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Published on: August 12, 2020
Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection
Santiago Mintegi1, Silvia Bressan2, Borja Gomez1
1Pediatric Emergency Department, Cruces University Hospital, University of the Basque Country, Bilbao, Spain.
Insights
A sequential approach using clinical and biomarker data effectively identifies low-risk febrile infants for outpatient management. This method improves accuracy in diagnosing invasive bacterial infections (IBI) compared to existing strategies.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Diseases
- Clinical Diagnostics
Background:
- Accurate tools for managing febrile infants are crucial, yet no optimal strategy exists.
- A sequential approach integrating clinical assessment, urinalysis, and biomarkers like procalcitonin shows promise.
- Identifying low-risk febrile infants facilitates safe outpatient management, reducing hospitalizations.
Purpose of the Study:
- To evaluate a sequential ('step by step') approach for identifying febrile infants at low risk of invasive bacterial infections (IBI).
- To compare the efficacy of the sequential approach against the Rochester criteria and Lab-score.
- To determine suitability for outpatient management based on the sequential approach.
Main Methods:
- Retrospective comparison of three strategies: step by step, Lab-score, and Rochester criteria.
- Study included 1123 febrile infants (<3 months) across seven European pediatric emergency departments.
- Invasive bacterial infection (IBI) defined by pathogen isolation from blood or cerebrospinal fluid.
Main Results:
- The step by step approach classified 43.4% of infants as low-risk, with a 0.2% IBI prevalence.
- Compared to Lab-score (0.7% IBI) and Rochester criteria (1.1% IBI), the step by step approach showed lower IBI rates in low-risk infants.
- The step by step approach had a misclassification rate of 2.0% for IBI, significantly lower than the 10.4% for the other two methods.
Conclusions:
- A sequential approach integrating clinical findings and laboratory results, including procalcitonin, is superior for identifying febrile infants suitable for outpatient care.
- This strategy enhances diagnostic accuracy and optimizes the management of young febrile infants.
- The step by step method offers a more reliable tool for risk stratification in febrile infants.
Introduction:
Much effort has been put in the past years to create and assess accurate tools for the management of febrile infants. However, no optimal strategy has been so far identified. A sequential approach evaluating, first, the appearance of the infant, second, the age and result of the urinanalysis and, finally, the results of the blood biomarkers, including procalcitonin, may better identify low risk febrile infants suitable for outpatient management.
Objective:
To assess the value of a sequential approach ('step by step') to febrile young infants in order to identify patients at a low risk for invasive bacterial infections (IBI) who are suitable for outpatient management and compare it with other previously described strategies such as the Rochester criteria and the Lab-score.
Methods:
A retrospective comparison of three different approaches (step by step, Lab-score and Rochester criteria) was carried out in 1123 febrile infants less than 3 months of age attended in seven European paediatric emergency departments. IBI was defined as isolation of a bacterial pathogen from the blood or cerebrospinal fluid.
Results:
Of the 1123 infants (IBI 48; 4.2%), 488 (43.4%) were classified as low-risk criteria according to the step by step approach (vs 693 (61.7%) with the Lab-score and 458 (40.7%) with the Rochester criteria). The prevalence of IBI in the low-risk criteria patients was 0.2% (95% CI 0% to 0.6%) using the step by step approach; 0.7% (95% CI 0.1% to 1.3%) using the Lab-score; and 1.1% (95% CI 0.1% to 2%) using the Rochester criteria. Using the step by step approach, one patient with IBI was not correctly classified (2.0%, 95% CI 0% to 6.12%) versus five using the Lab-score or Rochester criteria (10.4%, 95% CI 1.76% to 19.04%).
Conclusions:
A sequential approach to young febrile infants based on clinical and laboratory parameters, including procalcitonin, identifies better patients more suitable for outpatient management.
