pecarn febrile infant

Data were analyzed between April 2014 and April 2018. Pantell In addition, we did not study biomarkers other than procalcitonin. Front Pediatr. Brieman Pediatrics. Thanks in advance. BK, PMC 2019. Validation of a laboratory risk index score for the identification of severe bacterial infection in children with fever without source. The https:// ensures that you are connecting to the CH, Hsieh MI, Valls L. Bedside procalcitonin and acute care. As noted in the Supplement, alternative cutoffs for ANC (4,000) and procalcitonin (0.5) were studied and found to be comparable to the published cutoffs in terms of accuracy. Herpes simplex virus infection in infants undergoing meningitis evaluation. Terms of Use| Gene expression patterns in blood leukocytes discriminate patients with acute infections. et al. It also develops a sequential rule where the most important variable is considered first, followed by the second most important variable, and so on. Chong SL, Niu C, Piragasam R, Koh ZX, Guo D, Lee JH, Ong GY, Ong MEH, Liu N. Ann Transl Med. What to to do with the intermediate group after observation in the ED. W, Chung Aronson JAMA Pediatr. L, Friedman Epidemiology of bacteremia in febrile infants in the United States. Finally, until further validation of the prediction rule, clinicians must remain most cautious with infants younger than 28 days, in whom the risks of bacteremia and bacterial meningitis as well as herpes encephalitis70 are the greatest. J, W, Luo A, Gala The research was conducted as part of the Pediatric Emergency Care Applied Research Network (PECARN). However, previous literature strongly suggests that procalcitonin has superior test characteristics for bacteremia and bacterial meningitis than C-reactive protein and other biomarkers.16,18,19 Additionally, we did not evaluate viral testing in the prediction rule because these tests were not part of the protocol nor uniformly performed at the study sites. GA. Gene expression profiles in febrile children with defined viral and bacterial infection. DG, Reitsma No patients who did not have CSF cultures obtained were later found to have bacterial meningitis. PL, Sharpe The febrile infant: whats new? Infants from whom blood cultures were obtained for evaluation of SBIs during times when research staff were available were eligible (Figure 1). L, Gervaix N, Fever was defined as rectal temperature of at least 38 in the ED, a prior health care setting, or at home, within the last 24 hours. In a cohort of 1821 febrile infants 60 days and younger, 170 (9.3%) had serious bacterial infections, and using recursive partitioning analysis, we derived a low-risk prediction rule involving 3 variables: normal urinalysis, absolute neutrophil count 4090/L, and serum procalcitonin 1.71 ng/mL. et al. R, Sofer The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. Baker Prevalence of Urinary Tract Infection, Bacteremia, and Meningitis Among Febrile Infants Aged 8 to 60 Days With SARS-CoV-2. Of the 16 with multiple infections, 1 had UTI, bacteremia, and meningitis; 5 had bacteremia and meningitis; and 10 had UTI and bacteremia. Interestingly the authors also considered altering the cutoffs of the ANC and procalcitonin to historically accepted cutoffs of ANC of 4,000 and procalcitonin of 0.5 (available in the electronic supplement to the article). McCaig official website and that any information you provide is encrypted JK, Blaschke Serious bacterial infections were diagnosed in 170 infants (9.3%; 95% CI, 8.1-10.8), including 151 (8.3%; 95% CI, 7.1-9.6) with UTIs, 26 (1.4%; 95% CI, 1.0-2.1) with bacteremia, and 10 (0.5%; 95% CI, 0.3-1.0) with bacterial meningitis; 16 (0.9%; 95% CI, 0.5-1.4) had concurrent bacterial infections (eTable 2 in the Supplement). government site. Design: Secondary analysis of a prospective registry. Neither clinician suspicion nor the YOS added significantly to the rule, as we and others have previously demonstrated.8,9 The prediction rule had high sensitivity for identifying infants with SBIs and high negative predictive value while maintaining moderately high specificity. Why is this important? MeSH terms Bacteremia / complications Bacteremia / diagnosis* Clinical Decision Rules* PS, Ballard A, Stein G. Epidemiology of bacteriuria during the first year of life. The urinalysis, absolute neutrophil count, and serum procalcitonin levels may accurately identify febrile infants 60 days and younger at low risk for serious bacterial infections. When applied to the new analytic cohort, the recursive partitioning analysis selected the same variables and numerical cutoffs, and the model had similar test accuracies (data not shown). Failure of infant observation scales in detecting serious illness in febrile, 4- to 8-week-old infants. MN, Fleisher CSF results were not included as predictors as part of the goal of these rules is to decrease the need for lumbar puncture. Concept and design: Kuppermann, Dayan, Dean, Ramilo, Mahajan. P, Bonsu ER, 2023 May 30;11:1196992. doi: 10.3389/fped.2023.1196992. A, In addition, because bacteremia and bacterial meningitis are more invasive infections than UTIs, we performed a subanalysis to evaluate the rule accuracy for identifying patients with those infections (including patients with concurrent UTI and bacteremia or meningitis). N, Mejias A review and suggested modifications of methodological standards. 