Clinical Focus

  • Pediatric Hospital Medicine

Academic Appointments

Administrative Appointments

  • Associate Program Director, Pediatric Hospital Medicine Fellowship (2019 - Present)

Honors & Awards

  • Excellence in Improvement Publication Award - Best Publication Focused on a Pediatric Population, Stanford Medicine Center for Improvement (2023)
  • Maxwell Finland Award for Excellence in Research, Massachusetts Infectious Diseases Society (2016)

Boards, Advisory Committees, Professional Organizations

  • Associate Editor, Journal of Hospital Medicine (2024 - Present)
  • Editorial Board Member, Hospital Pediatrics (2021 - 2024)
  • Expert Work Group Member, Better Antibiotic Selection in Children (BASIC), AAP Value in Inpatient Pediatrics Network (2019 - 2021)
  • Editorial Fellow, Journal of Hospital Medicine (2019 - 2020)
  • Member, Pediatric Infectious Diseases Society (2013 - Present)
  • Fellow, American Academy of Pediatrics (2009 - Present)

Professional Education

  • Board Certification, American Board of Pediatrics, Pediatric Hospital Medicine (2022)
  • Board Certification: American Board of Pediatrics, Pediatric Infectious Diseases (2017)
  • MPH, Harvard School of Public Health, Clinical Effectiveness (2016)
  • Fellowship, Boston Children's Hospital, Pediatric Infectious Diseases (2016)
  • Board Certification: American Board of Pediatrics, Pediatrics (2012)
  • Residency: Stanford Health Care at Lucile Packard Children's Hospital (2012) CA
  • MD, Stanford University School of Medicine (2009)
  • BA, Stanford University, Human Biology

Current Research and Scholarly Interests

Evaluation and management of the febrile young infant and infections in hospitalized children; promotion of appropriate antibiotic use.

All Publications

  • Clinical course of children 1-24 months old with positive urine cultures without pyuria. Academic pediatrics Wang, M. E., Jones, V. G., Kane, M., Allan, J. M., Maleknia, L., Patel, R., Ip, W., Newman, T. B., Roberts, K. B., Schroeder, A. R. 2023


    To describe the clinical course of children with positive urine cultures without pyuria who were not given antibiotics initially, identify predictors of subsequent antibiotic treatment, and evaluate the association between subsequent treatment and urinary tract infection (UTI) within 30 days.We conducted a multicenter retrospective cohort study of children 1-24 months old who had positive urine cultures without pyuria and who were not started on antibiotics upon presentation to 3 healthcare systems from 2010-2021. Outcomes included clinical status at the time urine cultures resulted, escalation of care (emergency department visit or hospitalization) and subsequent antibiotic treatment within 7 days, and subsequent UTI within 30 days of presentation.Of 202 included children, 61% were female and median age was 9 months. Of 151 patients with clinical status information when cultures resulted, 107 (70.8%, 95% confidence interval [CI] 62.9-77.9%) were improved. Two of 202 children (1.0%, 95% CI 0.2-4.0%) experienced care escalation. Antibiotics were started in 142 (82.2%) children and treatment was associated with prior UTI (risk ratio [RR] 1.20, 95% CI 1.15-1.26) and lack of improvement (RR 1.22, 95% CI 1.13-1.33). Subsequent UTI was diagnosed in 2 of 164 (1.2%, 95% CI 0.1-4.3%) treated and 0 of 36 (0%, 95% CI 0-9.7%) untreated children.Seventy percent of children with positive urine cultures without pyuria improved before starting antibiotics, however >80% were ultimately treated. Future research should study the impact of diagnostic stewardship interventions and various urine testing strategies to optimize management of children evaluated for UTI.Seventy percent of children with positive urine cultures without pyuria improved before starting antibiotics, however >80% were ultimately treated. Future research should study the impact of diagnostic stewardship interventions to optimize management of children evaluated for UTI.

    View details for DOI 10.1016/j.acap.2023.06.023

    View details for PubMedID 37354950

  • Management and Outcomes in Children with Third-Generation Cephalosporin-Resistant Urinary Tract Infections. Journal of the Pediatric Infectious Diseases Society Wang, M. E., Greenhow, T. L., Lee, V., Beck, J., Bendel-Stenzel, M., Hames, N., McDaniel, C. E., King, E. E., Sherry, W., Parmar, D., Patrizi, S. T., Srinivas, N., Schroeder, A. R. 2021


    BACKGROUND: Third-generation cephalosporin-resistant urinary tract infections (UTIs) often have limited oral antibiotic options with some children receiving prolonged parenteral courses. Our objectives were to determine predictors of long parenteral therapy and the association between parenteral therapy duration and UTI relapse in children with third-generation cephalosporin-resistant UTIs.METHODS: We conducted a multisite retrospective cohort study of children <18 years presenting to acute care at 5 children's hospitals and a large managed care organization from 2012 to 2017 with a third-generation cephalosporin-resistant UTI from Escherichia coli or Klebsiella spp. Long parenteral therapy was ≥3 days and short/no parenteral therapy was 0-2 days of concordant parenteral antibiotics. Discordant therapy was antibiotics to which the pathogen was non-susceptible. Relapse was a UTI from the same organism within 30 days.RESULTS: Of the 482 children included, 81% were female and the median age was 3.3 years (interquartile range: 0.8-8). Fifty-four children (11.2%) received long parenteral therapy (median duration: 7 days). Predictors of long parenteral therapy included age <2 months (adjusted odds ratio [aOR] 67.3; 95% confidence interval [CI]: 16.4-275.7), limited oral antibiotic options (aOR 5.9; 95% CI: 2.8-12.3), and genitourinary abnormalities (aOR 5.4; 95% CI: 1.8-15.9). UTI relapse occurred in 1 of the 54 (1.9%) children treated with long parenteral therapy and in 6 of the 428 (1.5%) children treated with short/no parenteral therapy (P = .57). Of the 105 children treated exclusively with discordant antibiotics, 3 (2.9%, 95% CI: 0.6%-8.1%) experienced UTI relapse.CONCLUSIONS: Long parenteral therapy was associated with age <2 months, limited oral antibiotic options, and genitourinary abnormalities. UTI relapse was rare and not associated with duration of parenteral therapy. For UTIs with limited oral options, further research is needed on the effectiveness of continued discordant therapy.

    View details for DOI 10.1093/jpids/piab003

    View details for PubMedID 33595081

  • The Future of Pediatric Hospital Medicine: Challenges and Opportunities. Journal of hospital medicine Wang, M. E., Shaughnessy, E. E., Leyenaar, J. K. 2020; 15 (2): E1–E3

    View details for DOI 10.12788/jhm.3373

    View details for PubMedID 32118553

  • Clinical Response to Discordant Therapy in Third-Generation Cephalosporin-Resistant UTIs. Pediatrics Wang, M. E., Lee, V. n., Greenhow, T. L., Beck, J. n., Bendel-Stenzel, M. n., Hames, N. n., McDaniel, C. E., King, E. E., Sherry, W. n., Parmar, D. n., Patrizi, S. T., Srinivas, N. n., Schroeder, A. R. 2020


    To describe the initial clinical response and care escalation needs for children with urinary tract infections (UTIs) resistant to third-generation cephalosporins while on discordant antibiotics.We performed a retrospective study of children <18 years old presenting to an acute care setting of 5 children's hospitals and a large managed care organization from 2012 to 2017 with third-generation cephalosporin-resistant UTIs (defined as the growth of ≥50 000 colony-forming units per mL of Escherichia coli or Klebsiella spp. nonsusceptible to ceftriaxone with a positive urinalysis). We included children started on discordant antibiotics who had follow-up when culture susceptibilities resulted. Outcomes were escalation of care (emergency department visit, hospital admission, or ICU transfer while on discordant therapy) and clinical response at follow-up (classified as improved or not improved).Of the 316 children included, 78% were girls and the median age was 2.4 years (interquartile range 0.6-6.5). Children were evaluated in the emergency department (56%) or clinic (43%), and 90% were started on a cephalosporin. A total of 7 of 316 children (2.2%; 95% confidence interval 0.8%-4.5%) experienced escalation of care. For the 230 children (73%) with clinical response recorded, 192 of 230 (83.5%; 95% confidence interval 78.0%-88.0%) experienced clinical improvement. In children with repeat urine testing while on discordant therapy, pyuria improved or resolved in 16 of 19 (84%) and urine cultures sterilized in 11 of 17 (65%).Most children with third-generation cephalosporin-resistant UTIs started on discordant antibiotics experienced initial clinical improvement, and few required escalation of care. Our findings suggest that narrow-spectrum empiric therapy is appropriate while awaiting final urine culture results.

