Journal Feed Weekly Wrap-Up
- May 1st, 2021
- Clay Smith
Serious infection was rare among infants ≤60 days with hypothermia (2.6% prevalence). The three infants with serious infection all had hypothermia plus some other red flag, but be very careful how you use this in practice.
Why does this matter?
Hypothermia (rectal temperature ≤36.0°C) in young infants may be a sign of sepsis, especially infection caused by HSV, but it may simply be from exposure to a cool environment. Should we consider hypothermia alone as a reason to initiate a sepsis workup, as we do fever (≥38.0°C)?
Oh, that’s cool!
This was a single center retrospective study of 4,797 infant ≤60 days over ~3 years who presented to the ED for any reason. Of these, 116 were hypothermic. Prevalence of a serious infection, defined as urinary tract infection (UTI), bacteremia, meningitis, pneumonia, or herpes infection, was 2.6% (3/116) among hypothermic infants; prevalence was 15.2% (61/401) among febrile infants. The three hypothermic infants with serious infection all had other clinical features in addition to hypothermia, such as, “prematurity, apnea, poor feeding, lethargy, ill-appearance, and respiratory signs.” No infants with isolated hypothermia had serious infection, that the authors could detect. Here is a major caveat – just 33/116 (28.4%) of the hypothermic infants had any workup for serious infection, and not all (91.4%) could be followed up. Clearly, the emergency physicians treated hypothermia as benign 72% of the time and did not perform a workup. And the three infants with serious infection (that we know about) all had hypothermia plus something else that indicated the infant had something more serious. However, we should not view this study as definitive, since the sample size is relatively small, most of the hypothermic infants did not have infectious workup, and some were lost to follow up. Generally, this affirms my practice. In a healthy appearing infant ≤60 days with hypothermia, I may not do a full sepsis workup, especially if there is a reasonable explanation – blanket fell off, cold room, etc. But if there is one thing I take away, it is that hypothermia plus any other red flag means that child should get a full workup for serious infection.
Hypothermia: A Sign of Sepsis in Young Infants in the Emergency Department? Pediatr Emerg Care. 2021 Mar 1;37(3):e124-e128. doi: 10.1097/PEC.0000000000001539.
When forgoing paralytics for perceived difficult airways, there are several options. Intubation with ketamine alone is uncommon, and when compared to topical anesthesia is associated with decreased first pass success and an increased number of adverse events.
Why does this matter?
When there is concern for difficult anatomic or physiologic airways (can’t intubate/oxygenate, critical hypoxemia, distorted anatomy, apnea intolerance), paralytics are sometimes avoided. Traditionally, these airways are approached with topical anesthesia and low-dose sedatives – but what about ketamine? Given it preserves respiratory drive, could ketamine be a better alternative?
The K-hole isn’t the ideal place for RSI
To evaluate the success and complications of ketamine-only intubation in the ED, 12,511 patients from the NEAR database were included in analysis. 80 (0.6%) were intubated with topical anesthesia alone; 102 (0.8%) underwent intubation with ketamine alone; and the rest (12,329; 95%) underwent traditional RSI. First pass success rate for all three groups was 85%, 61%, and 90%, respectively. When comparing ketamine-only vs topical anesthesia-only intubation, there was a 13% greater incidence of ≥1 adverse events (cardiac arrest, dental trauma, airway injury, esophageal intubation, hypoxemia, bleeding, hypotension, laceration) in the ketamine group.
When facing a potentially difficult airway for which paralysis is frightening, a ketamine-only approach doesn’t seem to be the right move at this time. Of course, the study is retrospective, and the sample size is very small compared to overall intubation attempts – but the results are striking. While a prospective randomized control of topical vs ketamine only approach would help answer this question better, this study makes that harder to justify.
Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department. J Emerg Med. 2021 Mar;60(3):265-272. doi: 10.1016/j.jemermed.2020.10.042. Epub 2020 Dec 9.
In outpatient children with community acquired pneumonia (CAP), 5 days of amoxicillin was non-inferior to 10 days.
Why does this matter?
Using the narrowest spectrum antibiotic for the shortest period of time is key for reducing antibiotic resistance. CAP in children is usually treated with 10 days of amoxicillin as first line therapy. Would a shorter course be just as effective?
Is this SAFER?
This was a two-center RCT with 281 children 6 months to 10 years with CAP comparing outpatient treatment with 5 days of amoxicillin vs 10 days. Pneumonia was diagnosed by presence of recent fever, respiratory symptoms, CXR findings, and “pneumonia” listed as the primary diagnosis. They found no difference in clinical cure rate at 14 to 21 days in the intention to treat (ITT) group, which was the primary outcome. They set the 97.5% lower confidence limit for non-inferiority at -7.5%. In ITT, clinical cure was seen in 85.7% in the 5-day group and 84.1% in the 10-day group (risk difference, 2.3%; 97.5% CL, -6.1%). In the per protocol analysis, clinical cure was 88.6% in the 5-day group and 90.8% in the 10-day group (risk difference, -1.6%; 97.5% CL, -8.7%). A post hoc outcome was created because the authors realized some aspects of “clinical cure,” such as fever spikes after antibiotics with no other findings, no adverse outcomes, and no intervention were not relevant and would not be an indication of clinical failure in practice. This outcome, “clinical cure not requiring additional intervention” occurred in: 93.5% in the 5-day ITT group vs. 90.4% 10-day ITT group; difference 2.8 (97.5%CL −3.8%). I was pretty skeptical as I started reading this. But I think this is probably going to change my practice.
Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. 2021 Mar 8. doi: 10.1001/jamapediatrics.2020.6735. Online ahead of print.