to 0.4% (0 – 2.2%) between the pre- and post- PCV7 era, fever with no focus  No change in UTI rates (6.8% vs. 7.6%)  However, antibiotic usage did not change Source: Waddle E, Jhaveri R. “Outcomes of febrile children without localising signs after pneumococcal conjugate vaccine.” Archives of Disease in Childhood. 2009; 94:

17 Wilkinson et al. (2009)  Retrospective chart review over 4 years  8408 children, 3-36 months  Not all children got blood cultures with fever (results are therefore underreported)  Occult bacteremia: 0.25% ( %)  Streptococcal bacteremia: 0.17% ( %)  7.6 contaminants for every true positive blood culture Source: Wilkinson M, Bulloch B, Smith M. “Prevalence of Occult Bacteremia in Children Aged 3 to 36 Months Presenting to the Emergency Department with Fever in the Postpneumococcal Conjugate Vaccine Era.” Academic Emergency Medicine. 2000; 16:

18 Implications  Need 588 cultures to detect 1 case  Need 14,700 cultures to detect one S. Pneumoniae meningitis, 49,000 cultures to prevent one neurologic sequelae and 184,000 cultures to prevent 1 S. pneumoniae death  Large costs associated with contaminated blood cultures

19 Summary of Articles 3 to 36 months, well-appearing children:  % have pneumococcal bacteremia  % have occult bacteremia  UTI rates have not declined (consideration for during urinalysis)  Time to get rid of the blood culture and relying on the WBC count if the child is immunized  There is something that is useful, but expensive: pro-Calcitonin … (Enguix et al. Intensive Care Medicine, 2001: 27: )

20 The evidence for doing bloodwork Risk of bacteremia 0.2%.025% 15,00030,000 WBC

21 Caveats  Evidence of serotype replacement occurring (with non-vaccine specific serotypes) *  Immunization accuracy is questionable when taken from parents, an ED registry, and a state immunization registry † Sources: * Singleton RJ, Hennessy TW, Bulkow LR. “Invasive Pneumococcal Disease Caused by Nonvaccine Serotypes Among Alaska Native Children With High Levels of 7-Valent Pneumococcal Conjugate Vaccine Coverage.” JAMA. April 25, 2007; 297 (16): † Williams ER, Meza Ye, Salazar S, Dominici P, Fasano CJ. “Immunization Histories Given by Adult Caregivers Accompanying Children 3-36 Months to the Emergency Department: Are Their Histories Valid for the Haemophilus influenza B and Pneumococcal Vaccines?” Pediatric Emergency Care. May 2007; 23 (5):

22 For Children, days old  Evidence of a decline in Invasive Pneumococcal Disease (bacteremia or meningitis) secondary to herd effects  43% reduction of population rates in the US  Studies from Ontario show 30% reduction  At this time, no studies on initial ED presentation and correlation with outcomes  Time to revisit the Boston/Rochester/ Philadelphia criteria? Source: Poehling KA, Talbot TR, Griffin MR et al. “Invasive Pneumococcal Disease Among infants Before and After Introduction of Pneumococcal Conjugate Vaccine.” JAMA. 2006; 295 (14):

23  Rates of UTI generally hover about 7% (Levine et al. Pediatrics; 2004: 113: )  Even in RSV+ bronchiolitis patients, the UTI risk is 5.4% ( %)  In RSV- bronchiolitis, the UTI risk is 10.1% ( %)  However, urine bag specimens are not useful (Al-Orifi F, J Peds, 2000: 137: )  63% false positivity rate leading to significant call backs, and too many children being placed on antibiotics inappropriately The need for urine

24  If there’s no symptoms, there’s no value in doing a CXR (Bramson, Pediatrics: 1993: 92 (4): )  Clinical findings  Tachypnea  Rales/rhonchi  Retractions, wheezing, coryza  Grunting, stridor, nasal flaring  Cough Do I need to do a CXR?

25  1 in about 12 children with fever and cough past 48 hours would have a lobar pneumonia (irrespective of the severity)  In the post-Prevenar era, this is about 1 in (Nelson et al. Vaccine. 2008; 26 : ) Previously

26  Infectious Disease Society of North America (Bradley et al. Clinical Infectious Disease; (7): e25-e76)  Treat if looks like pneumonia  Don’t treat if it doesn’t look like pneumonia  Do CXR if you’re not sure, but not useful if done too early (at least 24 hours)  There is another argument, do CXR to prevent overprescribing antibiotics What to do?