    View details for DOI 10.1542/peds.2019-1608

    View details for PubMedID 31953316

  • Prioritization of Randomized Clinical Trial Questions for Children Hospitalized With Common Conditions: A Consensus Statement. JAMA network open Coon, E. R., McDaniel, C. E., Paciorkowski, N., Grimshaw, M., Frakes, E., Ambroggio, L., Auger, K. A., Cohen, E., Garber, M., Gill, P. J., Jennings, R., Joshi, N. S., Leyenaar, J. K., McCulloh, R., Pantell, M. S., Sauers-Ford, H. S., Schroeder, A. R., Srivastava, R., Wang, M. E., Wilson, K. M., Kaiser, S. V., RCT conference series group, Kemper, A. R., Heath, A., Fromme, H. B., Jennings, B. N., Wainscott, C. E., Russell, C. J., McCulloch, C. E., Snow, C. H., Alvarez, F. J., Percelay, J. M., Nicholson, K. S., Morton, K. M., Dias, M., Marek, R. L., Wilcox, R. A., Hyde, S. A., Mahant, S., Edwards, Y. R. 2024; 7 (5): e2411259


    Importance: There is a lack of randomized clinical trial (RCT) data to guide many routine decisions in the care of children hospitalized for common conditions. A first step in addressing the shortage of RCTs for this population is to identify the most pressing RCT questions for children hospitalized with common conditions.Objective: To identify the most important and feasible RCT questions for children hospitalized with common conditions.Design, Setting, and Participants: For this consensus statement, a 3-stage modified Delphi process was used in a virtual conference series spanning January 1 to September 29, 2022. Forty-six individuals from 30 different institutions participated in the process. Stage 1 involved construction of RCT questions for the 10 most common pediatric conditions leading to hospitalization. Participants used condition-specific guidelines and reviews from a structured literature search to inform their development of RCT questions. During stage 2, RCT questions were refined and scored according to importance. Stage 3 incorporated public comment and feasibility with the prioritization of RCT questions.Main Outcomes and Measures: The main outcome was RCT questions framed in a PICO (population, intervention, control, and outcome) format and ranked according to importance and feasibility; score choices ranged from 1 to 9, with higher scores indicating greater importance and feasibility.Results: Forty-six individuals (38 who shared demographic data; 24 women [63%]) from 30 different institutions participated in our modified Delphi process. Participants included children's hospital (n=14) and community hospital (n=13) pediatricians, parents of hospitalized children (n=4), other clinicians (n=2), biostatisticians (n=2), and other researchers (n=11). The process yielded 62 unique RCT questions, most of which are pragmatic, comparing interventions in widespread use for which definitive effectiveness data are lacking. Overall scores for importance and feasibility of the RCT questions ranged from 1 to 9, with a median of 5 (IQR, 4-7). Six of the top 10 selected questions focused on determining optimal antibiotic regimens for 3 common infections (pneumonia, urinary tract infection, and cellulitis).Conclusions and Relevance: This consensus statementhas identified the most important and feasible RCT questions for children hospitalized with common conditions. This list of RCT questions can guide investigators and funders in conducting impactful trials to improve care and outcomes for hospitalized children.

    View details for DOI 10.1001/jamanetworkopen.2024.11259

    View details for PubMedID 38748429

  • A National Quality Improvement Collaborative to Improve Antibiotic Use in Pediatric Infections. Pediatrics McCulloh, R. J., Kerns, E., Flores, R., Cane, R., El Feghaly, R. E., Marin, J. R., Markham, J. L., Newland, J. G., Wang, M. E., Garber, M. 2024


    Nearly 25% of antibiotics prescribed to children are inappropriate or unnecessary, subjecting patients to avoidable adverse medication effects and cost.We conducted a quality improvement initiative across 118 hospitals participating in the American Academy of Pediatrics Value in Inpatient Pediatrics Network 2020 to 2022. We aimed to increase the proportion of children receiving appropriate: (1) empirical, (2) definitive, and (3) duration of antibiotic therapy for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infections to ≥85% by Jan 1, 2022. Sites reviewed encounters of children >60 days old evaluated in the emergency department or hospital. Interventions included monthly audit with feedback, educational webinars, peer coaching, order sets, and a mobile app containing site-specific, antibiogram-based treatment recommendations. Sites submitted 18 months of baseline, 2-months washout, and 10 months intervention data. We performed interrupted time series (analyses for each measure.Sites reviewed 43 916 encounters (30 799 preintervention, 13 117 post). Overall median [interquartile range] adherence to empirical, definitive, and duration of antibiotic therapy was 67% [65% to 70%]; 74% [72% to 75%] and 61% [58% to 65%], respectively at baseline and was 72% [71% to 72%]; 79% [79% to 80%] and 71% [69% to 73%], respectively, during the intervention period. Interrupted time series revealed a 13% (95% confidence interval: 1% to 26%) intercept change at intervention for empirical therapy and a 1.1% (95% confidence interval: 0.4% to 1.9%) monthly increase in adherence per month for antibiotic duration above baseline rates. Balancing measures of care escalation and revisit or readmission did not increase.This multisite collaborative increased appropriate antibiotic use for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infection among diverse hospitals.

    View details for DOI 10.1542/peds.2023-062246

    View details for PubMedID 38682258

  • Lime-Induced Phytophotodermatitis: A Rash That Requires Explicit Questioning. The journal of allergy and clinical immunology. In practice Jiang, S. Y., Wright, C. M., Hinton, A., Green, G., Moyer, A. R., Gerstbacher, D., Kushner, L. E., Wang, M. E., Schor, J. S., Trietsch, J., Chu, D., McGhee, S. 2024

    View details for DOI 10.1016/j.jaip.2024.02.035

    View details for PubMedID 38506786

  • Incidence of Pediatric Urinary Tract Infections Before and During the COVID-19 Pandemic. JAMA network open Liang, D., Wang, M. E., Dahlen, A., Liao, Y., Saunders, A. C., Coon, E. R., Schroeder, A. R. 2024; 7 (1): e2350061


    Urinary tract infection (UTI) is common in children, but the population incidence is largely unknown. Controversy surrounds the optimal diagnostic criteria and how to balance the risks of undertreatment and overtreatment. Changes in health care use during the COVID-19 pandemic created a natural experiment to examine health care use and UTI diagnosis and outcomes.To examine the population incidence of UTI in children and assess the changes of the COVID-19 pandemic regarding UTI diagnoses and measures of UTI severity.This retrospective observational cohort study used US commercial claims data from privately insured patients aged 0 to 17 years from January 1, 2016, to December 31, 2021.Time periods included prepandemic (January 1, 2016, to February 29, 2020), early pandemic (April 1 to June 30, 2020), and midpandemic (July 1, 2020, to December 31, 2021).The primary outcome was the incidence of UTI, defined as having a UTI diagnosis code with an accompanying antibiotic prescription. Balancing measures included measures of UTI severity, including hospitalizations and intensive care unit admissions. Trends were evaluated using an interrupted time-series analysis.The cohort included 13 221 117 enrollees aged 0 to 17 years, with males representing 6 744 250 (51.0%) of the population. The mean incidence of UTI diagnoses was 1.300 (95% CI, 1.296-1.304) UTIs per 100 patient-years. The UTI incidence was 0.86 per 100 patient-years at age 0 to 1 year, 1.58 per 100 patient-years at 2 to 5 years, 1.24 per 100 patient-years at 6 to 11 years, and 1.37 per 100 patient-years at 12 to 17 years, and was higher in females vs males (2.48 [95% CI, 2.46-2.50] vs 0.180 [95% CI, 0.178-0.182] per 100 patient-years). Compared with prepandemic trends, UTIs decreased in the early pandemic: -33.1% (95% CI, -39.4% to -26.1%) for all children and -52.1% (95% CI, -62.1% to -39.5%) in a subgroup of infants aged 60 days or younger. However, all measures of UTI severity decreased or were not significantly different. The UTI incidence returned to near prepandemic rates (-4.3%; 95% CI, -32.0% to 34.6% for all children) after the first 3 months of the pandemic.In this cohort study, UTI diagnosis decreased during the early pandemic period without an increase in measures of disease severity, suggesting that reduced overdiagnosis and/or reduced misdiagnosis may be an explanatory factor.

