RESEARCH ARTICLE

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AUTHORSMatthew Mischler, MD,1 Michael S. Ryan, MD,2 JoAnna K. Leyenaar, MD, MPH, MSc,3 Allison Markowsky, MD,4 Midori Seppa, MD, PhD,5 Kelly Wood, MD,6 Jinma Ren, PhD,7 Carl Asche, PhD,8 Francis Gigliotti, MD,9 Eric Biondi, MD10

1University of Illinois College of Medicine at Peoria, Peoria, Illinois2Virginia Commonwealth University School of Medicine, Richmond, Virginia3Tufts Medical Center, Boston, Massachusetts4The George Washington University School of Medicine, Washington, District of Columbia5Stanford University, Palo Alto, California6University of Iowa Children’s Hospital, Iowa City, Iowa7University of Illinois College of Medicine at Peoria, Peoria, Illinois8University of Illinois College of Medicine at Peoria, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois9University of Rochester Medical Center, Rochester, New York10University of Rochester Medical Center, Rochester, New York

KEY WORDSfebrile infant, bacteremia, epidemiology, group B Streptococcus, Escherichia coli, Listeria monocytogenes

ABBREVIATIONSCoNS: coagulase-negative StaphylococcusGBS: group B StreptococcusLP: lumbar punctureSBI: serious bacterial infectionUTI: urinary tract infection

www.hospitalpediatrics.orgdoi:10.1542/hpeds.2014-0121

abstractOBJECTIVE: Describe the etiology of bacteremia among a geographically diverse sample of previously well infants with fever admitted for general pediatric care and to characterize demographic and clinical characteristics of infants with bacteremia according to bacterial etiology. We hypothesized that the epidemiology of bacteremia in febrile infants from a geographically diverse cohort would show similar results to smaller or single-center cohorts previously reported.

METHODS: This was a retrospective review of positive, pathogenic blood cultures in previously healthy, febrile infants ≤90 days old admitted to a general unit. In total, there were 17 participating sites from diverse geographic regions of the United States. Cultures were included if the results were positive for bacteria, obtained from an infant 90 days old or younger with a temperature ≥38.0°C, analyzed using an automated detection system, and treated as pathogenic.

RESULTS: Escherichia coli was the most prevalent species, followed by group B Streptococcus, Streptococcus viridans, and Staphylococcus aureus. Among the most prevalent bacteria, there was no association between gender and species (Ps > .05). Age at presentation was associated only with Streptococcus pneumoniae. There were no cases of Listeria monocytogenes.

CONCLUSIONS: Our study confi rms the data from smaller or single-center studies and suggests that the management of febrile well-appearing infants should change to refl ect the current epidemiology of bacteremia. Further research is needed into the role of lumbar puncture, as well as the role of Listeriaand Enterococcus species in infantile bacteremia.

Epidemiology of Bacteremia in Previously Healthy Febrile Infants: A Follow-up Study

(Continued on last page)

In the past 20 years, signifi cant advances in vaccine development, increasingly stringent food safety guidelines, and the use of prophylactic antibiotics before delivery have shifted the epidemiology of serious bacterial infection (SBI) in infancy.1–12 However, the choice of empirical antibiotic therapy has not changed over the past several decades.13–15 The accepted standard of care is to initiate broad-spectrum antibiotics, typically ampicillin and either gentamicin or a third-generation cephalosporin, before culture data availability because of the high morbidity and mortality of untreated SBI.16

However, recent data suggest that common empirical antibiotic choices may not be well matched to the current pattern of organisms that cause SBI.1,3,12,17–20 For example, Listeria monocytogenes currently makes up a small subset of cases of bacteremia in this population, with some studies failing to identify any cases of listeriosis in hospitalized infants with fever.1,2,12,20 As a sign of shifting epidemiology, group B Streptococcus(GBS), once the most common cause of bacteremia in infants, now comprises as few

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as 16% of cases overall.5,6 In contrast, Escherichia coli has been identifi ed as a major pathogen, the importance of which has increased in recent years.1,2,12,20

Previous studies designed to characterize the epidemiology of bacteremia in the postvaccine era have been limited by geographic isolation and relatively small sample sizes.4,13,21,22 We previously reported epidemiologic data for febrile infants with bacteremia from a small multicenter cohort of hospitals.12 In an attempt to improve on the external validity of research in this area, we sought a larger sample from a geographically diverse group of institutions to better address this question. The objectives of this study were to describe the etiology of bacteremia among previously well infants with fever ≤90 days of age admitted for general pediatric care and to characterize demographic and clinical characteristics of infants with bacteremia according to bacterial etiology.

