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Subscribe To Our Weekly Free Medical BooksJoin our mailing list to receive the latest Free Medical Books from our team. ADAM AND EVE SEED GATHERING MINISTRY - A GO TO THE HIPPOCRATES LINK BELOW TO VIEW THE END OF AGEING FUND RISING SITE!A i»?i»?i»? LINK: TO THE ADAM AND EVE WORD RESEARCH BLOG! To identify factors associated with culture-proven serious bacterial infection (SBI) and positive emergency department septic screening (EDSS) tests in children with bronchiolitis and to identify factors associated with the performance of EDSS. Testing was more likely to be performed in children younger than two months of age, and in those who were febrile, dehydrated, and had more severe chest wall retractions.
The detection of respiratory syncytial virus (RSV) decreases the probability of a concurrent bacterial illness in infants with fever without source.1–3 The clinical presentation of RSV is highly variable. The primary purpose of this study was to identify those clinical factors most likely associated with SBI and positive ED screening tests in children with bronchiolitis. We made the following assailable but unavoidable assumptions about bacterial illness in these patients. The parent study was conducted at two centers; this study used data only from the primary study site. Bronchiolitis was defined as clinical evidence of lower airway obstruction (physical findings of wheezing and chest wall retractions) following an upper respiratory tract infection.
We performed RSV antigen detection on nasal aspirates samples using the BD Directigen™ RSV Test Kit (Becton, Dickinson and Company, Franklin Lakes, NJ). An ED septic screen (EDSS) was considered positive if urine or CSF analysis showed ?10 WBC per high power field (>25 WBC in neonates) or organisms were identified on gram stain regardless of subsequent culture being positive or negative.
We defined culture-proven SBI as a significant growth of a known bacterial pathogen in urine (10,000 or more colony-forming units per milliliter of a single pathogenic organism on a catheterized specimen), CSF or blood regardless of initial urine or CSF WBC results. We created a composite endpoint comprised of either a positive EDSS or a culture-proven SBI, or both.
We did not address the possibility of pneumonia as an SBI because of the inability to differentiate a viral from a bacterial cause on chest x-ray. We compared the prevalence of outcomes between RSV-positive and RSV-negative groups using Fisher’s exact test for categorical data. Although 14 patients were treated as having a positive EDSS or SBI by their treating physicians, our study definitions led us to discount three cases. Prior antibiotic use did not seem to alter outcome; low colony count plates were not used in some children who had had prior antibiotics. In children up to their eighteenth month of life with bronchiolitis, an EDSS was more likely to be performed in those who were less than two months old, febrile, dehydrated, and had more severe chest wall retractions; in short, those who appeared sicker. Why the prevalence of either a positive EDSS or SBI should differ in RSV as distinct from non-RSV bronchiolitis is a matter of conjecture. A related limitation is the possibility of a missed SBI in those not screened and who did not have an adverse outcome within three days of enrollment in the parent study. Finally, when studying rare events, using a sensible combined outcome measure may allow insights to be obtained with smaller sample sizes than would otherwise be possible. Our study definitions sometimes conflicted with the treating physicians’ clinical impression of a coexisting bacterial illness. Unlike prior work2,31,34–36we included children older than three months of age; this allowed us to prove the importance of age as a predictor of concurrent bacterial infection.
Future work establishing the prevalence of concurrent bacterial lung infection in children with bronchiolitis is needed. In those children with bronchiolitis in whom ED testing for bacterial illness was performed, younger age and a negative RSV antigen test was associated with a positive EDSS or SBI. Lorena Tuchscherr, Eva Medina, Muzaffar Hussain, Wolfgang Volker, Vanessa Heitmann, Silke Niemann, Dirk Holzinger, Johannes Roth, Richard A. Author AffiliationsLorena Tuchscherr1, Eva Medina2, Muzaffar Hussain1, Wolfgang Volker3, Vanessa Heitmann1, Silke Niemann1, Dirk Holzinger4,5, Johannes Roth4,5, Richard A.
We defined a positive EDSS as urine with ?10 WBC per high power field or cerebrospinal fluid (CSF) with ?10 WBC per high power field (>25 WBC in neonates), or if organisms were identified on gram stain.
The secondary purpose was to identify factors associated with obtaining these screening tests and cultures.
Firstly, we assumed that if both screening tests and cultures were negative that SBI was absent. The primary study site was a county teaching hospital ED with an annual census of 53,000 (23% children less than 14 years) serving a mixed urban, suburban, and rural population.