    View details for DOI 10.1001/jamanetworkopen.2023.50061

    View details for PubMedID 38170521

    View details for PubMedCentralID PMC10765266

  • Research Methods: Diagnostic Test Characteristics. Hospital pediatrics Mediratta, R. P., Newman, T. B., Wang, M. E. 2023


    The goal of a diagnostic test is to provide information on the probability of disease. In this article, we review the principles of diagnostic test characteristics, including sensitivity, specificity, positive and negative predictive value, receiver operating characteristics curves, likelihood ratios, and interval likelihood ratios. We illustrate how interval likelihood ratios optimize the information that can be obtained from test results that can take on >2 values, how they are reflected in the slope of the receiver operating characteristics curve, and how they can be easily calculated from published data.

    View details for DOI 10.1542/hpeds.2023-007149

    View details for PubMedID 37144292

  • Prevalence of Urinary Tract Infection, Bacteremia, and Meningitis Among Febrile Infants Aged 8 to 60 Days With SARS-CoV-2. JAMA network open Aronson, P. L., Louie, J. P., Kerns, E., Jennings, B., Magee, S., Wang, M. E., Gupta, N., Kovaleski, C., McDaniel, L. M., McDaniel, C. E. 2023; 6 (5): e2313354


    The prevalence of urinary tract infection (UTI), bacteremia, and bacterial meningitis in febrile infants with SARS-CoV-2 is largely unknown. Knowledge of the prevalence of these bacterial infections among febrile infants with SARS-CoV-2 can inform clinical decision-making.To describe the prevalence of UTI, bacteremia, and bacterial meningitis among febrile infants aged 8 to 60 days with SARS-CoV-2 vs without SARS-CoV-2.This multicenter cross-sectional study was conducted as part of a quality improvement initiative at 106 hospitals in the US and Canada. Participants included full-term, previously healthy, well-appearing infants aged 8 to 60 days without bronchiolitis and with a temperature of at least 38 °C who underwent SARS-CoV-2 testing in the emergency department or hospital between November 1, 2020, and October 31, 2022. Statistical analysis was performed from September 2022 to March 2023.SARS-CoV-2 positivity and, for SARS-CoV-2-positive infants, the presence of normal vs abnormal inflammatory marker (IM) levels.Outcomes were ascertained by medical record review and included the prevalence of UTI, bacteremia without meningitis, and bacterial meningitis. The proportion of infants who were SARS-CoV-2 positive vs negative was calculated for each infection type, and stratified by age group and normal vs abnormal IMs.Among 14 402 febrile infants with SARS-CoV-2 testing, 8413 (58.4%) were aged 29 to 60 days; 8143 (56.5%) were male; and 3753 (26.1%) tested positive. Compared with infants who tested negative, a lower proportion of infants who tested positive for SARS-CoV-2 had UTI (0.8% [95% CI, 0.5%-1.1%]) vs 7.6% [95% CI, 7.1%-8.1%]), bacteremia without meningitis (0.2% [95% CI, 0.1%-0.3%] vs 2.1% [95% CI, 1.8%-2.4%]), and bacterial meningitis (<0.1% [95% CI, 0%-0.2%] vs 0.5% [95% CI, 0.4%-0.6%]). Among infants aged 29 to 60 days who tested positive for SARS-CoV-2, 0.4% (95% CI, 0.2%-0.7%) had UTI, less than 0.1% (95% CI, 0%-0.2%) had bacteremia, and less than 0.1% (95% CI, 0%-0.1%) had meningitis. Among SARS-CoV-2-positive infants, a lower proportion of those with normal IMs had bacteremia and/or bacterial meningitis compared with those with abnormal IMs (<0.1% [0%-0.2%] vs 1.8% [0.6%-3.1%]).The prevalence of UTI, bacteremia, and bacterial meningitis was lower for febrile infants who tested positive for SARS-CoV-2, particularly infants aged 29 to 60 days and those with normal IMs. These findings may help inform management of certain febrile infants who test positive for SARS-CoV-2.

    View details for DOI 10.1001/jamanetworkopen.2023.13354

    View details for PubMedID 37171815

  • Trends in Prevalence of Bacterial Infections in Febrile Infants During the COVID-19 Pandemic. Pediatrics Aronson, P. L., Kerns, E., Jennings, B., Magee, S., Wang, M. E., McDaniel, C. E. 2022


    OBJECTIVES: Our objective was to describe the prevalence of urinary tract infection (UTI) and invasive bacterial infection (IBI) in febrile infants during the coronavirus disease 2019 pandemic.METHODS: We conducted a multicenter cross-sectional study that included 97 hospitals in the United States and Canada. We included full-term, well-appearing infants 8 to 60 days old with a temperature of ≥38°C and an emergency department visit or hospitalization at a participating site between November 1, 2020 and March 31, 2022. We used logistic regression to determine trends in the odds of an infant having UTI and IBI by study month and to determine the association of COVID-19 prevalence with the odds of an infant having UTI and IBI.RESULTS: We included 9112 infants; 603 (6.6%) had UTI, 163 (1.8%) had bacteremia without meningitis, and 43 (0.5%) had bacterial meningitis. UTI prevalence decreased from 11.2% in November 2020 to 3.0% in January 2022. IBI prevalence was highest in February 2021 (6.1%) and decreased to 0.4% in January 2022. There was a significant downward monthly trend for odds of UTI (odds ratio [OR] 0.93; 95% confidence interval [CI]: 0.91-0.94) and IBI (OR 0.90; 95% CI: 0.87-0.93). For every 5% increase in COVID-19 prevalence in the month of presentation, the odds of an infant having UTI (OR 0.97; 95% CI: 0.96-0.98) or bacteremia without meningitis decreased (OR 0.94; 95% CI: 0.88-0.99).CONCLUSIONS: The prevalence of UTI and IBI in eligible febrile infants decreased to previously published, prepandemic levels by early 2022. Higher monthly COVID-19 prevalence was associated with lower odds of UTI and bacteremia.

    View details for DOI 10.1542/peds.2022-059235

    View details for PubMedID 36353853

  • Clinical progress note: Poliomyelitis. Journal of hospital medicine Wang, M. E., Ratner, A. J. 2022

    View details for DOI 10.1002/jhm.12989

    View details for PubMedID 36314273

  • Duration of Antibiotic Therapy for Bacterial Meningitis in Young Infants: A Systematic Review. Pediatrics Van Hentenryck, M., Schroeder, A. R., McCulloh, R. J., Stave, C. D., Wang, M. E. 2022


    BACKGROUND AND OBJECTIVES: Recommendations for parenteral antibiotic therapy duration in bacterial meningitis in young infants are based predominantly on expert consensus. Prolonged durations are generally provided for proven and suspected meningitis and are associated with considerable costs and risks. The objective of the study was to review the literature on the duration of parenteral antibiotic therapy and outcomes of bacterial meningitis in infants <3 months old.METHODS: We searched PubMed, Embase, and the Cochrane Library for publications until May 31, 2021. Eligible studies were published in English and included infants <3 months old with bacterial meningitis for which the route and duration of antibiotic therapy and data on at least 1 outcome (relapse rates, mortality, adverse events, duration of hospitalization, or neurologic sequelae) were reported.RESULTS: Thirty-two studies were included: 1 randomized controlled trial, 25 cohort studies, and 6 case series. The randomized controlled trial found no difference in treatment failure rates between 10 and 14 days of therapy. One cohort study concluded that antibiotic courses >21 days were not associated with improved outcomes as compared with shorter courses. The remaining studies had small sample sizes and/or did not stratify outcomes by therapy duration. Meta-analysis was not possible because of the heterogeneity of the treatments and reported outcomes.CONCLUSIONS: Rigorous, prospective clinical trial data are lacking to determine the optimal parenteral antibiotic duration in bacterial meningitis in young infants. Given the associated costs and risks, there is a pressing need for high-quality comparative effectiveness research to further study this question.