We hypothesized that the epidemiology of bacteremia in febrile infants would show similar results in a larger, more nationally representative sample. Data from this article represent the complete data of all participating institutions recruited to answer this question and include data from our previous smaller cohort.

METHODSThis was a retrospective, multicenter, cross-sectional review of positive, patho-genic blood cultures in previously healthy, febrile infants ≤90 days old admitted to a general inpatient unit. The Pediatric Research in Inpatient Settings Network was used to facilitate site recruitment through participating hospitals. In total, there were 17 hospital systems from diverse geographic regions of the United States.

All sites used an automated blood culture detection system. The study collection period refl ected available data from each site between January 2006 and January 2013. This study was independently approved by the institutional review boards at all par -ticipating institutions. Informed consent was waived.

Participating sites obtained all positive blood cultures from their microbiology laboratory in infants ≤90 days old that were drawn in their emergency depar t-ment, outpatient clinics, and general inpatients units. A detailed description of culture inclusion and exclusion criteria, including full methodology of the epidemiology aspect of the cultures, has been previously published.23 Cul-tures were included for analysis if they were positive for bacteria, obtained from an infant 90 days of age or younger with a temperature ≥38°C recorded on presentation or reported by a caregiver, analyzed using an automated bacterial detection system, and treated as a pathogen by the medical team (defi ned as a full course of antibiotics intended to treat the bacteria identifi ed in culture). Cultures were excluded if they were drawn in any method other than peripheral venipuncture, obtained from a patient in the ICU or admitted to the ICU within 5 hours after the culture, from patients with central indwelling catheters or hardware, or with a history of intraabdominal, intracranial, or intra-thoracic comorbidities or surgical pro-cedures, or drawn from a hospital or clinic outside the system of any participating site.

For cultures that met study criteria, clinical and demographic informa-tion was collected using a standard-ized data extraction tool. Information collected included patient age at the

time of collection, gender, hospital site, antibiotics received within 24 hours preceding the culture, highest recorded temperature within 1 hour of obtaining the blood culture, and bacterial species isolated from the blood. Infants were stratifi ed as either low risk or non–low risk based on modifi ed Rochester Criteria. As in previous studies, infants not meeting all of the low-risk criteria or who had classifying data that was unavailable, were placed in the non–low-risk group.18,24,25 Infants were considered low risk if they had no evidence of focal infection, no previous hospitalization, treatment of hyperbilirubinemia or antibiotic administration, no history of preterm birth (<37 weeks), no chronic medical conditions, normal white blood cell count (>5000 and <15 000 cells per mm3), absolute band count of <1500 cells per mm3, and no pyuria (<10 white blood cells/high powered fi eld). If available, urine and cerebrospinal fl uid culture results were also recorded to assess for concurrent urinary tract infection (UTI) and/or meningitis.

Data Analysis

Descriptive statistics were calculated for each positive culture included in the study. χ2 testing was used to determine variation in bacterial species related to the sites. A continuity adjusted χ2 test or Fisher’s exact test were used to examine the associations among species and gender, species and non–low risk, and species and age group among the most prevalent bacterial species. A geographic block map was created to describe the distribution of sample collection. All statistics were computed using SAS 9.3 (SAS Institute, Cary, NC). A 2-tailed P value was calculated for all tests, and P ≤ .05 was considered signifi cant.

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RESULTSWe previously reported detailed data regarding the numbers of cultures meeting each specifi c inclusion and exclusion criterion.23 In total, 392 cultures were identifi ed from 17 sites for analysis. Figure 1 displays the geographic distribution of culture collection from our sample, with the largest number of cultures collected in Minnesota, Texas, Ohio, and Colorado, representing a fairly diverse geographic sample. Table 1 shows the demographic characteristics for each site, including the distribution of the 4 most common organisms in our sample by site. Of the 25 species recovered, E coli was the most prevalent, followed by GBS, Streptococcus viridans, and Staphylococcus aureus. The median age range in the sample was 36 days of age, with the majority (75%) collected from infants considered to be non–low risk. Figure 2 displays the variation in the most common bacterial species across the sites, with sites 13 through 17 combined into 1 group. There was a statistically signifi cant difference in

the prevalence of GBS, E coli, and the remaining bacterial species between sites (χ2 = 35.09, P < .05).