27 The false-positive rate of blood cultures in infants may be as high as 10%, and the false-negative rate . We strive to reshape medical education and academia in their evolution beyond the traditional classroom. Management and outcomes of care of fever in early infancy. Reappraisal of criteria used to predict serious bacterial illness in febrile infants less than 8 weeks of age. 1. 4 Standardized clinical, laboratory, and telephone follow-up data were collected for all infants. Identifying febrile young infants with bacteremia: is the peripheral white blood cell count an accurate screen? Hu Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. Epub 2022 Dec 16. R, Gmez A paper titled " A Clinical Prediction Rule to Identify Febrile Infants 60 days and Younger at Low Risk for Serious Bacterial Infections " was published in JAMA Pediatrics in February of 2019. I, Klein Evaluating the impact of implementing a clinical practice guideline for febrile infants with positive respiratory syncytial virus or enterovirus testing. SJ, Crain Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. L; European Group for Validation of the Step-by-Step Approach. JA, Kaforou The .gov means its official. This is an interesting and important contribution to the care of febrile infants 60 days old. In this large, prospective, multicenter study, we derived and validated a highly accurate prediction rule to identify febrile infants 60 days and younger at low risk of SBIs using 3 laboratory test results: the urinalysis, ANC, and serum procalcitonin levels. Immature neutrophils in the blood smears of young febrile children. The rule sensitivity was 97.7%, specificity was 60.0%, and negative predictive value was 99.6%; no infant with bacterial meningitis was missed. 2017;33 (11):748-753. doi: This site needs JavaScript to work properly. Results: DD, Schuster EA, Greenhow Low-risk infants evaluated with the PECARN clinical prediction rule had a 0.52% risk of having a missed UTI and 0.79% risk of having missed bacteremia. We obtained written informed consent from the legal guardians of enrolled patients. Case Presentations A 20-day-old boy presents to the ED in August for evaluation of a rectal temperature of 38C (100.4F). Enrolled infants had temperatures 38 C in the ED from a referring facility or by history. Diagnostic performance of the lab-score in predicting severe and invasive bacterial infections in well-appearing young febrile infants. CL. JAMA Pediatrics. (2021, May 3). aThis includes patients for whom procalcitonin (PCT) could not be sampled, regardless of whether an eligible RNA biosignature sample was obtained in the parent study. The PECARN group derived and internally validated a new infant fever prediction rule in 26 EDs around the US. et al; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. To verify that patients discharged from the ED without CSF testing did not have bacterial meningitis, we contacted families of those patients by telephone 8 to 14 days after the ED visit and/or reviewed their medical records. Bookshelf B, Jodal The types of SBIs in each risk category (ie, each cell of the decision tree) are shown in eFigures 1 and 2 in the Supplement. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. PV, Blumberg Patients were not excluded for otitis media. Li V, Dauber A, Sekar Febrile infants ages 29-90 days evaluated in US emergency departments (EDs) proceeded through the decision tree until they reached a terminal endpoint. However, lumbar punctures and hospitalizations involve risks and costs. P, Kuppermann 2023 May 1;6(5):e2313354. N, Stiell To empirically derive and validate a prediction rule to identify febrile infants 60 days at low risk for SBI. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. C, Neto S, Nylen The PECARN rule's sensitivity dropped from 97.7% in the original study to 89.8% and specificity dropped to from 60% in the original study to 55.5%. At this level of risk, the number of successful lumbar . Careers. Kuppermann N, Dayan PS, Levine DA, Vitale M, Tzimenatos L, Tunik MG, Saunders M, Ruddy RM, Roosevelt G, Rogers AJ, Powell EC, Nigrovic LE, Muenzer J, Linakis JG, Grisanti K, Jaffe DM, Hoyle JD Jr, Greenberg R, Gattu R, Cruz AT, Crain EF, Cohen DM, Brayer A, Borgialli D, Bonsu B, Browne L, Blumberg S, Bennett JE, Atabaki SM, Anders J, Alpern ER, Miller B, Casper TC, Dean JM, Ramilo O, Mahajan P; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). RW, Oudesluys-Murphy 2023 May 1;12(9):3242. doi: 10.3390/jcm12093242. In a sensitivity analysis, we reclassified 17 patients with urine culture colony counts of less than 50000 cfu/mL as SBI-negative. 