    View details for DOI 10.1542/peds.2022-057510

    View details for PubMedID 36195580

  • A Cross-sectional Study Characterizing Pediatric Temperature Percentiles in Children at Well-Child Visits. Academic pediatrics Dang, R., Schroeder, A. R., Weng, Y., Wang, M. E., Patel, A. I. 2022


    BACKGROUND: Temperature measurement plays a central role in determining pediatric patients' disease risk and management. However, current pediatric temperature thresholds may be outdated and not applicable to children.OBJECTIVE: To characterize pediatric temperature norms and variation by patient characteristics, time of measurement, and thermometer route.METHODS: In this cross-sectional study, we analyzed 134,641 well-child visits occurring between 2014-2019 at primary care clinics that routinely measured temperature. We performed bivariate and multivariable quantile regressions with clustered standard errors to determine temperature percentiles and variation by age, sex, time of measurement, and thermometer route. We performed sensitivity analyses: 1) using a cohort that excluded visits with infectious diagnoses that could explain temperature aberrations and 2) including clinic as a fixed effect.RESULTS: The median rectal temperature for visits of infants ≤12 months old was 37.2˚C, which was 0.4˚C higher than the median axillary temperature. The median axillary temperature for children 1-18 years old was 36.7˚C, which was 0.1˚C lower than the median values of all other routes. The 99th percentile for rectal temperatures in infants was 37.8˚C and the 99.9th percentile for axillary temperatures in children was 38.5˚C. Adjusted analyses did not demonstrate clinically significant variation in temperature by sex, age, or time of measurement.CONCLUSIONS: These updated temperature norms can serve as reference values in clinical practice and should be considered in the context of thermometer route used and the clinical condition being evaluated. Variations in temperature values by sex, age, and time of measurement were not clinically significant.

    View details for DOI 10.1016/j.acap.2022.07.015

    View details for PubMedID 35914730

  • Improving Efficiency on a Pediatric Hospital Medicine Service With Schedule-Based Family-Centered Rounds. Hospital pediatrics Wang, M. E., Hutauruk, R. M., Perales, S., Chang, J., Kim, J., Singh, A. T. 2022


    BACKGROUND AND OBJECTIVES: Inconsistencies in the timing and process of family-centered rounds can contribute to inefficiencies in patient care, inconsistent nursing participation, and variable end times. Through the implementation of schedule-based rounds, our aims were to (1) start 90% of rounds encounters within 30 minutes of the scheduled time, (2) increase nursing presence from 79% to >90%, and (3) increase the percentage of rounds completed by 11:20 am from 0% to 80% within 1 year.METHODS: We used quality improvement methods to implement and evaluate a scheduled rounds process on a pediatric hospital medicine service at a university-affiliated children's hospital. Interventions included customization of an electronic health record-linked scheduling tool, daily schedule management by the senior resident, real-time rounds notification to nurses, improved education on rounding expectations, streamlined rounding workflow, and family notification of rounding time. Data were collected daily and run charts were used to track metrics.RESULTS: One year after implementation, a median of 96% of rounds encounters occurred within 30 minutes of scheduled rounding time, nursing presence increased from a median of 79% to 94%, and the percentage of rounds completed by 11:20 am increased from a median of 0% to 86%. Rounds end times were later with a higher patient census.CONCLUSIONS: We improved the efficiency of our rounding workflow and bedside nursing presence through a scheduled rounds process facilitated by an electronic health record-linked scheduling tool.

    View details for DOI 10.1542/hpeds.2021-006379

    View details for PubMedID 35434735

  • Clinical guideline highlights for the hospitalist: Diagnosis and management of acute hematogenous osteomyelitis in children. Journal of hospital medicine Palmer, B., Wang, M. E. 2022; 17 (2): 114-116


    Clinical practice guideline by the Pediatric Infectious Diseases Society and the Infectious Disease Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Children RELEASE DATE: August 5, 2021 PRIOR VERSION(S): n/a DEVELOPER: Pediatric Infectious Diseases Society (PIDS) and Infectious Disease Society of America (IDSA) FUNDING SOURCE: PIDS and IDSA TARGET POPULATION: Children with suspected or confirmed acute hematogenous osteomyelitis.

    View details for DOI 10.1002/jhm.2742

    View details for PubMedID 35504579

  • Healthcare utilization in children across the care continuum during the COVID-19 pandemic. PloS one Schroeder, A. R., Dahlen, A., Purington, N., Alvarez, F., Brooks, R., Destino, L., Madduri, G., Wang, M., Coon, E. R. 2022; 17 (10): e0276461


    OBJECTIVES: Healthcare utilization decreased during the COVID-19 pandemic, likely due to reduced transmission of infections and healthcare avoidance. Though various investigations have described these changing patterns in children, most have analyzed specific care settings. We compared healthcare utilization, prescriptions, and diagnosis patterns in children across the care continuum during the first year of the pandemic with preceding years.STUDY DESIGN: Using national claims data, we compared enrollees under 18 years during the pre-pandemic (January 2016 -mid-March 2020) and pandemic (mid-March 2020 through March 2021) periods. The pandemic was further divided into early (mid-March through mid-June 2020) and middle (mid-June 2020 through March 2021) periods. Utilization was compared using interrupted time series.RESULTS: The mean number of pediatric enrollees/month was 2,519,755 in the pre-pandemic and 2,428,912 in the pandemic period. Utilization decreased across all settings in the early pandemic, with the greatest decrease (76.9%, 95% confidence interval [CI] 72.6-80.5%) seen for urgent care visits. Only well visits returned to pre-pandemic rates during the mid-pandemic. Hospitalizations decreased by 43% (95% CI 37.4-48.1) during the early pandemic and were still 26.6% (17.7-34.6) lower mid-pandemic. However, hospitalizations in non-psychiatric facilities for various mental health disorders increased substantially mid-pandemic.CONCLUSION: Healthcare utilization in children dropped substantially during the first year of the pandemic, with a shift away from infectious diseases and a spike in mental health hospitalizations. These findings are important to characterize as we monitor the health of children, can be used to inform healthcare strategies during subsequent COVID-19 surges and/or future pandemics, and may help identify training gaps for pediatric trainees. Subsequent investigations should examine how changes in healthcare utilization impacted the incidence and outcomes of specific diseases.

    View details for DOI 10.1371/journal.pone.0276461

    View details for PubMedID 36301947

  • A National Survey of Outpatient Parenteral Antibiotic Therapy Practices. Journal of the Pediatric Infectious Diseases Society Vaz, L. E., Felder, K. K., Newland, J. G., Hersh, A. L., Rajapakse, N. S., Willis, Z. I., Banerjee, R., Gerber, J. S., Schwenk, H. T., Wang, M. E. 1800


    We conducted a national survey of pediatric infectious diseases (ID) clinicians on outpatient parenteral antibiotic therapy (OPAT) practices and post-discharge ID follow-up. Only 15% of sites required ID consultation for all OPAT. ID division resources for post-discharge care varied. Opportunities exist to increase ID involvement in post-discharge management of serious infections.

    View details for DOI 10.1093/jpids/piab127

    View details for PubMedID 34939654

  • Temperature Measurement at Well-Child Visits in the United States. The Journal of pediatrics Dang, R. n., Schroeder, A. R., Patel, A. I., Parsonnet, J. n., Wang, M. n. 2021


    To determine the frequency and predictors of temperature measurement at well-child visits in the US and report rates of interventions associated with visits at which temperature is measured and fever is detected.In this cross-sectional study, we analyzed 22,518 sampled well-child visits from the National Ambulatory Medical Care Survey (NAMCS) between 2003 and 2015. We estimated the frequency of temperature measurement and performed multivariable regression to identify patient, provider/clinic and seasonal factors associated with the practice. We described rates of interventions (complete blood count, x-ray, urinalysis, antibiotic prescription, and emergency department/hospital referral) by measurement and fever (temperature ≥100.4˚F, ≥38.0˚C) status.Temperature was measured in 48.5% (95% CI 45.6-51.4) of well-child visits. Measurement was more common during visits by non-pediatric providers (adjusted odds ratio [aOR] 2.0, 95% CI 1.6-2.5; ref: pediatricians), in Hispanic (aOR 1.9, 95% CI 1.6-2.3) and Black (aOR 1.5, 95% CI 1.2-1.9; ref: non-Hispanic White) patients, and in patients with government (aOR 2.0, 95% CI 1.7-2.4; ref: private) insurance. Interventions were more commonly pursued when temperature was measured (aOR 1.3, 95% CI 1.1-1.6) and fever was detected (aOR 3.8, 95% CI 1.5-9.4).Temperature was measured in nearly half of all well-child visits. Interventions were more common when temperature was measured and fever was detected. The value of routine temperature measurement during well-child visits warrants further evaluation.

