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Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections
Todd W Lyons1, Aris C Garro2, Andrea T Cruz3
1Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; todd.lyons@childrens.harvard.edu.
Insights
The Boston and Philadelphia criteria for identifying serious bacterial infections in infants are not fully accurate. These criteria misclassified many infants with invasive bacterial infections, including bacterial meningitis.
Area of Science:
- Pediatrics
- Infectious Diseases
- Clinical Diagnostics
Background:
- Established Boston and Philadelphia criteria for serious bacterial infections in infants require reevaluation.
- Recent data on the diagnostic accuracy of these criteria in young infants is limited.
Purpose of the Study:
- To assess the performance of modified Boston and Philadelphia criteria in identifying invasive bacterial infections (IBIs) in infants aged 29 to 60 days.
- To determine the accuracy of these criteria in diagnosing bacterial meningitis and bacteremia.
Main Methods:
- A multicenter cohort study included infants aged 29 to 60 days with cerebrospinal fluid (CSF) and blood cultures.
- Modified Boston criteria: peripheral WBC ≥20,000, CSF WBC ≥10, urinalysis >10 WBC or positive dip.
- Modified Philadelphia criteria: peripheral WBC ≥15,000, CSF WBC ≥8, positive CSF Gram-stain, urinalysis >10 WBC or positive dip.
Main Results:
- Modified Boston criteria (n=8344) had 62.7% sensitivity and 59.2% specificity for IBI.
- Modified Philadelphia criteria (n=8131) had 71.7% sensitivity and 46.1% specificity for IBI.
- Both criteria misclassified a significant proportion of infants with bacterial meningitis (32.1% and 23.3%, respectively).
Conclusions:
- Modified Boston and Philadelphia criteria demonstrate suboptimal performance in identifying invasive bacterial infections in infants aged 29-60 days.
- These criteria misclassify a substantial number of infants, including those with serious conditions like bacterial meningitis.
- Revising diagnostic guidelines may be necessary to improve the accurate identification of serious bacterial infections in this age group.
Background:
The ability of the decades-old Boston and Philadelphia criteria to accurately identify infants at low risk for serious bacterial infections has not been recently reevaluated.
Methods:
We assembled a multicenter cohort of infants 29 to 60 days of age who had cerebrospinal fluid (CSF) and blood cultures obtained. We report the performance of the modified Boston criteria (peripheral white blood cell count [WBC] ≥20 000 cells per mm3, CSF WBC ≥10 cells per mm3, and urinalysis with >10 WBC per high-power field or positive urine dip result) and modified Philadelphia criteria (peripheral WBC ≥15 000 cells per mm3, CSF WBC ≥8 cells per mm3, positive CSF Gram-stain result, and urinalysis with >10 WBC per high-power field or positive urine dip result) for the identification of invasive bacterial infections (IBIs). We defined IBI as bacterial meningitis (growth of pathogenic bacteria from CSF culture) or bacteremia (growth from blood culture).
Results:
We applied the modified Boston criteria to 8344 infants and the modified Philadelphia criteria to 8131 infants. The modified Boston criteria identified 133 of the 212 infants with IBI (sensitivity 62.7% [95% confidence interval (CI) 55.9% to 69.3%] and specificity 59.2% [95% CI 58.1% to 60.2%]), and the modified Philadelphia criteria identified 157 of the 219 infants with IBI (sensitivity 71.7% [95% CI 65.2% to 77.6%] and specificity 46.1% [95% CI 45.0% to 47.2%]). The modified Boston and Philadelphia criteria misclassified 17 of 53 (32.1%) and 13 of 56 (23.3%) infants with bacterial meningitis, respectively.
Conclusions:
The modified Boston and Philadelphia criteria misclassified a substantial number of infants 29 to 60 days old with IBI, including those with bacterial meningitis.
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