27  <28 days, full septic work-up  days is controversial  Full septic  Partial septic are generally agreed upon (from PAS conference 2013) Investigations for fever

28 For children > 60 days  Sick or not sick?  If sick, investigate  Vaccinated or unvaccinated?  If unvaccinated, consider investigating  Then, take a urine  CXR if unsure about respiratory diagnosis Investigations for fever

29  There’s no clear statement in the literature  Generally, accepted at 14 days, you should test  Essentially to r/o leukemia  But investigate chronic infections/rheumatologic conditions  5-14 days is a gray zone  Definitely, if Kawasaki’s suspected  Otherwise, no clear literature  <5 days, looking well: no need for bloodwork When do I investigate when fever persists?

30  A 14 year-old girl comes in with RLQ pain for 12 hours, she has a fever, anorexia, but has not vomited. The pain did not migrate, but she does have cough and percussion tenderness. She comes back and has a normal WBC and no left shift. What is the likelihood that she has appendicitis? Case #2

31  Cough/percussion tenderness = 2  Anorexia = 1  Pyrexia (fever) = 1  Nausea/emesis = 1  Tenderness in the RLQ = 2  Leukocytosis (> 10,000 WBC) = 1  PMN = 1  Migration of pain = 1 Pediatric Appendicitis Score

32  Score 8 and above, indicates a likely appendicitis  Score 3 and below, indicates unlikely appendicitis Pediatric Appendicitis Score

33  A 14 year-old girl comes in with RLQ pain for 12 hours, she has a fever, anorexia, but has not vomited. The pain did not migrate, but she does have cough and percussion tenderness. She comes back and has a normal WBC and no left shift. What is the likelihood that she has appendicitis?  Her PAS is 6. We’re not sure … she’s equivocal. Case #2

34  Established by Barbara Garcia-Pena (at Children’s Hospital, Boston) was to do US then CT for suspected pediatric appendicitis (AJR, 2000; 175 (1): 71-74)  Currently, the recommendation by the American Society of Radiology  Recognition of CT abdomen and its potential cancer risks (Brenner, AJR, 2001; 176: , and Pearce, Lancet, 2012, 380: ) The American Algorithm

35  Initial U/S, with a repeat U/S for equivocal examinations  Grant Thompson did a survey across the PERC sites and showed that this was the most common algorithm The Canadian Algorithm

36 Combined Use of Ultrasound and Interval Pediatric Appendicitis Score in Suspected Appendicitis Suzanne Schuh, Andrea Doria, Marcela Preto-Zampreski, Jacob Langer, Carina Man, and Kevin Chan

37  Looked at a 4 hour PAS scores, in combination with an U/S to determine if repeated clinical examination could eliminate the need for further testing  Primary objective: To compare the proportion of children who are candidates for early disposition from the ED  US-PAS approach versus a strict (1 or 2) Ultrasound approach  Secondary objectives:  Clinical outcomes, resource use and economic costs Our Research

38 Candidates for Early Disposition

39  The U/S approach = 72/294 (24.5%) could be discharged early  The U/S – PAS approach = 179/294 (60.9%) could be discharge early (p<0.0001) What does this mean for early discharge?

40 Test characteristics of 2 pathways US approach  93.2% diagnostically accurate  97.2% of appendicitis cases detected  90.7% of non-appendicitis cases detected  Sens: 97.3%, Spec: 90.7%, PPV: 86.4%, NPV: 98.2% US – PAS Approach  95.2% diagnostically accurate  97.2% of appendicitis cases detected  94% of non-appendicitis cases detected  Sens: 97.3%, Spec: 94%, PPV: 90.8%, NPV: 98.2%

41 Resource Usage of 2 pathways US approach  43 second ultrasounds  4 CTs  120 surgeries, 14 negative operations  136 hospitalizations  Mean LOS in ED = 597 minutes US – PAS approach  38 second ultrasounds  4 CTs  115 operations, 9 negative operations  128 hospitalizations  Mean LOS = 530 minutes

42  The US-PAS approach saves approximately $110 million ($ million) to the health care system and $115 million ($ million) to society in the US  It saves $1.8 million ($ million) to the health care system and $2.4 million ($ million) to society in Canada  Compared to the US-CT approach, the savings are approximately $170 million ($126-$245 million) in the US. Cost Savings

43  First study to look at the interval PAS score to help disposition decisions in suspected appendicitis  Doing this, reduces the number of CTs, and provides an indication of who can be discharged sooner in the Emergency department  This approach saves resources and costs, and represents a small but sizable savings in appendicitis care. Discussion