    View details for DOI 10.1016/j.jpeds.2021.01.045

    View details for PubMedID 33508277

  • Pediatric antimicrobial stewardship practices at discharge: A national survey Infection Control & Hospital Epidemiology Wang, M. E., Felder, K., Newland, J. G., Hersh, A. L., Rajapakse, N. S., Willis, Z. I., Banerjee, R., Gerber, J. S., Schwenk, H. T., Vaz, L. E. 2021: 1-3


    We surveyed pediatric antimicrobial stewardship program (ASP) site leaders within the Sharing Antimicrobial Reports for Pediatric Stewardship collaborative regarding discharge stewardship practices. Among 67 sites, 13 (19%) reported ASP review of discharge antimicrobial prescriptions. These findings highlight discharge stewardship as a potential opportunity for improvement during the hospital-to-home transition.

    View details for DOI 10.1017/ice.2021.283

  • Frequency and Consequences of Routine Temperature Measurement at Well-Child Visits. Pediatrics Dang, R., Patel, A. I., Marlow, J., Weng, Y., Wang, M. E., Schroeder, A. R. 2021


    To determine the (1) frequency and visit characteristics of routine temperature measurement and (2) rates of interventions by temperature measurement practice and the probability of incidental fever detection.In this retrospective cohort study, we analyzed well-child visits between 2014-2019. We performed multivariable regression to characterize visits associated with routine temperature measurement and conducted generalized estimating equations regression to determine adjusted rates of interventions (antibiotic prescription, and diagnostic testing) and vaccine deferral by temperature measurement and fever status, clustered by clinic and patient. Through dual independent chart review, fever (≥100.4°F) was categorized as probable, possible, or unlikely to be incidentally detected.Temperature measurement occurred at 155 527 of 274 351 (58.9%) well-child visits. Of 24 clinics, 16 measured temperature at >90% of visits ("routine measurement clinics") and 8 at <20% of visits ("occasional measurement clinics"). After adjusting for age, ethnicity, race, and insurance, antibiotic prescription was more common (adjusted odds ratio: 1.21; 95% CI 1.13-1.29), whereas diagnostic testing was less common (adjusted odds ratio: 0.76; 95% CI 0.71-0.82) at routine measurement clinics. Fever was detected at 270 of 155 527 (0.2%) routine measurement clinic visits, 47 (17.4%) of which were classified as probable incidental fever. Antibiotic prescription and diagnostic testing were more common at visits with probable incidental fever than without fever (7.4% vs 1.7%; 14.8% vs 1.2%; P < .001), and vaccines were deferred at 50% such visits.Temperature measurement occurs at more than one-half of well-child visits and is a clinic-driven practice. Given the impact on subsequent interventions and vaccine deferral, the harm-benefit profile of this practice warrants consideration.

    View details for DOI 10.1542/peds.2021-053412

    View details for PubMedID 34890449

  • Characteristics of Afebrile Infants ≤60 Days of Age With Invasive Bacterial Infections. Hospital pediatrics Wang, M. E., Neuman, M. I., Nigrovic, L. E., Pruitt, C. M., Desai, S., DePorre, A. G., Sartori, L. F., Marble, R. D., Woll, C., Leazer, R. C., Balamuth, F., Rooholamini, S. N., Aronson, P. L., FEBRILE YOUNG INFANT RESEARCH COLLABORATIVE 2020


    OBJECTIVES: To describe the characteristics and outcomes of afebrile infants ≤60 days old with invasive bacterial infection (IBI).METHODS: We conducted a secondary analysis of a cross-sectional study of infants ≤60 days old with IBI presenting to the emergency departments (EDs) of 11 children's hospitals from 2011 to 2016. We classified infants as afebrile if there was absence of a temperature ≥38°C at home, at the referring clinic, or in the ED. Bacteremia and bacterial meningitis were defined as pathogenic bacterial growth from a blood and/or cerebrospinal fluid culture.RESULTS: Of 440 infants with IBI, 78 (18%) were afebrile. Among afebrile infants, 62 (79%) had bacteremia without meningitis and 16 (20%) had bacterial meningitis (10 with concomitant bacteremia). Five infants (6%) died, all with bacteremia. The most common pathogens were Streptococcus agalactiae (35%), Escherichia coli (16%), and Staphylococcus aureus (16%). Sixty infants (77%) had an abnormal triage vital sign (temperature <36°C, heart rate ≥181 beats per minute, or respiratory rate ≥66 breaths per minute) or a physical examination abnormality (ill appearance, full or depressed fontanelle, increased work of breathing, or signs of focal infection). Forty-three infants (55%) had ≥1 of the following laboratory abnormalities: white blood cell count <5000 or >15000 cells per muL, absolute band count >1500 cells per mul, or positive urinalysis. Presence of an abnormal vital sign, examination finding, or laboratory test result had a sensitivity of 91% (95% confidence interval 82%-96%) for IBI.CONCLUSIONS: Most afebrile young infants with an IBI had vital sign, examination, or laboratory abnormalities. Future studies should evaluate the predictive ability of these criteria in afebrile infants undergoing evaluation for IBI.

    View details for DOI 10.1542/hpeds.2020-002204

    View details for PubMedID 33318052

  • Febrile Infants ≤60 Days Old With Positive Urinalysis Results and Invasive Bacterial Infections. Hospital pediatrics Yankova, L. C., Neuman, M. I., Wang, M. E., Woll, C., DePorre, A. G., Desai, S., Sartori, L. F., Nigrovic, L. E., Pruitt, C. M., Marble, R. D., Leazer, R. C., Rooholamini, S. N., Balamuth, F., Aronson, P. L. 2020


    OBJECTIVES: We aimed to describe the clinical and laboratory characteristics of febrile infants ≤60 days old with positive urinalysis results and invasive bacterial infections (IBI).METHODS: We performed a planned secondary analysis of a retrospective cohort study of febrile infants ≤60 days old with IBI who presented to 11 emergency departments from July 1, 2011, to June 30, 2016. For this subanalysis, we included infants with IBI and positive urinalysis results. We analyzed the sensitivity of high-risk past medical history (PMH) (prematurity, chronic medical condition, or recent antimicrobial receipt), ill appearance, and/or abnormal white blood cell (WBC) count (<5000 or >15000 cells/muL) for identification of IBI.RESULTS: Of 148 febrile infants with positive urinalysis results and IBI, 134 (90.5%) had bacteremia without meningitis and 14 (9.5%) had bacterial meningitis (11 with concomitant bacteremia). Thirty-five infants (23.6%) with positive urinalysis results and IBI did not have urinary tract infections. The presence of high-risk PMH, ill appearance, and/or abnormal WBC count had a sensitivity of 53.4% (95% confidence interval: 45.0-61.6) for identification of IBI. Of the 14 infants with positive urinalysis results and concomitant bacterial meningitis, 7 were 29 to 60 days old. Six of these 7 infants were ill-appearing or had an abnormal WBC count. The other infant had bacteremia with cerebrospinal fluid pleocytosis after antimicrobial pretreatment and was treated for meningitis.CONCLUSIONS: The sensitivity of high-risk PMH, ill appearance, and/or abnormal WBC count is suboptimal for identifying febrile infants with positive urinalysis results at low risk for IBI. Most infants with positive urinalysis results and bacterial meningitis are ≤28 days old, ill-appearing, or have an abnormal WBC count.

