Validating a decision tree for serious infection: diagnostic accuracy in acutely ill children in ambulatory care

Abstract

ObjectiveAcute infection is the most common presentation of children in primary care with only few having a serious infection (eg, sepsis, meningitis, pneumonia). To avoid complications or death, early recognition and adequate referral are essential. Clinical prediction rules have the potential to improve diagnostic decision-making for rare but serious conditions. In this study, we aimed to validate a recently developed decision tree in a new but similar population.DesignDiagnostic accuracy study validating a clinical prediction rule.Setting and participantsAcutely ill children presenting to ambulatory care in Flanders, Belgium, consisting of general practice and paediatric assessment in outpatient clinics or the emergency department.InterventionPhysicians were asked to score the decision tree in every child.Primary outcome measuresThe outcome of interest was hospital admission for at least 24 h with a serious infection within 5 days after initial presentation. We report the diagnostic accuracy of the decision tree in sensitivity, specificity, likelihood ratios and predictive values.ResultsIn total, 8962 acute illness episodes were included, of which 283 lead to admission to hospital with a serious infection. Sensitivity of the decision tree was 100% (95% CI 71.5% to 100%) at a specificity of 83.6% (95% CI 82.3% to 84.9%) in the general practitioner setting with 17% of children testing positive. In the paediatric outpatient and emergency department setting, sensitivities were below 92%, with specificities below 44.8%.ConclusionsIn an independent validation cohort, this clinical prediction rule has shown to be extremely sensitive to identify children at risk of hospital admission for a serious infection in general practice, making it suitable for ruling out.Trial registration numberNCT02024282.

Should all acutely ill children in primary care be tested with point-of-care CRP: a cluster randomised trial

“…In contrast, serious infections have become rare and are now estimated to constitute < 1 % of childhood infections presenting to primary care [ 5 ]. Pneumonia represents four-fifths of all cases, followed by urinary tract infections, and now very few cases of sepsis, meningitis, or osteomyelitis [ 6 – 8 ], which, although rare, their prompt recognition is essential to avoid complications or death [ 9 ]. This is challenging in primary care because the clinical presentations are highly non-specific, especially in the early stages of illness.…”

Point-of-care C reactive protein to identify serious infection in acutely ill children presenting to hospital: prospective cohort study

“…We included 5517 new illness episodes (figure 1) in 4608 children14; 944 children had two separate illness episodes and 611 had three or more. The children’s median age was 1.5 years (age range: 1 month–15.8 years) and 2951 were boys (53.5%) (table 1).…”

“…This study was conducted in Belgium, from 15 February 2013 to 28 February 2014 14. Children aged 1 month–16 years presenting with an acute illness to ambulatory care were recruited to have POC CRP testing 20.…”

“…The primary outcome of the study was hospital admission (>24 hours) for SI within 5 days after initial presentation,14 which was verified by a search of the electronic medical records of all paediatric clinics and EDs.…”

Translational Education

“…However, this tool falsely identified many acutely ill children as potentially at risk of a serious infection, and while these results are not ideal, physicians can manage the need for additional testing [15]. …”