Those with bronchiolitis so mild as to not require bronchodilator treatment and those with illness so severe as to require immediate intubation were excluded. Potentially eligible children were identified by trained research assistants, residents and faculty. Urinalysis was performed with an Iris iQ200 Automated Urine Microscopy Analyzer (Iris Diagnostics, Chatsworth, CA).

CSF WBC counts were corrected assuming one additional WBC to be normal for every 500 RBCs present.
When more than one organism was detected in a urine culture the specimen was considered contaminated. Patients who did not have laboratory tests and were alive 72 hours post-ED discharge (as assessed by telephone follow-up) were assumed not to have had either an SBI or the composite endpoint.
We analyzed the importance of age, gender, presence of fever, clinical exam findings, and prior community antibiotic use on outcomes using logistic regression multivariate analysis. There were differences between children in whom physicians did and did not perform testing for bacterial illness. Predicted probability of a positive emergency department septic screening or serious bacterial infection (SBI) by age and respiratory syncytial virus (RSV) testing results.
Prevalence of Respiratory Syncytial Virus (RSV) and serious bacterial infection (SBI) or emergency department septic screening (EDSS) by age. This evaluation was more likely to be positive in those who were younger and had a negative RSV antigen test.
Some children had blood, CSF and urine cultured, and some, typically older infants, only had urine cultured.
The most likely source in these cases would be urinary, and the most likely pathogen Escherichia coli, (E.
The sensitivity and specificity of the test we used is modest, 78 % and 67% respectively.26 Whether and how PCR testing would have changed our results is speculative. Culture- negative SBI can occur, with diagnosis hinging on screening tests and clinical judgment. The rarity of our outcome means that despite a sample size of 640 patients our confidence intervals are wide. Two neonates who were treated based on CSF results were ultimately felt not to have an SBI.
We found that while the presence of fever influenced the decision to work up an infant, once that decision was made, neither the presence nor height of the fever was associated with a concurrent bacterial illness.
In Liebelt et al 211 infants aged 90 days or younger with clinical bronchiolitis, no case of SBI was found. Among those who do, a UTI is the most common diagnosis.1,2,19,32,36 For individual patients, clinical judgment, which may be more cost effective than using “clinical rules,”37 remains necessary. Secondly, we assumed if no screening was performed without any adverse clinical outcomes three days post-ED visit, then SBI was absent.
These criteria reflect the design of the parent study, a randomized controlled trial of bronchodilators in bronchiolitis. Urine culture was performed using the calibrated-loop method on well-mixed, uncentrifuged specimens on blood agar and MacConkey agar plates. The clinical record was reviewed by first and second authors to determine whether positive cultures were treated by the physician.
We considered blood cultures contaminated if they grew organisms commonly not accepted as pathogens (such as coagulase-negative staphylococcus, diphtheroids, and alpha- or gamma-hemolytic streptococcus). In cases where both telephone and written follow-up failed, and a review of hospital medical records showed no further contact with the patient, the county coroner’s records were used to determine vital status.
A modified multivariate Poisson analysis15 was performed to determine factors associated with having an EDSS performed or not performed. Once the decision to screen was made, neither fever nor the height of the fever was associated with SBI or positive EDSS.
Our necessarily practical definition of EDSS in this study included only tests with a turnaround time short enough to impact ED management. We were also surprised that blood cultures were ordered more frequently than urine cultures.
Had we excluded infants who were afebrile on presentation we would not have been able to demonstrate this point. We anticipated that the outcomes we were seeking would be sufficiently rare that our primary analysis would require a combined endpoint rather than separate analyses of several single endpoints. We restricted this study to patients from that study to ensure the quality of data collected. Clinical findings, including prior antibiotic and steroid use, were recorded on a specifically designed data collection.
Low colony count plates (recommended if the child has received antibiotics prior to the sample being obtained) were used if specified by the physician.
The paucity of positive outcomes despite relatively large sample size resulted in broad confidence intervals for our estimates of these effects. One might reasonably expect, therefore, that RSV antigen testing would add little information in the risk stratification of these children.

Even if a purely prospective design were employed, it would not be ethical to subject children to investigations that the treating clinician did not believe were indicated. Where the infection is confined to the urinary tract it is possible that some infants would have cleared the infection spontaneously.