    View details for DOI 10.1542/hpeds.2020-000638

    View details for PubMedID 33239319

  • Reconsidering Discharge Criteria in Children With Neurologic Impairment and Acute Respiratory Infections. Journal of hospital medicine Wang, M. E., Leyenaar, J. K., Leykum, L. 2020; 15 (9): 576

    View details for DOI 10.12788/jhm.3496

    View details for PubMedID 32924930

  • Diagnosis and Management of UTI in Febrile Infants Age 0-2 Months: Applicability of the AAP Guideline. Journal of hospital medicine Chang, P. W., Wang, M. E., Schroeder, A. R. 2020; 15 (2): e1–e5


    Urinary tract infections (UTIs) are the most common bacterial infection in young infants. The American Academy of Pediatrics' (AAP) clinical practice guideline for UTIs focuses on febrile children age 2-24 months, with no guideline for infants <2 months of age, an age group commonly encountered by pediatric hospitalists. In this review, we assess the applicability of the AAP UTI Guideline's action statements for previously healthy, febrile infants <2 months of age. We also discuss additional considerations in this age group, including concurrent bacteremia and routine testing for meningitis.

    View details for DOI 10.12788/jhm.3349

    View details for PubMedID 32118563

  • Short Parenteral Courses for Young Infants With UTI. Hospital pediatrics Joshi, N. S., Wang, M. E. 2020

    View details for DOI 10.1542/hpeds.2020-001685

    View details for PubMedID 32817063

  • Height of fever and invasive bacterial infection. Archives of disease in childhood Michelson, K. A., Neuman, M. I., Pruitt, C. M., Desai, S. n., Wang, M. E., DePorre, A. G., Leazer, R. C., Sartori, L. F., Marble, R. D., Rooholamini, S. N., Woll, C. n., Balamuth, F. n., Aronson, P. L. 2020


    We aimed to evaluate the association of height of fever with invasive bacterial infection (IBI) among febrile infants <=60 days of age.In a secondary analysis of a multicentre case-control study of non-ill-appearing febrile infants <=60 days of age, we compared the maximum temperature (at home or in the emergency department) for infants with and without IBI. We then computed interval likelihood ratios (iLRs) for the diagnosis of IBI at each half-degree Celsius interval.The median temperature was higher for infants with IBI (38.8°C; IQR 38.4-39.2) compared with those without IBI (38.4°C; IQR 38.2-38.9) (p<0.001). Temperatures 39°C-39.4°C and 39.5°C-39.9°C were associated with a higher likelihood of IBI (iLR 2.49 and 3.40, respectively), although 30.4% of febrile infants with IBI had maximum temperatures <38.5°C.Although IBI is more likely with higher temperatures, height of fever alone should not be used for risk stratification of febrile infants.

    View details for DOI 10.1136/archdischild-2019-318548

    View details for PubMedID 32819913

  • Clinical Progress Note: Procalcitonin in the Identification of Invasive Bacterial Infections in Febrile Young Infants. Journal of hospital medicine Wang, M. E., Srinivas, N. n., McCulloh, R. J. 2020

    View details for DOI 10.12788/jhm.3451

    View details for PubMedID 33147137

  • Clinical Guideline Highlights for the Hospitalist: Diagnosis and Management of Measles. Journal of hospital medicine Wang, M. E., Ratner, A. J. 2019; 14: E1–E2


    GUIDELINE TITLE: (1) Measles (Rubeola): For Healthcare Professionals and (2) Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings RELEASE DATE: (1) February 5, 2018, and (2) July 2019 PRIOR VERSION(S): n/a DEVELOPER: Centers for Disease Control and Prevention (CDC) FUNDING SOURCE: CDC TARGET POPULATION: Children and adults with suspected or confirmed measles.

    View details for DOI 10.12788/jhm.3346

    View details for PubMedID 31869297

  • Cerebrospinal Fluid Profiles of Infants ≤60 Days of Age With Bacterial Meningitis. Hospital pediatrics Fleischer, E. n., Neuman, M. I., Wang, M. E., Nigrovic, L. E., Desai, S. n., DePorre, A. G., Leazer, R. C., Marble, R. D., Sartori, L. F., Aronson, P. L. 2019


    We aimed to describe the cerebrospinal fluid (CSF) profiles of infants ≤60 days old with bacterial meningitis and the characteristics of infants with bacterial meningitis who did not have CSF abnormalities.We included infants ≤60 days old with culture-positive bacterial meningitis who were evaluated in the emergency departments of 11 children's hospitals between July 1, 2011, and June 30, 2016. From medical records, we abstracted clinical and laboratory data. For infants with traumatic lumbar punctures (CSF red blood cell count of ≥10 000 cells per mm3), we used a red blood cell count/white blood cell (WBC) count correction factor of 1000:1 to determine the corrected CSF WBC count. We calculated the sensitivity for bacterial meningitis of a CSF Gram-stain and corrected CSF pleocytosis (≥16 WBCs per mm3 for infants ≤28 days old and ≥10 WBCs per mm3 for infants 29-60 days old).Among 66 infants with bacterial meningitis, the sensitivity of a CSF Gram-stain was 71.9% (95% confidence interval [CI]: 59.2-82.4), and the sensitivity of corrected CSF pleocytosis was 80.3% (95% CI: 68.7-89.1). The sensitivity of combining positive Gram-stain results with corrected CSF pleocytosis was 86.4% (95% CI: 75.7-93.6). Of 9 infants with meningitis who had a negative Gram-stain result and no corrected CSF pleocytosis, 8 (88.9%) had either an abnormal peripheral WBC count (>15 000 or <5000 cells per μL) or bandemia >10%.Most infants ≤60 days old with bacterial meningitis have CSF pleocytosis or a positive Gram-stain result. Infants with no CSF pleocytosis and a negative Gram-stain result are unlikely to have bacterial meningitis in the absence of other laboratory abnormalities.

    View details for DOI 10.1542/hpeds.2019-0202

    View details for PubMedID 31690569

  • Parenteral Antibiotic Therapy Duration in Young Infants With Bacteremic Urinary Tract Infections. Pediatrics Desai, S. n., Aronson, P. L., Shabanova, V. n., Neuman, M. I., Balamuth, F. n., Pruitt, C. M., DePorre, A. G., Nigrovic, L. E., Rooholamini, S. N., Wang, M. E., Marble, R. D., Williams, D. J., Sartori, L. n., Leazer, R. C., Mitchell, C. n., Shah, S. S. 2019


    To determine the association between parenteral antibiotic duration and outcomes in infants ≤60 days old with bacteremic urinary tract infection (UTI).This multicenter retrospective cohort study included infants ≤60 days old who had concomitant growth of a pathogen in blood and urine cultures at 11 children's hospitals between 2011 and 2016. Short-course parenteral antibiotic duration was defined as ≤7 days, and long-course parenteral antibiotic duration was defined as >7 days. Propensity scores, calculated using patient characteristics, were used to determine the likelihood of receiving long-course parenteral antibiotics. We conducted inverse probability weighting to achieve covariate balance and applied marginal structural models to the weighted population to examine the association between parenteral antibiotic duration and outcomes (30-day UTI recurrence, 30-day all-cause reutilization, and length of stay).Among 115 infants with bacteremic UTI, 58 (50%) infants received short-course parenteral antibiotics. Infants who received long-course parenteral antibiotics were more likely to be ill appearing and have growth of a non-Escherichia coli organism. There was no difference in adjusted 30-day UTI recurrence between the long- and short-course groups (adjusted risk difference: 3%; 95% confidence interval: -5.8 to 12.7) or 30-day all-cause reutilization (risk difference: 3%; 95% confidence interval: -14.5 to 20.6).Young infants with bacteremic UTI who received ≤7 days of parenteral antibiotics did not have more frequent recurrent UTIs or hospital reutilization compared with infants who received long-course therapy. Short-course parenteral therapy with early conversion to oral antibiotics may be considered in this population.