Table 2 displays the species recovered from blood culture and the corresponding demographic characteristics and rates of concurrent UTI and meningitis of each bacterial species. Table 3 displays the clinical variables associated with the most prevalent bacteria. Among the 4 most prevalent bacteria, there was no association between gender and bacterial species (P > .05). Age at presentation was associated with Streptococcus pneumoniae only, with older infants more likely than younger infants to show bacteremia due to this organism (P < .05). Infants with bacteremia due to E coli and GBS were more likely to be stratifi ed as non–low risk (P < .05). There were no cases of L monocytogenes in the cohort during the time period sampled.

Urine cultures were obtained in our sample in 378 cases (96.4%) and were positive for pathogenic infection in 168 cases (44.4%). Of these, E coli

was the most frequent, found in 142 of 157 (90.4%) cases of bacteremia. Eight infants with UTI had concurrent meningitis (4.8%), with age ranges of 3 to 85 days. Five of 8 infants(63%) were considered non–low risk on presentation. Of the 3 who were considered low risk, 1 was >30 days of age. Thus, of the 142 infants presenting with E coli bacteremia, 1 infant (0.70%) was >30 days of age and considered low risk on presentation with concurrent meningitis.

The remaining distribution of con-current UTI is noted in Table 2.

Cerebrospinal fl uid cultures were obtained in our sample in 327 cases (83.4%) and were positive in 32 cases (9.7%). Of these, GBS was the most likely organism to show concurrent infection, with 16 cases of meningitis out of 87 cases of bacteremia (18.3%).

DISCUSSIONThis multiregional study assessed the epidemiology of bacteremia in previously healthy febrile infants ≤90 days of age outside of the ICU. By expanding to include 17 centers, this study expanded the results of our previously published study allowing for a more broad generalization of its fi ndings. The total number of blood cultures in the current sample is 392, slightly more than double the previous sample of 181 cultures. This larger, more nationally diverse sample confi rms the results of our initial smaller study of 6 hospital systems, identifying E coli as the predominate pathogen in bacteremic infants ≤90 days of age, followed by GBS. The emergence of E coli may represent the success of maternal intrapartum antibiotic prophylaxis for prevention of early-onset GBS sepsis.5,6 Although FIGURE 1 Geographic distribution of blood cultures.

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the overall proportion of bacteremia caused by Gram-negative organisms was lower in this sample (52%) than in other studies (63%–80%), it is consistent with our previous

study (53%).1,5,12,20 As has been done previously, we considered a bacteria to be a pathogen if it was treated as such by the primary team.1,12 S viridans was the next most common

organism in our sample; however, 47% (n = 15) of these cases came from a single institution. The incidence of bacteremia due to this organism in our sample, as well as its skewed site variability may refl ect provider level and hospital level variation in considering the organism as a pathogen or a contaminant. S aureus, an emerging pathogen in febrile infants with skin and/or soft tissue infections was isolated from 6% of bacteremic infants.7,19,26 In our current study, bacteremia due to S aureus was more prevalent than S pneumonia, possibly refl ecting an increase in skin and soft tissue infections during this time period in certain geographic locations. Interestingly, 7 of 23 infants with S aureus bacteremia were considered low risk by Rochester criteria. Although this result was not statistically signifi cant, it does bear further investigation as to the behavior of S aureus as a pathogen in this age group. Also, similar to our previous study, S pneumoniae bacteremia was

TABLE 1 Site-Specifi c Demographic Data for Bacteremic Infants

Site n Male (%) Median Age, d (Range)

Non–low Risk (%)

Most Common Organisms (%)

