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Predictive value of AFR and UCR for the methicillin-resistant Staphylococcus aureus infection in children with bone

Chaochen Zhao1, Chenghui Ke1, Zhiye Guan1

  • 1Department of Orthopedics, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.

Scientific Reports
|December 19, 2025
PubMed

Insights

Lower admission albumin-to-fibrinogen ratio (AFR) and urea-to-creatinine ratio (UCR) predict methicillin-resistant Staphylococcus aureus (MRSA) in pediatric bone and joint infections. These ratios can aid early risk assessment for MRSA in children.

Area of Science:

  • Pediatric Infectious Diseases
  • Clinical Diagnostics
  • Biomarker Research

Background:

  • Pediatric bone and joint infections (BJIs) caused by Staphylococcus aureus present diagnostic and treatment challenges, particularly with methicillin-resistant Staphylococcus aureus (MRSA) strains.
  • Early identification of MRSA is crucial for effective empirical antibiotic selection and improved patient outcomes.

Purpose of the Study:

  • To evaluate the admission albumin-to-fibrinogen ratio (AFR) and urea-to-creatinine ratio (UCR) as predictors of MRSA in pediatric patients with culture-confirmed S. aureus BJIs.
  • To develop and validate a composite indicator using AFR and UCR for early MRSA risk assessment.

Main Methods:

  • Retrospective analysis of 77 pediatric patients with S. aureus BJIs (23 MRSA, 54 MSSA) from two centers (2015-2024).
  • Clinical data and laboratory values (AFR, UCR) obtained before antibiotic initiation were reviewed.
  • Firth's penalized logistic regression was used to construct a composite indicator (AFR + UCR), with model performance assessed by discrimination (AUC) and calibration (Hosmer-Lemeshow, Brier score), and validated using 10-fold cross-validation and bootstrap resampling.

Main Results:

  • The MRSA group exhibited significantly lower admission AFR and UCR values compared to the methicillin-sensitive Staphylococcus aureus (MSSA) group.
  • The composite AFR + UCR model demonstrated acceptable discrimination (AUC = 0.724) and good calibration.
  • At a probability cutoff of 0.293, the model achieved a sensitivity of 0.826 and specificity of 0.611, indicating clinical utility across a range of threshold probabilities.

Conclusions:

  • Lower admission AFR and UCR are associated with an increased risk of MRSA in pediatric S. aureus BJIs.
  • The combination of AFR and UCR serves as a valuable adjunctive tool for early risk stratification and guiding empirical treatment decisions in pediatric BJIs.
  • Further external validation in larger, multicenter cohorts is recommended to confirm generalizability and clinical utility.
Keywords:
Albumin to fibrinogen ratioBone and joint infectionsMethicillin-resistant Staphylococcus aureusPediatricsPredictive biomarkersUrea to creatinine ratio

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