    View details for DOI 10.1542/peds.2018-3844

    View details for PubMedID 31431480

  • Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis. Pediatrics Wang, M. E., Biondi, E. A., McCulloh, R. J., Garber, M. D., Natt, B. C., Lucas, B. P., Schroeder, A. R. 2019


    To determine factors associated with cerebrospinal fluid (CSF) testing in febrile young infants with a positive urinalysis and assess the probability of delayed diagnosis of bacterial meningitis in infants treated for urinary tract infection (UTI) without CSF testing.We performed a retrospective cohort study using data from the Reducing Excessive Variability in Infant Sepsis Evaluation quality improvement project. A total of 20 570 well-appearing febrile infants 7 to 60 days old presenting to 124 hospitals from 2015 to 2017 were included. A mixed-effects logistic regression was conducted to determine factors associated with CSF testing. Delayed meningitis was defined as a new diagnosis of bacterial meningitis within 7 days of discharge.Overall, 3572 infants had a positive urinalysis; 2511 (70.3%) underwent CSF testing. There was wide variation by site, with CSF testing rates ranging from 64% to 100% for infants 7 to 30 days old and 10% to 100% for infants 31 to 60 days old. Factors associated with CSF testing included: age 7 to 30 days (adjusted odds ratio [aOR]: 4.6; 95% confidence interval [CI]: 3.8-5.5), abnormal inflammatory markers (aOR: 2.2; 95% CI: 1.8-2.5), and site volume >300 febrile infants per year (aOR: 1.8; 95% CI: 1.2-2.6). Among 505 infants treated for UTI without CSF testing, there were 0 (95% CI: 0%-0.6%) cases of delayed meningitis.There was wide variation in CSF testing in febrile infants with a positive urinalysis. Among infants treated for UTI without CSF testing (mostly 31 to 60-day-old infants), there were no cases of delayed meningitis within 7 days of discharge, suggesting that routine CSF testing of infants 31 to 60 days old with a positive urinalysis may not be necessary.

    View details for DOI 10.1542/peds.2018-3979

    View details for PubMedID 31395621

  • A Prediction Model to Identify Febrile Infants ≤60 Days at Low Risk of Invasive Bacterial Infection. Pediatrics Aronson, P. L., Shabanova, V. n., Shapiro, E. D., Wang, M. E., Nigrovic, L. E., Pruitt, C. M., DePorre, A. G., Leazer, R. C., Desai, S. n., Sartori, L. F., Marble, R. D., Rooholamini, S. N., McCulloh, R. J., Woll, C. n., Balamuth, F. n., Alpern, E. R., Shah, S. S., Williams, D. J., Browning, W. L., Shah, N. n., Neuman, M. I. 2019


    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).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.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 μL (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.Infants ≤60 days old with fever by history only, a normal urinalysis result, and an absolute neutrophil count <5185 cells per μL have a low probability of IBI.

    View details for DOI 10.1542/peds.2018-3604

    View details for PubMedID 31167938

  • Respiratory Syncytial Virus The 5-Minute Pediatric Consult Wang, M. E., Schroeder, A. R. Wolters Kluwer. 2019; 8th edition
  • Epidemiology and Etiology of Invasive Bacterial Infection in Infants ≤60 Days Old Treated in Emergency Departments. The Journal of pediatrics Woll, C. n., Neuman, M. I., Pruitt, C. M., Wang, M. E., Shapiro, E. D., Shah, S. S., McCulloh, R. J., Nigrovic, L. E., Desai, S. n., DePorre, A. G., Leazer, R. C., Marble, R. D., Balamuth, F. n., Feldman, E. A., Sartori, L. F., Browning, W. L., Aronson, P. L. 2018


    To help guide empiric treatment of infants ≤60 days old with suspected invasive bacterial infection by describing pathogens and their antimicrobial susceptibilities.Cross-sectional study of infants ≤60 days old with invasive bacterial infection (bacteremia and/or bacterial meningitis) evaluated in the emergency departments of 11 children's hospitals between July 1, 2011 and June 30, 2016. Each site's microbiology laboratory database or electronic medical record system was queried to identify infants from whom a bacterial pathogen was isolated from either blood or cerebrospinal fluid. Medical records of these infants were reviewed to confirm the presence of a pathogen and to obtain demographic, clinical, and laboratory data.Of the 442 infants with invasive bacterial infection, 353 (79.9%) had bacteremia without meningitis, 64 (14.5%) had bacterial meningitis with bacteremia, and 25 (5.7%) had bacterial meningitis without bacteremia. The peak number of cases of invasive bacterial infection occurred in the second week of life; 364 (82.4%) infants were febrile. Group B streptococcus was the most common pathogen identified (36.7%), followed by Escherichia coli (30.8%), Staphylococcus aureus (9.7%), and Enterococcus spp (6.6%). Overall, 96.8% of pathogens were susceptible to ampicillin plus a third-generation cephalosporin, 96.0% to ampicillin plus gentamicin, and 89.2% to third-generation cephalosporins alone.For most infants ≤60 days old evaluated in a pediatric emergency department for suspected invasive bacterial infection, the combination of ampicillin plus either gentamicin or a third-generation cephalosporin is an appropriate empiric antimicrobial treatment regimen. Of the pathogens isolated from infants with invasive bacterial infection, 11% were resistant to third-generation cephalosporins alone.

    View details for PubMedID 29784512

  • Risk Stratification of Febrile Infants ≤60 Days Old Without Routine Lumbar Puncture. Pediatrics Aronson, P. L., Wang, M. E., Shapiro, E. D., Shah, S. S., DePorre, A. G., McCulloh, R. J., Pruitt, C. M., Desai, S. n., Nigrovic, L. E., Marble, R. D., Leazer, R. C., Rooholamini, S. N., Sartori, L. F., Balamuth, F. n., Woll, C. n., Neuman, M. I. 2018


    : media-1vid110.1542/5840460609001PEDS-VA_2018-1879Video Abstract OBJECTIVES: 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.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.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.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.

    View details for PubMedID 30425130

  • Factors Associated with Adverse Outcomes among Febrile Young Infants with Invasive Bacterial Infections. The Journal of pediatrics Pruitt, C. M., Neuman, M. I., Shah, S. S., Shabanova, V. n., Woll, C. n., Wang, M. E., Alpern, E. R., Williams, D. J., Sartori, L. n., Desai, S. n., Leazer, R. C., Marble, R. D., McCulloh, R. J., DePorre, A. G., Rooholamini, S. N., Lumb, C. E., Balamuth, F. n., Shin, S. n., Aronson, P. L. 2018


    To determine factors associated with adverse outcomes among febrile young infants with invasive bacterial infections (IBIs) (ie, bacteremia and/or bacterial meningitis).Multicenter, retrospective cohort study (July 2011-June 2016) of febrile infants ≤60 days of age with pathogenic bacterial growth in blood and/or cerebrospinal fluid. Subjects were identified by query of local microbiology laboratory and/or electronic medical record systems, and clinical data were extracted by medical record review. Mixed-effect logistic regression was employed to determine clinical factors associated with 30-day adverse outcomes, which were defined as death, neurologic sequelae, mechanical ventilation, or vasoactive medication receipt.Three hundred fifty infants met inclusion criteria; 279 (79.7%) with bacteremia without meningitis and 71 (20.3%) with bacterial meningitis. Forty-two (12.0%) infants had a 30-day adverse outcome: 29 of 71 (40.8%) with bacterial meningitis vs 13 of 279 (4.7%) with bacteremia without meningitis (36.2% difference, 95% CI 25.1%-48.0%; P < .001). On adjusted analysis, bacterial meningitis (aOR 16.3, 95% CI 6.5-41.0; P < .001), prematurity (aOR 7.1, 95% CI 2.6-19.7; P < .001), and ill appearance (aOR 3.8, 95% CI 1.6-9.1; P = .002) were associated with adverse outcomes. Among infants who were born at term, not ill appearing, and had bacteremia without meningitis, only 2 of 184 (1.1%) had adverse outcomes, and there were no deaths.Among febrile infants ≤60 days old with IBI, prematurity, ill appearance, and bacterial meningitis (vs bacteremia without meningitis) were associated with adverse outcomes. These factors can inform clinical decision-making for febrile young infants with IBI.