E. coli GBS S. viridans S. aureus

1 87 45 (52) 33 (7–88) 70 (80) 44 (51) 15 (17) 4 (5) 4 (5)2 53 30 (57) 33 (3–88) 46 (87) 31 (58) 9 (17) 4 (8) 4 (8)3 44 24 (55) 40 (5–89) 28 (64) 11 (25) 8 (18) 15 (34) 0 (0)4 36 14 (39) 43 (11–89) 27 (75) 19 (53) 9 (25) 0 (0) 0 (0)5 31 14 (45) 36 (10–81) 27 (87) 13 (42) 6 (19) 1 (3) 1 (3)6 27 17 (63) 39 (6–90) 23 (85) 12 (44) 6 (22) 1 (4) 0 (0)7 23 12 (52) 42 (3–81) 15 (65) 4 (17) 9 (39) 1 (4) 2 (9)8 17 10 (59) 50 (4–88) 5 (29) 2 (12) 7 (41) 1 (6) 0 (0)9 14 10 (71) 34 (18–80) 6 (43) 4 (29) 4 (29) 0 (0) 3 (21)10 12 6 (50) 37 (5–79) 8 (67) 4 (33) 3 (25) 2 (17) 0 (0)11 11 4 (36) 42 (11–74) 10 (91) 2 (18) 3 (27) 0 (0) 4 (36)12 10 3 (30) 23 (15–66) 6 (60) 1 (10) 4 (40) 1 (10) 1 (10)13–17 27 12 (44) 32 (1–90) 22 (81) 12 (44) 4 (15) 2 (7) 4 (15)Total 392 201 (51) 36 (1–90) 293 (75) 159 (41) 87 (22) 32 (8) 23 (6)

1, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN; 2, Children’s Medical Center Dallas, Dallas, TX; 3, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 4, Children’s Hospital Colorado, Aurora, CO; 5, The Children’s Hospital of The King’s Daughters, Norfolk, VA; 6, Children’s Hospital Los Angeles, Los Angeles, CA; 7, Children’s Hospital of Illinois, Peoria, IL; 8, Nemours/A.I. DuPont Hospital for Children, Wilmington, DE; 9, Children’s National Medical Center, Washington, DC; 10, University of Iowa Children’s Hospital, Iowa City, IA; 11, State University of New York Upstate, Syracuse, NY; 12, University of Rochester Medical Center, Rochester, NY; 13, Albany Medical Center, Albany, NY; 14, Tufts University School of Medicine, Boston, MA; 15, Virginia Commonwealth University School of Medicine, Richmond, VA; 16, Packard Children’s Hospital at Stanford, Palo Alto, CA; 17, St Joseph’s Mercy Hospital, Ann Arbor, MI.

FIGURE 2 Variation in the most common bacterial pathogens between sites.

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more common in infants older than 60 days (P < .05) in this larger sample.

In designating infants as low risk or non–low risk according to modifi ed Rochester criteria, we aimed to determine if the risk status of a febrile infant could help differentiate the bacterial cause. As expected, most infants (75%) with bacteremia met non–low-risk criteria. Similar to our previous study, infants with bacteremia classifi ed as non–low risk are more likely to have E coli or GBS as the source than infants classifi ed as low risk. However, because of low numbers of bacteremia in each individual species, statistical comparisons between species could

not be performed. Only positive blood cultures were included in this analysis; therefore, calculation of positive and negative predictive value of “risk” criteria was not possible.

Compared with our previous study, concurrent UTI was slightly less prevalent in the current sample (44% vs 49%), whereas meningitis was similar (10% vs 13%).12 The majority of infants with E coli bacteremia had a concurrent UTI (90%), but few had concurrent meningitis. Previous literature has suggested a high rate of concurrent meningitis in infantile UTI.27 More recent literature suggests that older infants (30–90 days of life) with UTI have a low rate of concurrent

meningitis.28–30 It has been suggested that in well-appearing infants in this age group considered to be at low risk on presentation, lumbar puncture to assess for concurrent meningitis may not be necessary.31,32 However, because our study only examines children with bacteremia, which may indicate a higher level of illness compared with the standard child presenting with UTI, it is diffi cult to draw fi rm conclusions about the role of lumbar puncture in infants with both bacteremia and UTI.

