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Figures
- FIGURE 1
Patient screening and identification. aOne infant had a positive CSF culture result, which was clinically verified by the infectious disease expert after inclusion in the study to be a contaminant (coagulase-negative staphylococci).
Tables
Demographic Median age, d (IQR) 68 (49–80) Age, d, n (%) 0–28 100 (6.1) 29–56 444 (27.1) 57–90 1093 (66.8) Male, n (%) 957 (58.5) Ethnicity, n (%) Hispanic 595 (36.3) Not Hispanic 859 (52.5) Unknown or other 183 (11.2) Term gestation, n (%) 1217 (74.3) Chronic illnessa, n (%) 49 (3.0) History of presenting illness, n (%) History of tactile warmth 257 (15.7) Measured fever >2 d before ED visit 92 (5.6) Ear discharge 422 (25.8) Difficulty feeding 429 (26.2) Vomiting 276 (16.9) Diarrhea 119 (7.3) Decreased urine output 96 (5.9) Symptoms of upper respiratory infection 1179 (72.0) General examination, n (%); kb Ill appearancek 30 (1.8); 0.56 Respiratory distressk 75 (4.6); 0.44 Dehydrationk 28 (1.7); 0.21 Ear examination ≥1 ear , n (%) Tympanic membrane erythema 970 (59.3) Bulging tympanic membrane 564 (34.5) Otorrhea 477 (29.1) All values are frequency (%) except where otherwise indicated.
↵a Includes congenital heart disease (19), major congenital anomaly other than congenital heart disease (10), renal or urologic disorder (6), failure to thrive (4), disease or use of medications that would affect the immune system (3), neurologic disorder (3), chronic lung disease (1), presence of indwelling catheters or shunts (1), and other (7). Does not total 49 because an infant may have >1 chronic illness.
↵b Cohen unweighted k (interrater reliability) was used to measure interrater reliability of 2 assessors’ determination of these findings. Variables with k of 0.21 to 0.40 were considered to have fair agreement, those with k of 0.41 to 0.60 were considered to have moderate agreement, and those with k of 0.61 to 0.80 were considered to have substantial agreement.
Patient Age, d Ill Appearance Culture Results Adverse Event Clinical Course 1 45 No Blood: negative, CSF: negative, urine: negative, MEE: not obtained Lymphadenitis Initially discharged from the hospital on amoxicillin. Twenty days after index ED visit, returned with cervical lymphadenitis and perforated AOM, confirmed by an otolaryngologist. Hospitalized and treated with IV and otic antibiotics. 2 32 Yes Blood: negative, CSF: negative, urine: negative, MEE: Staphylococcus aureus Culture-negative sepsis Presented with severe illness during the index ED visit. AOM confirmed by an otolaryngologist. Source of culture-negative sepsis thought to be severe milk protein allergy. Hospitalized and treated with IV and otic antibiotics. IV, intravenous; MEE, middle ear effusion or ear discharge.
N (%) Overall (N = 1637) 0–28 d Old (n = 100) 29–56 d Old (n = 444) 57–90 d Old (n = 1093) Diagnostic testing Any testing for bacterial infectiona 355 (21.7) 58 (58.0) 177 (39.9) 120 (11.0) Complete blood count 311 (19.0) 54 (54.0) 164 (36.9) 93 (8.5) Blood culture 278 (17.0) 53 (53.0) 147 (33.1) 78 (7.1) Urine culture 207 (12.6) 46 (46.0) 102 (23.0) 59 (5.4) CSF culture 102 (6.2) 34 (34.0) 58 (13.1) 10 (0.9) Respiratory pathogen testb 161 (9.8) 27 (27.0) 46 (10.4) 88 (8.1) Consultations Otolaryngologist 64 (3.9) 8 (8.0) 40 (9.0) 16 (1.5) Treatment IV or IM antibiotics 175 (10.7) 37 (37.0) 86 (19.4) 52 (4.8) Prescription for oral antibioticc 1311 (90.4) 37 (71.2) 299 (81.3) 975 (94.7) Disposition Discharged from the ED 1450 (88.5) 52 (52.0) 368 (82.9) 1030 (94.2) Hospitalized 186 (11.4) 47 (47.0) 76 (17.1) 63 (5.8) Transferred to another hospital 1 (0.1) 1 (1.0) 0 (0) 0 (0) IM, intramuscular; IV, intravenous.
