Santiago Mintegi

Aim: To compare febrile infants aged 90 days or younger with Enterococcus spp. or Escherichia coli in urine cultures, overall and by urine dipstick findings. Methods: Matched cohort study in three Spanish paediatric emergency departments (2011–2023). Infants with Enterococcus spp. were matched 1:1 by age and sex with infants with E. coli and compared using paired tests; dipstick‐stratified analyses were exploratory. Results: Of 4006 febrile infants, 77 (1.9%) had Enterococcus spp. Abnormal dipstick findings were less frequent than with E. coli (27.3% vs. 80.5%; p < 0.001), and blood inflammatory markers were lower, largely reflecting the higher proportion of normal dipsticks. Abnormal voiding cystourethrogram findings were more frequent with Enterococcus spp., with abnormal (70.0% vs. 27.6%; p = 0.03) and normal dipsticks (33.3% vs. 0%; p = 0.04). With abnormal dipsticks, abnormal dimercaptosuccinic acid scans (6/11 vs. 0/17; p = 0.001) and recurrent urinary tract infections (33.3% vs. 8.1%; p = 0.009) were more frequent with Enterococcus spp. Conclusion: In these infants, Enterococcus spp. in urine usually had a normal dipstick but was associated with more urinary tract abnormalities than E. coli . Enterococcal infections with abnormal dipsticks were associated with more renal scan abnormalities and recurrences; the significance of isolates with normal dipsticks remains uncertain.

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Objectives: To identify early bedside clinical predictors of the need for organ support and mortality among critically ill children presenting to pediatric emergency departments (EDs). Methods: We conducted a prospective, registry-based, multicenter observational study across 21 pediatric emergency departments endorsed by the Spanish Society of Pediatric Emergencies. Critically ill children evaluated on the 4th, 14th, and 24th days of each month between February 2021 and July 2024 were included. Critical illness was defined as pediatric intensive care unit admission or advanced airway or circulatory intervention in the ED. The Pediatric Assessment Triangle (PAT) was recorded at arrival. Multivariable logistic regression was used to identify factors associated with severe clinical outcomes and mortality. Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Results: We included 412 critically ill children; 63 (15.3%) had severe clinical outcomes, and 12 (2.9%) died. Abnormal circulation and appearance when evaluating the PAT and abnormal systolic blood pressure were independently associated with severe clinical outcomes (AUC: 0.75; 95% CI: 0.68-0.82). Prior pediatric intensive care unit admission and abnormal appearance and abnormal circulation when evaluating the PAT were independently associated with mortality (AUC: 0.85; 95% CI: 0.76-0.95). Conclusions: Structured bedside assessment at ED presentation may provide clinically meaningful prognostic insight, supporting earlier prioritization and escalation of care for critically ill children, pending external validation.

Objectives: Highly toxic medications are thought to lead to fatal overdose even after single-dose ingestions. Recent evidence has questioned some of the assumptions underlying this concept. In this context, this study aimed to evaluate the incidence, management, and outcomes of accidental ingestions involving highly toxic drugs in young children presenting to pediatric emergency departments (EDs). Methods: We performed a descriptive and analytical study using a prospective, nationwide, multicenter pediatric poisoning registry including 58 Spanish EDs from 2008 to 2024. We analyzed accidental ingestions of therapeutic drugs in children under 8 years of age with a predefined subgroup of infants under 1 year. Highly toxic drugs were defined according to established pediatric toxicology criteria. Clinical presentation, ED management, hospital disposition, and outcomes were compared with other therapeutic drug ingestions. Results: Among 3577 poisoning episodes, 1189 (33.2%) involved accidental ingestion of therapeutic drugs in children under 8 years; 61 cases (5.1%) involved highly toxic drugs. Median age was 3 years (interquartile range 1 to 6), and 26 children (46.6%) were under 1 year. Cardiovascular drugs (37.7%) and opioids (24.5%) were the most frequent agents. Only 4 patients (6.8%) were symptomatic at presentation. No child required advanced airway or circulatory support, and no fatalities occurred. Hospital admission was more frequent after ingestion of highly toxic drugs. Conclusions: Accidental ingestion of highly toxic medications represents a small proportion of pediatric poisonings in EDs and is generally associated with favorable short-term outcomes. This supports a more evidence-based approach to risk stratification in the management of exploratory ingestions.