Similar to previous studies, no cases of L monocytogenes bacteremia were identifi ed in our population.1,12,20,33 Lab-oratory confi rmed cases of listerio-sis have decreased in recent decades, likely refl ecting the success of US food standard regulations prohibiting the sale of potentially contaminated food or preventive education efforts targeting pregnant women.14 Listerio-sis is a cyclical foodborne illness occurring in outbreaks, of which there were several during the time of data collection, making it unlikely that our results refl ect a “lull” in Listeria activity.15,16,33 The classic teaching that bacteremia in febrile infants is caused by GBS, E coli, and L monocytogenes is not supported by our data nor by regional studies1,4,12,20,33,34 Late-onset listeriosis typically presents with meningitis without bacteremia.35–37 As our study assessed bacteremia, cases of L monocytogenes meningitis without concurrent bacteremia may have occurred in our study population. However, the vast majority of central nervous system infections occur in neonates between the second and fourth weeks of life and present with fever, toxicity, and neurologic signs.35–37 Therefore, we speculate the

TABLE 2 Bacterial Pathogens Isolated From Bacteremic Infants

n (%) Male (%) Median Age, d (Range)

Concurrent UTI (%)

Concurrent Meningitis (%)

All species 392 (100) 201 (51) 36 (1–90) 168/378 (44) 34/327 (10)E coli 159 (40) 81 (51) 34 (3–89) 142/157 (90) 8/132 (6)GBS 87 (22) 40 (46) 38 (10–88) 7/83 (8) 17/79 (20)S viridans 32 (8) 19 (59) 30 (1–89) 1/30 (3) 1/25 (4)S aureus 23 (6) 12 (52) 35 (5–75) 1/22 (5) 0/18 (0)S pneumoniae 18 (5) 8 (44) 65 (10–90) 1/17 (6) 2/11 (18)Enterococcus sp 14 (4) 7 (50) 33 (4–71) 2/14 (14) 1/13 (8)Klebsiella sp 10 (3) 6 (60) 30 (11–90) 7/10 (70) 0/9 (0)Enterobacter sp 8 (2) 6 (75) 39 (24–80) 5/8 (63) 0/8 (0)Salmonella sp 6 (2) 3 (50) 42 (25–80) 0/6 (0) 0/6 (0)S pyogenes 5 (1) 3 (60) 42 (11–74) 0/5 (0) 0/5 (0)CoNS 5 (1) 4 (80) 24 (5–45) 0/5 (0) 2/4 (50)Othera 25 (6) 12 (48) 39 (3–88) 2/12 (16) 3/12 (25)a γ-hemolytic Streptococcus, Neisseria sp, Pseudomonas sp, Moraxella sp, Serratia sp, Pantoea sp, Micrococcus sp, Haemophilus infl uenza (nontypeable), B cereus, Citrobacter sp, Abiotrophia sp, Wautersia sp, Staphylococcus saccorolyticus, C. perfringens.

TABLE 3 Characteristics of the Most Common Pathogens in Bacteremic Infants

Bacterial Species Male (n) Non–Low Risk (n)

Infant Age, d

0–30 (n) 31–60 (n) 61–90 (n) P

E coli 81 140a 68 58 33 .53

GBS 40 53a 34 41 12 .10S viridans 19 20 17 9 6 .24S aureus 12 16 8 11 4 .68S pneumoniae 8 15 2 5 11 <.01Enterococcus sp 7 8 6 7 1 .40Klebsiella sp 6 9 5 3 2 .92All other 28 32 15 20 14 .27a P < .01, otherwise statistically insignifi cant unless noted.

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incidence of zero cases seen in both of our studies is a true refl ection of disease burden in our population of febrile infants presenting to general pediatric services. However, given the wide variability of ICU admission criteria nationwide, it is possible that a case of L monocytogenes meningitis without bacteremia in an infant was missed in our sample. On the basis of our previous study and now this larger sample, we suggest the etiologies of bacteremia taught and written in texts should be updated to refl ect the current epidemiologic data.

Current guidelines recommend empirical ampicillin and either gentamicin or a third-generation cephal osporin for the treatment of febrile infants suspected of having a SBI.16 In addition to Listeria coverage, ampicillin is included to pro vide coverage for Enterococcus species, an uncommon pathogen in this population. In our current sample, we identifi ed no cases of Listeria bacteremia and found 3.6% of infants in our cohort with Enterococcus bacteremia. Given the estimated 2% risk of bacteremia in our patient pop-ulation, we estimate that only 1 of every ∼1400 (95% confi dence interval 924–2883) previously healthy, febrile infants who has blood cultures drawn will have enterococcal bacteremia.1,4

These epidemiologic observations related to Listeria and Enterococcus sp. as well as growing ampicillin resistance among Gram-negative rods calls into question the empirical use of ampicillin in this population. Some have suggested empirical therapy with a third-generation cephalosporin such as cefotaxime without ampicillin.12,20 Cefotaxime is well tolerated and will provide coverage for the major bacterial pathogens identifi ed in this patient

population.38,39 However, larger studies examining emerging cephalosporin res istance rates are needed before fi rm recommendations can be made.