↵a Defined as obtaining ≥1 of the following tests: complete blood count, blood culture, CSF culture, or urine culture.
↵b Includes any respiratory testing, including point-of-care respiratory syncytial virus and influenza testing, as well viral pathogen panels.
↵c Percentage reflects total out of infants discharged from the ED (1311 out of 1450 for all ages, 37 out of 52 for 0–28 days, 299 out of 368 for 29–56 days, and 975 out of 1030 for 57–90 days).
Predictor Adjusted Odds Ratio (95% CI) P Demographic Agea <.001b 29–56 d 0.37 (0.23–0.60) <.001b 57–90 d 0.06 (0.04–0.10) <.001b Gestational agec .01b <37 weeks' gestation 1.60 (0.94–2.72) .08 Unknown 0.59 (0.36–0.96) .03b History of presenting illness Ear discharge 2.32 (1.62–3.34) <.001b Tactile warmth 2.29 (1.53–3.43) <.001b Upper respiratory infection symptomsd 0.88 (0.62–1.26) .50 ↵a Reference group: 0 to 28 d old.
↵b Statistical significance (P < .05). In this model, age, gestational age, history of ear discharge, and history of tactile fever were independently associated with obtaining a blood culture. In the subanalysis including only the 1459 infants meeting simplified AAP diagnostic criteria (data available on request), no meaningful changes were noted, except the predictor variable <37 wk gestational age was significant (P = .04).
↵c Reference group: ≥37 wk gestation.
↵d Include cough, new nasal congestion or sneezing, rhinorrhea, wheezing, noisy breathing, and difficulty breathing.
Predictor Adjusted Odds Ratio (95% CI) P Demographic Agea <.001b 29–56 d 0.11 (0.06–0.22) <.001b 57–90 d 0.07 (0.03–0.14) <.001b Gestational agec .02b <37 weeks' gestation 1.64 (0.80–3.38) .18 Unknown 0.38 (0.17–0.87) .02b History of chronic illness 2.27 (0.85–6.07) .10 History of presenting illness Decreased urine output 4.13 (1.88–9.07) <.001b Ear discharge 1.97 (1.17–3.31) .01b New difficulty feeding 1.36 (0.81–2.30) .25 Diarrhea 0.58 (0.21–1.59) .29 Physical examination Respiratory distress 40.54 (19.17–85.70) <.001b Dehydration 2.89 (0.87–9.61) .08 Ill appearance 1.64 (0.52–5.18) .40 Diagnostic test Complete blood countd <.001b Completed and within normal limits 10.95 (5.95–20.15) <.001b Completed and abnormal 9.25 (4.04–21.14) <.001b Urinalysise .05 Completed and within normal limits 2.11 (1.15–3.87) .02 Completed and abnormal 2.14 (0.49–9.26) .31 ↵a Reference group: 0 to 28 d old.
↵b µStatistical significance (P < .05). In this model, age, gestational age, history of decreased urine output, history of ear discharge, respiratory distress on examination, and completion of complete blood count were independently associated with hospitalization. In the subanalysis including only the 1459 infants meeting simplified AAP diagnostic criteria (data available on request), the following differences were observed: chronic illness was not included in the model (univariable P > .1) and dehydrated appearance was statistically significant in the regression model (P = .02).
↵c Reference group: ≥37 wk gestation.
↵d Reference group: complete blood count not obtained. Test was considered abnormal if the WBC count was <5 or >15 × 103 cells/µL.
↵e Reference group: urinalysis not obtained. Test was considered abnormal if any of the following was present: leukocyte esterase, nitrite, or >5 WBCs per high-power field.
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