Fellows journal Club
Fellow: Alison Carroll, MD. Vanderbilt University Medical Center, Monroe Carell Jr. Children’s Hospital at Vanderbilt
Article: Lyons, TW, Garro, AC, Cruz AT, et al. Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections. Pediatrics. 2020;145: 1-9. https://doi.org/10.1542/peds.2019-3538.
Summary: The ability of the Boston and Philadelphia criteria to identify infants at low risk for a serious bacterial infection (i.e., urinary tract infection, bacteremia or bacterial meningitis) has not been recently reevaluated. This multicenter retrospective cohort study of infants age 29 to 60 days from 23 tertiary care emergency departments in the US and Canada sought to measure the diagnostic accuracy of the Boston and Philadelphia criteria to identify infants at low risk for invasive bacterial infection (IBI), defined as bacterial meningitis or bacteremia.
A total of 10,928 infants 29 to 60 days old with blood and CSF cultures were included. The Boston criteria was applied to 8344 infants and the Philadelphia criteria to 8131 infants. Overall, 264 (2.4%) of the infants had an invasive bacterial infection. Of the 264 infants with an invasive bacterial infection, 193 had bacteremia and 71 had bacterial meningitis. The Boston criteria identified 133 of the 212 infants with IBI (sensitivity 62.7%; specificity 59.2%) and the Philadelphia criteria identified 157 of the 219 infants with IBI (sensitivity 71.7%; specificity 46.1%). In other words, the Boston criteria misclassified 37% of infants as low risk and the Philadelphia criteria misclassified 28% of infants as low risk. Among the 79 infants misclassified as low risk by the Boston Criteria 17 had bacterial meningitis. Among the 62 infants misclassified as low risk by the Philadelphia criteria 13 had bacterial meningitis.
Key Strengths: This study included a large multinational cohort of infants, increasing the generalizability of the results. The rates of serious bacterial infections found in this study were similar to the rates found in the original derivation studies for the Boston and Philadelphia criteria. The study highlights the changing microbiology of invasive infections in this age group; the top three pathogens identified were GBS, E. coli, and S. aureus.
Limitations: Since the Boston and Philadelphia criteria both require CSF results for application, this study only included infants who already had CSF values. Clinicians who already obtained CSF may have had a higher clinical concern for meningitis, leading the Boston and Philadelphia criteria to be applied to a different (and potentially sicker) patient population from which they were originally derived, creating the potential for selection bias. In addition, the authors were not able to determine infants’ clinical appearance, comorbidities, or indication for undergoing an evaluation. The authors attempted to mitigate this limitation by excluding infants admitted to the ICU as a proxy for critical illness.
Main Takeaway: The Boston and Philadelphia criteria misclassified about 1/3 of infants with an invasive bacterial infection as low risk including a substantial number with bacterial meningitis. This highlights the limitations of these criteria and the need to incorporate new evidence into our clinical practice guidelines for the management of these patients.
Impact on Practice: Reliance on these criteria may result in infants receiving more invasive testing (i.e., lumbar punctures) and hospitalizations, while also potentially missing up to 1/3 of infants with a serious bacterial infection. The incorporation of newer biomarkers such as procalcitonin, C-reactive protein, and multiplex bacterial polymerase chain reaction panels may be useful for developing new risk stratification tools that can rapidly and accurately identify febrile infants in order to reduce unnecessary lumbar punctures, hospitalizations, and exposure to antibiotics.
Article: Lyons, TW, Garro, AC, Cruz AT, et al. Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections. Pediatrics. 2020;145: 1-9. https://doi.org/10.1542/peds.2019-3538.
Summary: The ability of the Boston and Philadelphia criteria to identify infants at low risk for a serious bacterial infection (i.e., urinary tract infection, bacteremia or bacterial meningitis) has not been recently reevaluated. This multicenter retrospective cohort study of infants age 29 to 60 days from 23 tertiary care emergency departments in the US and Canada sought to measure the diagnostic accuracy of the Boston and Philadelphia criteria to identify infants at low risk for invasive bacterial infection (IBI), defined as bacterial meningitis or bacteremia.
A total of 10,928 infants 29 to 60 days old with blood and CSF cultures were included. The Boston criteria was applied to 8344 infants and the Philadelphia criteria to 8131 infants. Overall, 264 (2.4%) of the infants had an invasive bacterial infection. Of the 264 infants with an invasive bacterial infection, 193 had bacteremia and 71 had bacterial meningitis. The Boston criteria identified 133 of the 212 infants with IBI (sensitivity 62.7%; specificity 59.2%) and the Philadelphia criteria identified 157 of the 219 infants with IBI (sensitivity 71.7%; specificity 46.1%). In other words, the Boston criteria misclassified 37% of infants as low risk and the Philadelphia criteria misclassified 28% of infants as low risk. Among the 79 infants misclassified as low risk by the Boston Criteria 17 had bacterial meningitis. Among the 62 infants misclassified as low risk by the Philadelphia criteria 13 had bacterial meningitis.
Key Strengths: This study included a large multinational cohort of infants, increasing the generalizability of the results. The rates of serious bacterial infections found in this study were similar to the rates found in the original derivation studies for the Boston and Philadelphia criteria. The study highlights the changing microbiology of invasive infections in this age group; the top three pathogens identified were GBS, E. coli, and S. aureus.
Limitations: Since the Boston and Philadelphia criteria both require CSF results for application, this study only included infants who already had CSF values. Clinicians who already obtained CSF may have had a higher clinical concern for meningitis, leading the Boston and Philadelphia criteria to be applied to a different (and potentially sicker) patient population from which they were originally derived, creating the potential for selection bias. In addition, the authors were not able to determine infants’ clinical appearance, comorbidities, or indication for undergoing an evaluation. The authors attempted to mitigate this limitation by excluding infants admitted to the ICU as a proxy for critical illness.