Our study has several limitations. First, we conducted this study in a retro-spective manner, thus limiting our ability to review data beyond what was available in a chart review. Second, our sample may have included overrep-resentation of certain geographic areas and centers. More than half our data were obtained from 4 large children’s hospitals in the Midwest and Northeast with a notable absence of any representation from the South-east and Pacifi c Northwest. In addition, we did fi nd a statistically signifi cant difference in species distribution between sites. However, with a rela-tively large number of sites and a small number of blood cultures at some of the sites compared with others, we suspect that this likely does not represent true statistical variability but rather Type I error due to multiple dependent variables in determining site variability. Third, our analysis was limited to hospitals that possessed automated detection systems. Fourth, we suspect that individual hospitals had varying methods for determining ICU versus non-ICU placement. In addition, the exclusion of patients admitted into ICU settings at any point during their hospitalization hinders our ability to draw conclusions regarding that subset of infants. Although it excludes a cohort of infants for analysis, it also focuses the current data set on the majority of infants who present with fever for sepsis evaluation who do not require ICU level care after admission. Fifth, in regard to S aureus bacteremia, we did not collect information on concurrent skin and soft tissue infection, limiting our ability to inform the discussion further

on this organism. Finally, we defi ned bacteremia based on provider decision to treat a positive culture. It is possible that we either under- or overestimated the rates of pathogenic infections because of inherent subjectivity and institutional variability in using provider-based decision making to classify cases of bacteremia. The a priori approach to true bacteremia in this sample leads to the inclusion of S viridans as the third most common pathogen in our study. If the opposite approach is taken, with exclusion of all S viridans as contaminants, S aureus becomes the third most common pathogen, with S pneumoniae becoming the fourth most common. Unfortunately, because of the a priori approach to true infection versus contaminant, the true role of S viridans as a pathogen is diffi cult to ascertain from the current sample.

CONCLUSIONSThis multiregional study is the largest to date examining the epidemiology of bacteremia in infants ≤90 days of age admitted to the general care unit. The data from this large cohort of hospital systems confi rm the data from our smaller study and suggest that the management of febrile well-appearing infants, and the teaching that accompanies that management for residents and medical students, should change to refl ect the current epidemiology of bacteremia in this population. Further research is needed to defi ne the role of lumbar puncture in febrile infants with UTI, as well as the true role and pathogenesis of Listeria, Staphylococcus, and Enterococcus species in infantile bacteremia.

ACKNOWLEDGMENTSThe authors thank the executive council for the Pediatric Research in Inpatient Settings network for

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their help in facilitating network par-t icipation in this study.

The authors also thank the collaborators at each site who collected blood culture data for inclusion in the current study: Michael Bendel-Stenzel, MD, Children’s Hospitals and Clinics of Minnesota (Minneapolis, MN); Clifford Chen, MD, Children’s Medical Center, University of Texas Southwestern (Dallas, TX); Rianna Evans, MD, The Children’s Hospital of The King’s Daughters (Norfolk, VA); Jason French, MD, Children’s Hospital Colorado (Aurora, CO); Sara Horstmann, MD, Albany Medical Center (Albany, NY [now Carolinas Medical Center, Charlotte, NC]); Karen Jerardi MD, MEd, Cincinnati Children’s Hospital Medical Center (Cincinnati, OH); Vivian Lee, MD, Children’s Hospital Los Angeles (Los Angeles, CA); Melissa Schafer, MD, State University of New York Upstate (Syracuse, NY); Samir Shah, MD, Cincinnati Children’s Hospital Medical Center, Division of Hospital Medicine (Cincinnati, OH); Angela Statile, MD, MEd, Cincinnati Children’s Hospital Medical Center, Division of Hospital Medicine (Cincinnati, OH); Samuel C. Stubblefi eld, MD, Nemours/A.I. DuPont Hospital for Children (Wilmington, DE); Anne Vanden Belt, MD, St Joseph Mercy Hospital (Ann Arbor, MI).

