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Evaluation of a Pediatric Early Warning Score as a Predictor of Occult Invasive Bacterial Infection in the Pediatric
Michael A Gardiner1, Coburn H Allen, Nidhi V Singh2
1From the Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, CA.
Insights
The Pediatric Early Warning Score (PEWS) can indicate a higher chance of occult invasive bacterial infection (IBI) in children. However, PEWS alone is not a reliable tool for diagnosing IBI in pediatric emergency departments.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Diseases
- Diagnostic Accuracy Studies
Background:
- Occult invasive bacterial infection (IBI) is a concern in febrile pediatric emergency department (PED) patients.
- Predictive tools are needed to identify IBI in well-appearing children without known risk factors.
Purpose of the Study:
- To evaluate the diagnostic performance of the Pediatric Early Warning Score (PEWS) for predicting occult IBI.
- To compare PEWS with heart rate (HR) and Emergency Severity Index (ESI) in this patient population.
Main Methods:
- Retrospective case-control analysis of febrile PED patients (60 days to 18 years).
- Exclusion of ill-appearing children, ICU admissions, or those with known high-risk conditions.
- Cases defined by noncontaminant positive cultures; controls matched 2:1.
Main Results:
- Higher disposition PEWS (≥3) was associated with increased odds of occult IBI (OR, 2.57).
- Disposition HR and ESI also showed associations with occult IBI.
- Area under the curve (AUC) for PEWS was suboptimal, similar to HR, and lower than ESI.
Conclusions:
- A disposition PEWS of 3 or higher increases the odds of occult IBI in well-appearing febrile children.
- PEWS demonstrates poor discriminative ability for occult IBI when used in isolation.
- PEWS is not recommended as a standalone tool for predicting occult IBI.
Objectives:
The aims of the study were to evaluate the diagnostic performance of Pediatric Early Warning Score (PEWS) to predict occult invasive bacterial infection (IBI) in well-appearing pediatric emergency department (PED) patients without known risk factors for bacterial infection and to compare PEWS to heart rate (HR) and Emergency Severity Index (ESI).
Methods:
We performed a retrospective case-control analysis of febrile PED patients aged 60 days to 18 years over a 2-year period. Subjects were excluded if they were ill appearing, admitted to an intensive care unit, or had a known high-risk condition. Cases of occult IBI were included if they had a noncontaminant positive culture other than an isolated positive urine culture. Two febrile control subjects were identified for each case. Odds ratios and receiver operating characteristic curves were evaluated to determine performance characteristics of PEWS at triage and disposition, age-adjusted HR at triage and disposition, and ESI at triage.
Results:
Compared with 178 controls, 89 cases had higher disposition PEWS, higher disposition HR, lower ESI, and higher rate of hospital admission. Disposition PEWS ≥3 (odds ratio, 2.57; 95% confidence interval, 1.08-6.18), disposition HR > 99th percentile, and ESI demonstrated increased odds of occult IBI. Area under the receiver operating characteristic curve for disposition PEWS (0.56) was similar to triage PEWS (0.54), triage HR (0.54), disposition HR (0.58), and ESI (0.65).
Conclusions:
Subjects with PEWS ≥3 at PED disposition have increased odds of occult IBI; however, PEWS has poor discriminative ability at all cutoffs. We cannot recommend PEWS used in isolation to predict occult IBI.