44  A recent study by Mittal et al. (Academic Emergency Medicine. 2013; 20: ) showed that U/S have suboptimal sensitivity, and highlights the value of ultrasound with clinical re-assessment.  The initial PAS by itself was not helpful in identifying appendicitis. Discussion

45  Just because an ultrasound is reported at positive, 1/3 of them with low PAS scores (2-5) did NOT have appendicitis  Suggest surgical consultation with this group  Remember that negative appendectomies do have a complication risk of about 4.6%, and cannot be ignored. Note

46  In the US, still about 35% of children (Bachur et al., J Peds; 2012; 160: ) undergo a CT, yet only 3% of these cases required CT.  How do we avoid the CT?  Re-evaluation of the criteria of appendicitis at 6 mm may be warranted  New work on focused MRI examination of the RLQ being conducted  Longer duration of abdominal pain, increases U/S sensitivity Discussion

47  A 12 year-old boy is playing soccer and is pushed into the goal post. He comes in with a headache and is dizzy. He has a severe headache and a large hematoma on his frontal-temporal region. He has a GCS of 14. His examination right now is otherwise normal (including normal vital signs, no neck stiffness and a normal neurological exam.)  What do you do? a.Get a CT of the head b.Get a skull X-ray c.Observe for 6 hours in the ER d.Admit to hospital for observation Case #3

48  A 12 year-old boy is playing soccer and is pushed into the goal post. He comes in with a headache and is dizzy. He has a severe headache and a large hematoma on his frontal-temporal region. He has a GCS of 14. His examination right now is otherwise normal (including normal vital signs, no neck stiffness and a normal neurological exam)  What do you do? a.Get a CT of the head b.Get a skull X-ray c.Observe for 4-6 hours in the ER d.Admit to hospital for observation Case #3

49  CATCH rules (3866 patients (Osmond et al. CMAJ, 2010: 182 (4): ) (for patients with GCS of 13-15)  4 high risk factors (sensitivity of 100% ( %))  Failure to reach GCS within 2 hours  Suspicion of open skull fracture  Worsening headache  Irritability  3 medium risks factors (sensitivity of 98.1%) ( %))  Large, boggy hematoma  Signs of basilar skull fracture  Dangerous mechanism of injury  Any of them should necessitate a CT How important is mechanism?

50  PECARN has tracked out 42,412 patients (Kuperman et al., Lancet 2009; 374: )  Severe injury mechanisms:  High-speed MVA (either occupant or pedestrian struck)  Bicycle-related injury (or similar vehicle)  High-speed projectile  Fall from a height or down stairs  Isolated severe injury mechanisms (PECARN Head Injury Predictor Rules)  No significant signs or symptoms of TBI  Altered mental status (GCS < 15, agitation, sleepiness, slow responses or repetitive questioning)  Nonfrontal scalp hematoma  LOC > 5 seconds  Palpable skull fracture  Not acting normally according to parents How important is mechanism?

51  (Nigrovic et al. Arch Pediatr Adolescent Medicine, 2012 (4): )  42,099 had injury mechanisms  5869 (14%) had severe injury mechanisms  3302 (8%) had isolated severe injury mechanisms  367 children had clinically important Traumatic Brain Injuries (TBIs) (0.9%)  4/1327 children < 2 had clinically important TBIs with isolated severe injury mechanisms  12/1975 children > 2 had clinically important TBIs with isolated severe injury mechanisms The Results

52  Isolated severe injury mechanisms  No significant signs or symptoms of TBI  Altered mental status (GCS < 15, agitation, sleepiness, slow responses or repetitive questioning)  Nonfrontal scalp hematoma  LOC > 5 seconds  Palpable skull fracture  Not acting normally according to parents  If we add no  Seizures  Neurologic deficits on examination  Scalp hematoma  Skull fracture  LOC at any time  Vomiting  Headache (> 2 years)  Amnesia (> 2 years) If we add a few other criteria

53  < 2 years: 1 out of 756 (0.1%) had a significant TBI  4 month-old who fallen > 3 feet with evidence of facial trauma, who had a subarachnoid and subdural hemorrhage  > 2 years: 2 out of 730 (0.3%) had significant TBI  10 year-old ejected during a motor vehicle collision with multisystem trauma and traumatic hyphema with a cerebral hemorrhage  12 year-old struck by a motor vehicle who sustained multisystem trauma and facial trauma with a subarachnoid hemorrhage and subdural hematoma  None of them required neurosurgery The Results

54  If they look well, and the mechanism doesn’t appear significant, you can send the child home The bottom line

55  It is safe to d/c home  In the PECARN study, 100% (99.97%-100) had no need for neurosurgical intervention with a normal CT and GCS of (Holmes et al., Academic Emergency Medicine, Oct 2011, 58 (4): ). If you do a CT, with a GCS of …

56  Hamilton et al. (Pediatrics, 2010: 126 (1): e33)  17,962 children in Calgary  Missed 2 with delayed deterioration of LOC  1 case was an intracranial mass  Other case was a 7 year-old who ran into a wall and had an epidural bleed. Required neurosurgery, but no complications  Had seizure, headache and skull #  Missed 8 without deterioration of LOC  None of these required neurosurgery  Can safely send kids home at 6 hours, as long as none of the worrisome features are present But if I send the child home … will he be okay?

