OBJECTIVES: 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). METHODS: 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. RESULTS: 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 38.0-38.4°C (2 points) or $38.5°C (4 points), absolute neutrophil count $5185 cells per mL (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. CONCLUSIONS: Infants #60 days old with fever by history only, a normal urinalysis result, and an absolute neutrophil count ,5185 cells per mL have a low probability of IBI. WHAT'S KNOWN ON THIS SUBJECT: Commonly used risk-stratification criteria for febrile infants were either developed .2 decades ago in studies that included relatively few infants with bacteremia and/or bacterial meningitis or include procalcitonin, which is not readily available in some hospitals. WHAT THIS STUDY ADDS: A newly derived score is highly sensitive for the identification of non-ill-appearing febrile infants #60 days old with invasive bacterial infection. Infants with fever by history only, normal urinalysis results, and an absolute neutrophil count ,5185 cells per mL had a low probability of infection.

Objectives To examine the short-term (3 and 6-month), self-reported bleeding and cramping patterns with intrauterine devices (IUDs) and the contraceptive implant, and the association of these symptoms with method satisfaction. Study Design We analyzed 3 and 6-month survey data from IUD and implant users in the Contraceptive CHOICE Project, a prospective cohort study. Participants who received a long-acting reversible contraceptive (LARC) method (levonorgestrel intrauterine system (LNG-IUS), copper IUD, or the etonogestrel implant) and completed their 3- and 6-month surveys were included. Univariable and multivariable analyses were performed to examine the association of bleeding and cramping patterns with short-term satisfaction. Results Our analytic sample included 5,011 CHOICE participants: 3001 LNG-IUS users, 826 copper IUD users, and 1184 implant users. At 3 months, over 65% of LNG-IUS and implant users reported no change or decreased cramping, while 63% of copper IUD users reported increased menstrual cramping. Lighter bleeding was reported by 67% of LNG-IUS users, 58% of implant users, and 8% of copper IUD users. Satisfaction of all LARC methods was high (≥90%) and significantly higher than non-LARC methods (p<0.001). LARC users with increased menstrual cramping (HR 0.96, 95% CI 0.92 – 0.99), heavier bleeding (HR 0.91, 95% CI 0.87 – 0.96), and increased bleeding frequency (HR 0.92, 95% CI 0.89 – 0.96) were less likely to report being very satisfied at 6 months. Conclusion Regardless of the LARC method, satisfaction at 3 and 6 months is very high. Changes in self-reported bleeding and cramping are associated with short-term LARC satisfaction.

Sedation/anesthesia is critical to cardiac catheterization in the pediatric/congenital heart patient. We sought to identify current sedation/anesthesia practices, the serious adverse event rate related to airway, sedation, or anesthesia, and the rate of intra-procedural conversion from procedural sedation to the use of assisted ventilation or an artificial airway. Data from 13,611 patients who underwent catheterization at eight institutions were prospectively collected from 2007 to 2010. Ninety-four (0.69 %) serious sedation/airway-related adverse events occurred; events were more likely to occur in smaller patients (<4 kg, OR 4.4, 95 % CI 2.3-8.2, p < 0.001), patients with non-cardiac comorbidities (OR 1.7, 95 % CI 1.1-26, p < 0.01), and patients with low mixed venous oxygen saturation (OR 2.3, 95 % CI 1.4-3.6, p < 0.001). Nine thousand three hundred and seventy-nine (69 %) patients were initially managed with general endotracheal anesthesia, LMA, or tracheostomy, whereas 4232 (31 %) were managed with procedural sedation without an artificial airway, of which 75 (1.77 %) patients were converted to assisted ventilation/general anesthesia. Young age (<12 months, OR 5.2, 95 % CI 2.3-11.4, p < 0.001), higher-risk procedure (category 4, OR 10.1, 95 % CI 6.5-15.6, p < 0.001), and continuous pressor/inotrope requirement (OR 11.0, 95 % CI 8.6-14.0, p < 0.001) were independently associated with conversion. Cardiac catheterization in pediatric/congenital patients was associated with a low rate of serious sedation/airway-related adverse events. Smaller patients with non-cardiac comorbidities or low mixed venous oxygen saturation may be at higher risk. Patients under 1 year of age, undergoing high-risk procedures, or requiring continuous pressor/inotrope support may be at higher risk of requiring conversion from procedural sedation to assisted ventilation/general anesthesia.

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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.