Post on 17-Jan-2016
Validation of a laboratory risk score for the identification of severe bacterial infection in children with fever without source
Galetto-Lacour A, Zamora S, Andreola B, Bressan S, Lacroix L, Da Dalt L and Gervaix A
Arch Dis Child 2010; 95: 968-973
Dr Vanessa Craven
Procalcitonin
Healthy Individuals
Local Infections
Systemic Infections (Sepsis)
Severe Sepsis
Septic Shock
0.05 ng/ml
0.5 ng/ml
2 ng/ml
Brunkhorst FM et al. Intens. Care Med 1998; 24: 888-892
Pediatr Infect Dis J 2008; 27: 654-6• 202 7- 36 months• Rectal temp >38°C & no focus
• IOS• Urine MC&S• WCC, CRP & PCT• LP ‘when meningitis suspected’• Clinical follow up within 48 hours
Results• SBI 54 (27%)
• PCT: OR 37.6 (5.8 - 243)• CRP: OR 7.8 (2 - 30.4)• Urine dipstick: OR 23.2 (5.1 - 104.8)
Predictor Points
PCT (ng/ml)
< 0.5 ≥ 0.5 ≥ 2.0
024
CRP (mg/ml)
< 40 40-99 ≥ 100
024
Urine dipstick
Negative Positive
01
AIM• External validation• More children• 2007 Italian population
• Laboratory score ≥ 3
Methodology• Prospective enrolment - 408 children• Data from Italian study• May 2004 - October 2005• 7 days (>38C) to 36 months (>39.5°C)
7 days to 36 months
Fever without source
Exclusion criteria
Looking for severe bacterial infection (defined) – diagnosis ‘at end of follow up’
SBI vs ‘benign viral infection’
Retrospective (5 years)Using another study’s cohort
Reasonable age definition & exclusion criteria
Using another study’s data set
Higher temperature cut off than used in practice?
Laboratory measurements
Who confirmed FWS?
ALL were assessed at 72 hours (including telephone contact) – no details
Cultures would be back but not always reliable
What happened to the classification of children that did not improve? Or had focal infection and did not get Abx
DMSA to diagnose pyleonephritis (1/52)
Who did the assessments?Who followed up?
ALL were followed upNo details about - follow up length - locationWas 72 hr review conclusive in allAny need Abx/admissionWhat happened to the ‘focal bacterial infection’ 15.8%?
SBI in 92 (22.7%)
Score ≥3: Sens 86% (77-92%)
Spec: 83% (79-87%)
Sens ↑and spec ↓ with age
WBC: Sens 52%, Spec 75%
CRP: Sens 52%, Spec 75%
PCT: Sens 75%, Spec 76%
Missed 13 cases
Very large confidence intervals!
Large confidence intervalsSelected population
BUT referral pathway different
WCC poor predictorPediatr Infect Dis J 2008; 27: 654-6Results comparable to derivation set
Summary & Conclusion
There is insufficient evidence to support the sole use of the lab score to identify those with severe bacterial
infection