Thanks to the tireless work of countless staff and volunteers, the Pediatric Emergency Care Applied Research Network (PECARN) is approaching almost two decades of operation. I will admit to a biased fondness for the project, as I participated as one small cog in the nascent operation many years ago while a research assistant at The Children’s Hospital of Philadelphia. Now, PECARN can only be described as an unqualified success, using its resources to enroll sample sizes large enough to capture rare events, informing our care of everything from traumatic brain injury to diabetic ketoacidosis. Because of the continued investment of time and energy by its stewards, PECARN continues to conduct and publish high-quality research. Here’s a rundown on the network’s findings in the last year.
Explore This IssueACEP Now: Vol 40 – No 03 – March 2021
During 2020, the PECARN output featured several pieces of data exploring the management of febrile infants. The first of these is data regarding the time to culture positivity in infants with possible serious bacterial infections.1 The duration of hospitalization and antibiotic administration is predicated on the possibility that a pathogen will be isolated, and these hospital stays routinely exceed 24 hours. In this cohort, which included 303 positive blood cultures and 88 positive cerebrospinal fluid (CSF) cultures, the median times to positivity for true-positive blood and CSF cultures were 16.6 and 14.0 hours, respectively. Four-fifths of blood and CSF cultures were positive by 24 hours, leading the authors to suggest this time frame as reasonable for clinical reassessment. A well infant, with a normal blood culture and normal CSF findings, is likely a candidate for discharge depending on the greater clinical context.
Another article looked at the role of chest radiographs in the evaluation of febrile infants.2 In this retrospective cohort, radiography was performed in approximately one-third of subjects. Within this group, only about 6 percent had suspected or definite pneumonia. Drilling down even further, viral pathogens alone were isolated in half of those. There were, unfortunately, no clear predictors of true-positive findings or those differentiating viral from bacterial pneumonias. At the least, chest radiographs need not be considered an essential evaluation of fever without a source but rather left to best clinical judgment.
The PECARN group’s work in pneumonia is not limited to young infants but also includes older children.3 Looking retrospectively at 1,128 children with suspected pneumonia, the authors collected clinical features in an attempt to predict which children would develop moderate or severe disease. In this fairly ill cohort in which almost 40 percent required hospitalization, the authors derived a clinical instrument calibrated to predict the probability of severe disease in any child being evaluated for pneumonia. The most predictive features identified ought not be terribly surprising: elevated respiratory rate, increased work of breathing, impaired oxygenation, and abnormalities on chest radiography. The tool generated from these data will not replace clinician judgment, but if externally validated and evaluated as a component of decision support, using this checklist could identify the important subset of children who are at the greatest risk for deterioration.
A few years ago, the PECARN group derived a prediction instrument in an attempt to rule out neonatal sepsis and reduce unnecessary downstream evaluations.4 This instrument, derived utilizing the same recursive partitioning as the PECARN traumatic brain injury tool, was able to achieve sensitivity of 97.7 percent using urinalysis, absolute neutrophil count, and procalcitonin. In 2020, at least one group tested this rule in their population.5 Retrospectively applied to a research cohort containing 256 serious bacterial infections from their hospital in Bilbao, Spain, the PECARN instrument would have missed 26, including five with bacterial meningitis. Their reported sensitivity, based on their population, would ultimately be 89.8 percent. While the original 97.7 percent sensitivity puts it into discussion as clinically applicable, these data certainly cast doubt upon its use.