57  If any worrisome features, should conduct a CT  Most well looking kids with minor head injuries, can be quickly discharged  If concerned, monitor out up to 6 hours  If features are worsening, do CT  If features are getting better, can safely discharge  Do not tell parents to wake their child up at night (Carroll et al., Journal of Rehabilitation Medicine, 2004: 43 (Suppl): ) CT Head or not to CT Head?

58  A 10 year-old boy trips and falls while playing spotlight (a highly Newfoundland game, I suspect). It is an eversion injury.  He complains that his ankle hurts and his lateral malleolus is tender and sore. The rest of the ankle, including the medial malleolus is not tender. He could wait bear initially, but now cannot walk. Does he need an X-ray? a.Yes b.No Case #4

59  A 10 year-old boy trips and falls while playing spotlight (a highly Newfoundland game, I suspect). It is an eversion injury.  He complains that his ankle hurts and his lateral malleolus is tender and sore. The rest of the ankle, including the medial malleolus is not tender. He could wait bear initially, but now cannot walk. Does he need an X-ray? a.Yes b.No Case #4

60 Ottawa Ankle Rules

61  Plint et al (Academic Emergency Medicine, 1999: 6(10): ) showed that:  OAR was 100% (95-100%) sensitive for significant ankle fractures with 24% specificity (20-28%)  OAR was 100% sensitive (82-100%) for the midfoot, with 36% specificity (29-43%) Ottawa Ankle Rules in Children

62 Low Risk Ankle Rules These patients should be excluded

63  Boutis et al. (Lancet, 2001: 358: )  Showed 100% sensitivity ( %) and 100% NPV ( %)  Reduced X-rays by 62.8%  Follow-up study at 6 sites showed 100% sensitivity ( %) and 53.1 specificity ( %) (CMAJ 2013: e- print, DOI: /cmaj122050)  Reduced X-rays by 22% Low Risk Ankle Rules

64  Gravel et al (2009; Annals of Emergency Medicine, 54 (4): )  Showed that the sensitivity was higher in the OAR, 100% compared to LRAR: 87%)  LRAR missed some deemed significant fractures  Argument made that the application of LRAR in the study was not done correctly Comparison study

65  Application of the OAR  + application of the fibular swelling question (LRAR)  Reduces X-rays  Majority of these children with fibular swelling can be managed by ankle splints (Boutis et al., Pediatrics, 2007: 119: e1256)  Removable splints lead to faster recovery, better physical function, patients prefer, and saves money. Either way …

66  A 12 year-old girl twists her knee? She can weight bear, but it hurts to extend her knee fully?  Does she need an X-ray? a.Yes b.No Case #5

67  A 12 year-old girl twists her knee? She can weight bear, but it hurts to extend her knee fully?  Does she need an X-ray? a.Yes b.No Case #5

68  Isolated Patella tenderness  Tenderness at the head of the fibula  Inability to flex knee to 90 degrees  Inability to take 4 steps initially and in the emergency department Ottawa Knee Rules

69  Bullock et al (2003, Annals of Emergency Medicine, 42 (1): 48-55)  100% sensitive ( %) and 42.8% specific ( %)  Saves 31% of x-rays Results

70  If < 28 days: full septic work-up  days: no clear decision  Full-septic, partial septic or nothing (significant research being done on this group)  >60 days: urine + CXR if respiratory symptoms  WBC and left shift, not as useful  Prolonged fever > 14 days: bloodwork should be done Conclusions

71  Appendicitis testing  Clinical re-evaluation at 4 hours is useful  Positive appendicitis ultrasounds should be correlated with clinical findings to reduce the number of children taken to the OR  CTs only with significant mechanisms or clinical findings. If a child looks normal post head-injury, generally safe to send home. Observation period: 6 hours is all that is required to be pretty sure the child is fine.  We can reduce the number of x-rays by following ankle and knee rules Conclusions

72 Any questions?


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