Main Takeaway: The Boston and Philadelphia criteria misclassified about 1/3 of infants with an invasive bacterial infection as low risk including a substantial number with bacterial meningitis. This highlights the limitations of these criteria and the need to incorporate new evidence into our clinical practice guidelines for the management of these patients.
Impact on Practice: Reliance on these criteria may result in infants receiving more invasive testing (i.e., lumbar punctures) and hospitalizations, while also potentially missing up to 1/3 of infants with a serious bacterial infection. The incorporation of newer biomarkers such as procalcitonin, C-reactive protein, and multiplex bacterial polymerase chain reaction panels may be useful for developing new risk stratification tools that can rapidly and accurately identify febrile infants in order to reduce unnecessary lumbar punctures, hospitalizations, and exposure to antibiotics.
Fellow: Alison Carroll, MD. Vanderbilt University Medical Center, Monroe Carell Jr. Children’s Hospital at Vanderbilt
Fellowship Accomplishments/Current Research: In my first year of fellowship, I led a study evaluating racial disparities in outcomes for children hospitalized with a mental health condition. The study was selected for a platform presentation at the 2020 Pediatric Academic Societies Annual meeting (canceled due to COVID-19). A manuscript based on this work is currently being drafted. I have also been leading a quality improvement project to reduce unnecessary fasting times prior to sedated procedures for hospitalized patients. To date, we have decreased the mean fasting time from 10 hours 13 minutes to 6 hours 45 mins (goal of 5 hours or less).
Goals/Plans for the Future: My long-term career goal is to be a physician-scientist studying health disparities and transitions of care in hospitalized children. To achieve this goal, I have been awarded a T32 grant through the Vanderbilt Patient/pRactice Outcomes and Research in Effectiveness and Systems Science (PROgRESS) Program. I will be pursuing my MPH in epidemiology through the Vanderbilt School of Medicine and will complete a research project to develop and evaluate the effectiveness of a health literacy-informed communication intervention to decrease discharge medication errors among children discharged from the hospital.
Fun Fact: I attended Davidson College for undergrad where I played Varsity Division I soccer along with my twin sister (and I did hang out with Steph Curry!).
Fellowship Accomplishments/Current Research: In my first year of fellowship, I led a study evaluating racial disparities in outcomes for children hospitalized with a mental health condition. The study was selected for a platform presentation at the 2020 Pediatric Academic Societies Annual meeting (canceled due to COVID-19). A manuscript based on this work is currently being drafted. I have also been leading a quality improvement project to reduce unnecessary fasting times prior to sedated procedures for hospitalized patients. To date, we have decreased the mean fasting time from 10 hours 13 minutes to 6 hours 45 mins (goal of 5 hours or less).
Goals/Plans for the Future: My long-term career goal is to be a physician-scientist studying health disparities and transitions of care in hospitalized children. To achieve this goal, I have been awarded a T32 grant through the Vanderbilt Patient/pRactice Outcomes and Research in Effectiveness and Systems Science (PROgRESS) Program. I will be pursuing my MPH in epidemiology through the Vanderbilt School of Medicine and will complete a research project to develop and evaluate the effectiveness of a health literacy-informed communication intervention to decrease discharge medication errors among children discharged from the hospital.
Fun Fact: I attended Davidson College for undergrad where I played Varsity Division I soccer along with my twin sister (and I did hang out with Steph Curry!).
Previous Articles:
- Hannah Neubauer - HHFNC vs. low flow
- Amanda Messer - UTIs and renal scarring
- Christiane Lenzen - procalcitonin and CAP
- Melanie Rudnick - dexamethasone and parapneumonic effusions
- Jane Im - empiric antibiotic therapy in infants
- Ashley Jenkins - AKI with vancomycin and piperacillin/tazobactam therapy
- Fatuma Barqadle - US for LPs
- Marni Shear - Hypotonic IV fluids and bronchiolitis
- Ivy Tam - Ipratropium and IV magnesium in asthmatics
- Daniela Burger - HSV in Infants
- Lindsay Weiss - macrolides in pneumonia
- Tiranun Rungvivatjarus - High Flow Nasal Cannula
- Karisa Grizzle - Empiric Antibiotics in Osteomyelitis
- Mike Fenster - Bacterial meningitis in positive UA
- Courtney Charvat - CSF bioplex assay
- Audrey Uong - Complex Care Discharges
- Adam Cohen - Early Master Clinician Traits
- Alice Lee - Variation in Orbital Cellulitis Care
- Joy Solano - Family centered interventions to improve education
- Sunita Hemani - Discharging after q3 albuterol in asthma
- Jennifer Chen - Discharge Instruction Literacy
- John Morrison - Readmission Models for Complex Care
- Hanna Siddiqui - Fever, PEWS, and deterioration
- Kate Kyler - Reducing Safety Events in Suicidal Patients via QI
- Sonya Tang Girwood - Antibiotics in RSV Related Respiratory Failure
- Maria Santos - Positive UA and Meningitis
- Chionye Ossai - Parent Perception of Patient Portal
- Sarah Bram - Predictors of bacteremia in CAP
- Kris Chang - Note Bloat
- Risa Bochner - SBI with fever alone <60 days
- Alexandra Kilinsky - Promoting Fellow Autonomy
- Sasha Wee - Somatic Symptom Pathway
- Kate Donowitz - Predicting High Risk BRUE
- Caleb Hancock - Imaging Cervical Lymphadenitis
- Nathan Money - Duration of Antibiotics in Pyelonephritis