    View details for PubMedID 30297292

  • Time to Pathogen Detection for Non-ill Versus Ill-Appearing Infants ≤60 Days Old With Bacteremia and Meningitis. Hospital pediatrics Aronson, P. L., Wang, M. E., Nigrovic, L. E., Shah, S. S., Desai, S. n., Pruitt, C. M., Balamuth, F. n., Sartori, L. n., Marble, R. D., Rooholamini, S. N., Leazer, R. C., Woll, C. n., DePorre, A. G., Neuman, M. I. 2018


    We sought to determine the time to pathogen detection in blood and cerebrospinal fluid (CSF) for infants ≤60 days old with bacteremia and/or bacterial meningitis and to explore whether time to pathogen detection differed for non-ill-appearing and ill-appearing infants.We included infants ≤60 days old with bacteremia and/or bacterial meningitis evaluated in the emergency departments of 10 children's hospitals between July 1, 2011, and June 30, 2016. The microbiology laboratories at each site were queried to identify infants in whom a bacterial pathogen was isolated from blood and/or CSF. Medical records were then reviewed to confirm the presence of a pathogen and to extract demographic characteristics, clinical appearance, and the time to pathogen detection.Among 360 infants with bacteremia, 316 (87.8%) pathogens were detected within 24 hours and 343 (95.3%) within 36 hours. A lower proportion of non-ill-appearing infants with bacteremia had a pathogen detected on blood culture within 24 hours compared with ill-appearing infants (85.0% vs 92.9%, respectively; P = .03). Among 62 infants with bacterial meningitis, 55 (88.7%) pathogens were detected within 24 hours and 59 (95.2%) were detected within 36 hours, with no difference based on ill appearance.Among infants ≤60 days old with bacteremia and/or bacterial meningitis, pathogens were commonly identified from blood or CSF within 24 and 36 hours. However, clinicians must weigh the potential for missed bacteremia in non-ill-appearing infants discharged within 24 hours against the overall low prevalence of infection.

    View details for PubMedID 29954839

  • Risk factors for possible serious bacterial infection in a rural cohort of young infants in central India. BMC public health Wang, M. E., Patel, A. B., Hansen, N. I., Arlington, L., Prakash, A., Hibberd, P. L. 2016; 16 (1): 1097


    Possible serious bacterial infection (PBSI) is a major cause of neonatal mortality worldwide. We studied risk factors for PSBI in a large rural population in central India where facility deliveries have increased as a result of a government financial assistance program.We studied 37,379 pregnant women and their singleton live born infants with birth weight ≥ 1.5 kg from 20 rural primary health centers around Nagpur, India, using data from the 2010-13 population-based Maternal and Newborn Health Registry supported by NICHD's Global Network for Women's and Children's Health Research. Factors associated with PSBI were identified using multivariable Poisson regression.Two thousand one hundred twenty-three infants (6 %) had PSBI. Risk factors for PSBI included nulliparity (RR 1.13, 95 % CI 1.03-1.23), parity > 2 (RR 1.30, 95 % CI 1.07-1.57) compared to parity 1-2, first antenatal care visit in the 2(nd)/3(rd) trimester (RR 1.46, 95 % CI 1.08-1.98) compared to 1(st) trimester, administration of antenatal corticosteroids (RR 2.04, 95 % CI 1.60-2.61), low birth weight (RR 3.10, 95 % CI 2.17-4.42), male sex (RR 1.20, 95 % CI 1.10-1.31) and lack of early initiation of breastfeeding (RR 3.87, 95 % CI 2.69-5.58).Infants who are low birth weight, born to mothers who present late to antenatal care or receive antenatal corticosteroids, or born to nulliparous women or those with a parity > 2, could be targeted for interventions before and after delivery to improve early recognition of signs and symptoms of PSBI and prompt referral. There also appears to be a need for a renewed focus on promoting early initiation of breastfeeding following delivery in facilities.This trial is registered at ( NCT01073475 ).

    View details for DOI 10.1186/s12889-016-3688-3

    View details for PubMedID 27760543

  • Trends in the incidence of possible severe bacterial infection and case fatality rates in rural communities in Sub-Saharan Africa, South Asia and Latin America, 2010-2013: a multicenter prospective cohort study. Reproductive health Hibberd, P. L., Hansen, N. I., Wang, M. E., Goudar, S. S., Pasha, O., Esamai, F., Chomba, E., Garces, A., Althabe, F., Derman, R. J., Goldenberg, R. L., Liechty, E. A., Carlo, W. A., Hambidge, K. M., Krebs, N. F., Buekens, P., McClure, E. M., Koso-Thomas, M., Patel, A. B. 2016; 13 (1): 65


    Possible severe bacterial infections (pSBI) continue to be a leading cause of global neonatal mortality annually. With the recent publications of simplified antibiotic regimens for treatment of pSBI where referral is not possible, it is important to know how and where to target these regimens, but data on the incidence and outcomes of pSBI are limited.We used data prospectively collected at 7 rural community-based sites in 6 low and middle income countries participating in the NICHD Global Network's Maternal and Newborn Health Registry, between January 1, 2010 and December 31, 2013. Participants included pregnant women and their live born neonates followed for 6 weeks after delivery and assessed for maternal and infant outcomes.In a cohort of 248,539 infants born alive between 2010 and 2013, 32,088 (13 %) neonates met symptomatic criteria for pSBI. The incidence of pSBI during the first 6 weeks of life varied 10 fold from 3 % (Zambia) to 36 % (Pakistan), and overall case fatality rates varied 8 fold from 5 % (Kenya) to 42 % (Zambia). Significant variations in incidence of pSBI during the study period, with proportions decreasing in 3 sites (Argentina, Kenya and Nagpur, India), remaining stable in 3 sites (Zambia, Guatemala, Belgaum, India) and increasing in 1 site (Pakistan), cannot be explained solely by changing rates of facility deliveries. Case fatality rates did not vary over time.In a prospective population based registry with trained data collectors, there were wide variations in the incidence and case fatality of pSBI in rural communities and in trends over time. Regardless of these variations, the burden of pSBI is still high and strategies to implement timely diagnosis and treatment are still urgently needed to reduce neonatal mortality.The study was registered at ( NCT01073475 ).

    View details for DOI 10.1186/s12978-016-0177-1

    View details for PubMedID 27221099

    View details for PubMedCentralID PMC4877736

  • Immune Reconstitution Inflammatory Syndrome in Human Immunodeficiency Virus-Infected Children in Peru PEDIATRIC INFECTIOUS DISEASE JOURNAL Wang, M. E., Castillo, M. E., Montano, S. M., Zunt, J. R. 2009; 28 (10): 900-903


    Immune reconstitution inflammatory syndrome (IRIS) after initiating highly active antiretroviral therapy (HAART) has not been widely studied in children, especially in resource-poor settings.Retrospective cohort study of HIV-infected children initiating HAART between 2001 and 2006 at a tertiary pediatric hospital in Lima, Peru. Charts were reviewed for 1 year after HAART initiation. IRIS was defined as a HAART-associated adverse event caused by an infectious or inflammatory condition in patients with documented virologic or immunologic success.Ninety-one children (52% female) received HAART for at least 1 year. Median age at initiation was 5.7 years; 91% were ART naive and 73% had CDC stage C disease. The incidence of IRIS was 19.8 events per 100 person years (95% CI: 11.5-28.0). Median time to IRIS was 6.6 weeks after HAART initiation (range: 2-32 weeks). There were 18 IRIS events, 11 unmasking and 7 paradoxical. These included associations with Mycobacterium tuberculosis in 4 cases, Bacillus Calmette Guerin lymphadenitis in 1 case, varicella zoster virus in 6 cases and herpes simplex labialis in 6 cases. Children who developed IRIS had a higher baseline HIV viral load (P = 0.02) and an indicator of malnutrition (P = 0.007) before HAART initiation.IRIS occurred in 20% of HIV-infected children starting HAART in Peru and was associated with more advanced disease and malnutrition. Future research is needed to examine specific risk factors associated with pediatric IRIS to allow prompt identification and treatment of IRIS.

    View details for DOI 10.1097/INF.0b013e3181a4b7fa

    View details for Web of Science ID 000270407800009

    View details for PubMedID 19687769

    View details for PubMedCentralID PMC3514443

  • Changes in health insurance coverage during the economic downturn: 2000-2002. Health affairs Holahan, J., Wang, M. 2004: W4-31 42


    Using Current Population Survey data from 2000-2002, this paper documents the changes that led the uninsured population to grow by 3.8 million during that time period. All of the increase in the uninsured occurred among adults, and two-thirds was among low-income adults. The extent to which the loss of employer coverage resulted in people becoming uninsured depended on their access to public programs: Children were more likely than adults to gain public coverage; women more likely than men; and parents more likely than nonparents. Middle- and higher-income Americans were also affected because many lost income and because rates of employer coverage were lower.

    View details for PubMedID 15451962