Application of the Rochester Criteria to Identify Febrile Infants With Bacteremia and Meningitis

Aronson, Paul L.; McCulloh, Russell J.; Tieder, Joel S.; Nigrovic, Lise E.; Leazer, Rianna C.; Alpern, Elizabeth R.; Feldman, Elana A.; Balamuth, Fran; Browning, Whitney L.; Neuman, Mark I.

doi:10.1097/pec.0000000000001421

Cited by 24 publications

(12 citation statements)

References 41 publications

(44 reference statements)

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“…Another limitation lies in the year between data collection periods, which allowed for provider education of the CPG; to our knowledge, no major recommendation or administrative changes were made during this period that could confound the post-guideline population. There is also a growing body of literature examining decreased testing of this population, 4,19,24 which could have changed provider attitudes toward guideline recommendations.…”

Section: Discussionmentioning

confidence: 99%

Clinical Practice Guideline Reduces Evaluation and Treatment for Febrile Infants 0 to 56 Days of Age

Mercurio

Hill

Duffy

et al. 2020

Clin Pediatr (Phila)

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Invasive bacterial infection (IBI) is associated with significant morbidity and mortality among neonates. Clinical practice guidelines (CPGs) can expedite care and standardize management. We conducted a retrospective observational study of febrile infants aged 0 to 56 days to assess changes in clinical decision-making following febrile neonate CPG implementation in the pediatric emergency department of a tertiary care hospital. Data were reviewed pre- and post-CPG implementation, with 1-year separation for provider education. Fewer infants underwent laboratory testing (complete blood count, blood culture, urine culture, lumbar puncture), antibiotic administration, and hospital admission after implementation; the greatest decrease was observed among infants aged 29 to 56 days identified as not high risk for meningitis. Seven-day IBI readmission rate was 1% in both groups. Herpes simplex virus testing and treatment did not differ significantly between groups. These results suggest that CPGs can enable both standardized care and decreased intervention in this population with no change in 7-day readmission rates.

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Section: Discussionmentioning

confidence: 99%

Clinical Practice Guideline Reduces Evaluation and Treatment for Febrile Infants 0 to 56 Days of Age

Mercurio

Hill

Duffy

et al. 2020

Clin Pediatr (Phila)

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“…Despite this concern, our observed IBI rates are similar to other recent ED febrile infant cohorts. 2,9,28,39,[46][47][48] Although we cannot apply either the Boston or the Philadelphia criteria to those infants who did not have CSF obtained, newer strategies should focus on methods to identify febrile infants who may safely avoid diagnostic lumbar puncture.…”

Section: Discussionmentioning

confidence: 99%

Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections

et al. 2020

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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 mm 3 , CSF WBC $10 cells per mm 3 , and urinalysis with .10 WBC per high-power field or positive urine dip result) and modified Philadelphia criteria (peripheral WBC $15 000 cells per mm 3 , CSF WBC $8 cells per mm 3 , 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. WHAT'S KNOWN ON THIS SUBJECT: The Boston and Philadelphia criteria for febrile infants were developed decades ago, before widespread conjugate vaccine use to identify infants at low risk of serious and invasive bacterial infections. The continued applicability of these tools remains unclear. WHAT THIS STUDY ADDS: The Boston and Philadelphia criteria misclassified approximately one-third of infants 29 to 60 days old who had invasive bacterial infections as being low risk, including those with bacterial meningitis. Newer tools

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“…Identifying infants with serious bacterial infections (SBIs) or invasive bacterial infections (IBIs) based on clinical assessment alone may lead to delayed or missed diagnosis. 2 Previous diagnostic approaches include the Rochester criteria, which take into account clinical findings, white blood cell (WBC) and urinalysis, 3 as well as the…”

Section: Introductionmentioning

confidence: 99%

Validation and comparison of the PECARN rule, Step-by-Step approach and Lab-score for predicting serious and invasive bacterial infections in young febrile infants

Sutiman

Khoo

Ong

et al. 2022

Ann Acad Med Singap

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Introduction: Differentiating infants with serious bacterial infections (SBIs) or invasive bacterial infections (IBIs) from those without remains a challenge. We sought to compare the diagnostic performances of single biomarkers (absolute neutrophil count [ANC], C-reactive protein [CRP] and procalcitonin [PCT]) and 4 diagnostic approaches comprising Lab-score, Step-by-Step approach (original and modified) and Pediatric Emergency Care Applied Research Network (PECARN) rule. Method: This is a prospective cohort study involving infants 0–90 days of age who presented to an emergency department from July 2020 to August 2021. SBIs were defined as bacterial meningitis, bacteraemia and/or urinary tract infections. IBIs were defined as bacteraemia and/or bacterial meningitis. We evaluated the performances of Lab-score, Step-by-Step (original and modified) and PECARN rule in predicting SBIs and IBIs. Results: We analysed a total of 258 infants, among whom 86 (33.3%) had SBIs and 9 (3.5%) had IBIs. In predicting SBIs, ANC ≥4.09 had the highest sensitivity and negative predictive value (NPV), while PCT ≥1.7 had the highest specificity and positive predictive value (PPV). CRP ≥20 achieved the highest area under receiver operating characteristic curve (AUC) of 0.741 (95% confidence interval [CI] 0.672–0.810). The Step-by-Step (original) approach had the highest sensitivity (97.7%). Lab-score had the highest AUC of 0.695 (95% CI 0.621–0.768), compared to PECARN rule at 0.625 (95% CI 0.556–0.694) and Step-by-Step (original) at 0.573 (95% CI 0.502–0.644). In predicting IBIs, PCT ≥1.7 had the highest sensitivity, specificity, PPV and NPV. The Step-by-Step (original and modified) approach had the highest sensitivity of 100%. Lab-score had the highest AUC of 0.854 (95% CI 0.731–0.977) compared to PECARN rule at 0.589 (95% CI 0.420–0.758) and Step-by-Step at 0.562 (95% CI 0.392–0.732). Conclusion: CRP strongly predicted SBIs, and PCT strongly predicted IBI. The Step-by-Step approach had the highest sensitivity and NPV, while Lab-score had the highest specificity and AUC in predicting SBIs and IBIs. Keywords: Biomarkers, diagnostic approaches, febrile infants, Lab-score, PECARN rule, Step-by-Step approach

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Application of the Rochester Criteria to Identify Febrile Infants With Bacteremia and Meningitis

Abstract: The Rochester criteria identified 92% of infants aged 60 days or younger with invasive bacterial infection. However, 1 neonate 28 days or younger with meningitis was classified as low-risk.

Cited by 24 publications

References 41 publications

Clinical Practice Guideline Reduces Evaluation and Treatment for Febrile Infants 0 to 56 Days of Age

Clinical Practice Guideline Reduces Evaluation and Treatment for Febrile Infants 0 to 56 Days of Age

Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections

Validation and comparison of the PECARN rule, Step-by-Step approach and Lab-score for predicting serious and invasive bacterial infections in young febrile infants

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