Dropping “screen positive culture negative” cases does not help an EP who cannot know beforehand what cultures will grow. One case was treated by the clinician as having a real UTI based on urine culture of gamma hemolyticstreptococcus. They appear to have been ordered reflexively as part of the admission process in some cases. This approach also allowed us to capture the practice of experienced clinicians who occasionally perform an EDSS in infants without a fever yet look unwell. Antonow et al studied 282 infants less than two months of age with clinical bronchiolitis and found a SBI prevalence of 1.8%. The decision to perform testing was modeled using modified Poisson regression; the presence of the combined outcome was modeled using logistic regression modified for rare events.
Patients who received bronchodilators in the ED prior to screening for the parent study were excluded from that study and also from this.
We used Stata 9.2 statistical software, (Statacorp LP, College Station TX), for all analyses. Twenty-one of 183 blood cultures grew organisms; of these, only two were recognized pathogens. We analyzed a case of Candida glabrata as having an EDSS and SBI in one patient who had pyuria.
Instead we have provided our results in a way that we believe informs individual physicians’ risk tolerance for what is a rare but important outcome. Although the patients included in this study reflect the parent study design, it is difficult to imagine an EP prescribing antibiotics in infants with bronchiolitis so mild as to not be eligible for the original trial, or withholding them in patients intubated for bronchiolitis. Cerebrospinal fluid (CSF) specimens were processed for protein, glucose, red and white blood cell counts (RBC, WBC), gram stain (GS) and cultures. In our study, 32% were febrile on ED presentation (42% febrile in Liebelt and 65% in Antonow) and 55% were RSV-positive. We had only one case where this may have been an issue; however, this infant has had two subsequent UTIs. While reluctant to discount the judgment of the treating pediatrician, we felt obliged to analyze the data according to our study definitions. Reassuringly, when we analyzed the data based on the physicians’ clinical impressions the results were similar.
HE NOW again drowns many of His enemy, as "i" prophesy months back, and since He has drown many in Tonga, and crushed many in Haiti! As when "i" called for a storm Haiti in 2004, and even gave the date, the first time "i" ever asked for a certain day, and 2 months later storm rolled across Haiti on May 26th, the day "i" prophesy. Drowning more than 3000 devil worshiping beings, and on the very date "i" called for it,this is the season of our gathering for His Glory, and our Destiny.A A A 8.
Floods of biblical proportions from america, too australia, with great droughts in between. Sun soon again shoots flare's through its center as prophesy back in 2008, and since the sun has shot flares from its surface greater than any before.
He now shakes the earth to and fro so too prepare the earth for the Mighty quake of Destiny, too israel, making a great valley where once stood a blasphemous dome on His rock. Earthquakes the black sea as He foretold to me in a Dream, and "i" prophesy and since the volcanoe's beneath the black sea have began to shake, as prophesy by me HIS and your smallest prophet, and gathering Call. These along with many individual signs "i" have spoken to men and wo-men around earth that now come, and are coming!
Merely tossed boats onto the shore with His quaking hand, the same in Australia, it had been years since australia had had a tidal wave. Due to Him, having me speak Ezekiel 13:11, and Ezekiel 13:13, Yea, and O'GREAT HAIL STONE'S SHALL FALL ACROSS THE EARTH IN MANY OF THE SEVEN NATIONS IN WHICH "i" CALL AND GATHER! Hurricane houston Texas, as the Hurricane i prophesy too all last year and 2004, they touched the Bible, after GODS MESSIAH PROCLAIMED , TOUCH MY WORD, AND I WILL MAKE THIS LAND A WASTE LAND!" Isaiah28:2 4.
For fear of hitlers wrath, if they refused!" Now this man, JOSEF SCHEUNGRABER ESQ; 90 year old German Hero!" Has been chased and caught and accused of not stopping hitler!" Always during these tribunals, they say, well they could have stopped hitler from killing jews, or any, while knowing the jews themselves did nothing to stop hitler, he said walk to these trains and they did so!" Horrible, but not Josef's Fault!" Josef knew just like the jew, if he said NO, he died!" "So this day, when AMERICAN BUILDING'S ARE BLOWN up with 1000's of innocent, and then even presidents try too get the murders freed, and protecting them!" And while in scotland a murderer who killed 100's on Pam am flight 103, who killed 270 people, innocent people, was freed after 5 years!" And as stated those who have been freed of the muslim, {{ FREED FROM Guamtonimo prison }}that were killing and beheading our soldiers, and then went right back to war against us!"WHILETHIS GERMAN MAN, WHO DID WHAT HIS LEADERS told him to do, and was proved to be near where a massacretook place in Italy, of some men who had killed german soldiers, now receive's the Life sentence he did not deserve!" Why?

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