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Address correspondence to Matthew Mischler, MD, 530 NE Glen Oak, Peoria IL, 61637. E-mail: mmisch1@uic.edu

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671).

Copyright © 2015 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

(Continued on First page)

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DOI: 10.1542/hpeds.2014-01212015;5;293Hospital Pediatrics 

Midori Seppa, Kelly Wood, Jinma Ren, Carl Asche, Francis Gigliotti and Eric BiondiMatthew Mischler, Michael S. Ryan, JoAnna K. Leyenaar, Allison Markowsky,

StudyEpidemiology of Bacteremia in Previously Healthy Febrile Infants: A Follow-up

ServicesUpdated Information &

http://hosppeds.aappublications.org/content/5/6/293including high resolution figures, can be found at:

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ERRATUM

Mischler et al. Epidemiology of Bacteremia inPreviously Healthy Febrile Infants: A Follow-upStudy. Hospital Pediatrics 2015;5(6):293–300.

An error in authorship occurred in the article by Mischler et al, titled “Epidemiology of Bacteremia in PreviouslyHealthy Febrile Infants: A Follow-up Study,” published in the June 2015 issue of Hospital Pediatrics (2015;5[6 ]:293–300; doi:10.1542/hpeds.2014-0121). On page 293, the authorship reads: Matthew Mischler, MD, Michael S. Ryan,MD, JoAnna K. Leyenaar, MD, MPH, MSc, Allison Markowsky, MD, Midori Seppa, MD, PhD, Kelly Wood, MD6, Jinma Ren,PhD, Carl Asche, PhD, Francis Gigliotti, MD and Eric Biondi, MD

It should have read: Matthew Mischler, MD, Michael S. Ryan, MD, JoAnna K. Leyenaar, MD, MPH, MSc, AllisonMarkowsky, MD, Midori Seppa, MD, PhD, Kelly Wood, MD, Jinma Ren, PhD, Carl Asche, PhD, Francis Gigliotti, MD, andEric Biondi, MD; on behalf of the PRIS Network.

Pediatric Research in Inpatient Settings (PRIS) Network authoring group members:

Michael Bendel-Stenzel, MD, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN

Clifford Chen, MD, Children’s Medical Center, University of Texas Southwestern, Dallas, TX

Rianna Evans, MD, The Children’s Hospital of The King’s Daughters, Norfolk, VA

Jason French, MD, Children’s Hospital Colorado, Aurora, CO

Sara Horstmann, MD, Carolinas Medical Center, Charlotte, NC

Karen Jerardi, MD, MEd, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Vivian Lee, MD, Children’s Hospital Los Angeles, Los Angeles, CA

Melissa Schafer, MD, State University of New York Upstate, Syracuse, NY

Samir Shah, MD, Cincinnati Children’s Hospital Medical Center, Division of Hospital Medicine, Cincinnati, OH

Angela Statile, MD, MEd, Cincinnati Children’s Hospital Medical Center, Division of Hospital Medicine, Cincinnati, OH

Samuel C. Stubblefield, MD, Nemours/A.I. DuPont Hospital for Children, Wilmington, DE

Anna K. Vanden Belt, MD, St Joseph Mercy Hospital, Ann Arbor, MI

www.hospitalpediatrics.orgDOI:10.1542/hpeds.2016-001Copyright © 2016 by the American Academy of Pediatrics

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

HOSPITAL PEDIATRICS Volume 6, Issue 1, January 2016 55

DOI: 10.1542/hpeds.2014-01212015;5;293Hospital Pediatrics 

Midori Seppa, Kelly Wood, Jinma Ren, Carl Asche, Francis Gigliotti and Eric BiondiMatthew Mischler, Michael S. Ryan, JoAnna K. Leyenaar, Allison Markowsky,

StudyEpidemiology of Bacteremia in Previously Healthy Febrile Infants: A Follow-up

http://hosppeds.aappublications.org/content/5/6/293located on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://hosppeds.aappublications.org//content/6/1/55.full.pdf An erratum has been published regarding this article. Please see the attached page for:

Print ISSN: 2154-1663. Illinois, 60143. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca,publication, it has been published continuously since 2012. Hospital Pediatrics is owned, Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly

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