Objective: To analyze the reasons for ordering a CT scan and the abnormalities identified in children with mild head trauma classified as intermediate-risk according to the PECARN rule. Methods: This retrospective observational study included patients aged 3 months to 14 years who presented to the emergency department (ED) of a tertiary hospital between 2021 and 2022 with mild head trauma classified as intermediate-risk. Two multivariable analyses were performed to identify demographic and clinical factors associated with CT scan utilization and CT abnormalities. Results: We included 555 patients; 40% were girls, and the median age was 4 years (interquartile range: 1 to 8 y). Most patients (98.6%) were managed as outpatients after a median ED stay of 4.5 hours (IQR: 4 to 6.75). CT scans were performed in 78 patients (14.1%), of whom 24 (30.8%) had abnormalities: 13 had traumatic brain injuries and 11 had isolated skull fractures. Six patients (1.1%) had clinically important traumatic brain injuries (ciTBI). Four independent factors were associated with CT scan utilization: number of vomiting episodes (OR: 1.31; 95% CI: 1.16-1.49), headache (OR: 2.1; 95% CI: 1.21-3.6), abnormal behavior reported by parents (OR: 3.45; 95% CI: 1.99-5.95), and time elapsed before being seen by an ED physician (OR: 1.05; 95% CI: 1.01-1.08). Two factors were associated with CT abnormalities: younger age (OR: 0.82; 95% CI: 0.71-0.95) and severe injury mechanism (OR: 5.89; 95% CI: 2.04-18.37). Conclusions: In children with mild head trauma classified as intermediate-risk, the factors leading to CT scan utilization differ from those associated with CT abnormalities. Further studies are needed to confirm these findings.

Aim: To analyse the prevalence of electrolyte and kidney function alterations in infants ≤ 90 days with febrile urinary tract infection (UTI). Methods: Secondary analysis of a prospective registry including infants ≤ 90 days with fever without a source seen between 2010 and 2022 in an emergency department. We analysed electrolyte and kidney function laboratory parameters in relation to the definitive diagnosis and a group of healthy controls. Results: We registered 2361 episodes: 495 UTI (34 with an associated invasive bacterial infection [IBI]), 43 IBI not related to a UTI, and 1823 without bacterial infection. Further, we included 205 healthy controls. The median duration of fever was 4 h, and 98.5% were well appearing. Among infants with UTI without an associated IBI, blood creatinine levels were abnormal in 0.2%, urea in 1.1% and glomerular filtration rate in 3.2%, similar to infants not diagnosed with bacterial infections and healthy controls, and significantly lower than in those with UTI and an associated IBI (9.4%, 18.1% and 17.2% respectively). No patients had signs or symptoms of acute kidney injury. Conclusions: Electrolyte imbalance and kidney function impairment are rare in well‐appearing infants younger than 90 days with febrile UTI and a short duration of fever.

Aim: To analyse the relationship between fever severity and the rate of urinary tract infection (UTI) among well‐appearing febrile infants aged 61–90 days with fever without a source (FWS). Methods: We conducted a sub‐analysis of a multicentre retrospective study between 2011 and 2022. Results: 239 (21.4%) were diagnosed with UTI. UTIs were more common in males (odds ratio [OR]: 2.5; 95% confidence interval [CI]: 1.7–3.3), in infants with a longer fever duration (OR: 1.02; 95% CI: 1.01–1.03), and higher temperature (OR: 1.6; 95% CI: 1.2–2.2). The AUC for predicting a UTI based on fever degree was 0.59 (95% CI: 0.54–0.63). The prevalence of UTI was 22.3% (95% CI: 18.8%–26.1%) in infants with a temperature < 38.5°C, 12.5% (95% CI: 9.2%–16.4%) in infants with temperature 38.5°C–38.9°C, and 32.3% (95% CI: 26.5%–38.5%) in infants with temperature ≥ 39°C. The prevalence of invasive bacterial infection among patients diagnosed with UTI was 3.8% (95% CI: 1.7–7.0), with no significant differences across temperature categories. Conclusion: A urine dipstick test should be recommended for all well‐appearing infants aged 61–90 days with FWS regardless of the degree of fever. Blood culture should also be considered in infants with abnormal urine dipstick results, irrespective of fever severity.