2014 Dec;47(6):682-8. doi: 10.1016/j.jemermed.2014.07.034. As predictor variables, we included age group (28 days vs >28 days), qualifying temperature, duration of fever, YOS score, unstructured clinician suspicion, urinalysis, WBC count, absolute neutrophil count (ANC), and serum procalcitonin level. MW, Biondi M, Wan Cruz No patients with bacterial meningitis were missed by the rule. CRP was not included due to limited blood availability and a literature review showing that procalcitonin was a superior marker to CRP for evaluating febrile infants. P, Kuppermann A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. Findings SL, Dayan For details, see the eResults in the Supplement. Clinical prediction rules. AC, Microbiologic cultures of sterile fluids remain the standard for diagnosing bacterial infections in young febrile infants but have limitations and require invasive procedures to obtain samples (urinary catheterization, lumbar puncture). In that analysis, the sensitivity of the rule was 96.7% (95% CI, 83.3-99.4) and specificity was 61.5% (95% CI, 59.2-63.9). In this observational study, 7,407 febrile infants were enrolled from 26 emergency departments (EDs) across PECARN sites. Only the derivation cohort is shown in the tree portion of the figure. B, Mintegi Variation in care of the febrile young infant <90 days in US pediatric emergency departments. Overall classification counts and characteristics are shown for both the derivation and validation cohorts below the classification tree. ER. Tzimenatos A urinary tract infection (UTI) was defined as ANY ONE of the following: An abnormal UA was defined as ANY ONE of the following (LE and nitrite were considered positive if any amount including trace): The authors applied recursive partitioning analysis to both important variables and optimal thresholds for the variables. M, Willis Herberg Distribution of SBIs by Risk Category, Full Patient Cohort, eFigure 3. B, Hernndez-Bou S, Cheng et al. Byington Among the 500 infants in that risk category, there were 153 (30.6%) with procalcitonin levels of 0.18 ng/mL or lower. He has . Infants were eligible if they were 60 days of age, with fever, who had blood cultures collected. M, Shachak Methods Serious Bacterial Infections in Preterm Infants: Should Their Age Be "Corrected"? Baskin 2004 Jun;113(6):1728-34. doi: 10.1542/peds.113.6.1728. et al. Prediction rules for young febrile infants developed in the past decade include newer blood tests that are more sensitive and/or specific for SBI than the WBC count.16,18,38,61-63 The Step-by-Step rule combined both clinical factors (patient appearance) and laboratory factors (leukocyturia and procalcitonin, C-reactive protein, and ANC levels) in febrile infants aged 22 to 90 days.32,38,64 That model had a sensitivity of 98.9% to detect all SBIs and a sensitivity of 92.0% to detect invasive bacterial infections (bacteremia or bacterial meningitis).38 In contrast, our model was derived on a different age group (0-60 days) and does not exclude infants with symptoms or signs of respiratory infections. doi: 10.1001/jamanetworkopen.2023.13354. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. Gomez R, Stone To identify infants that do not need to be observed in the ED. Three were younger than 28 days (aged 10, 12, and 20 days) and had herpes simplex virus in the CSF; the other was aged 33 days and had herpes simplex virus detected in a nasopharyngeal swab only. They documented 4 factors associated with low risk of IBI: age 21 to 60 days, history of fever only (or a fever documented in the ED . Procalcitonin results were not available to the treating clinicians. et al; Pediatric Emergency Medicine Clinical Research Network (PEM CRC) Herpes Simplex Virus (HSV) Study Group. Fever is one of the most common chief complaints in the emergency department (ED), comprising 10-20% of all pediatric ED visits [1-3].Among infants 60 days old, the prevalence of serious bacterial infections (SBI), including bacterial meningitis, bacteremia and urinary tract infection (UTI), in the setting of fever ranges from 8 to 13% [4-9]. Clinical characteristics and outcomes in febrile infants aged 29-90 days with urinary tract infections and cerebrospinal fluid pleocytosis. Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. Learn more about PECARN. Drafting of the manuscript: Kuppermann, Dayan, Mahajan. Study methods have been previously described39 but are briefly summarized here. The PECARN rule for low-risk febrile infants predicts the risk for urinary tract infection, bacteremia, or bacterial meningitis in febrile infants aged 60 days. SM, SL, Diabetic ketoacidosis in children: Cerebral injury . So, how did Velasco's group calculate the sensitivities and specificities of the PECARN rule for different groups in their dataset? All patients had blood and urine cultures obtained. Klinger However, lumbar punctures and hospitalizations involve risks and costs. Increased clinician suspicion was also associated with increased SBI risk. identify febrile young infants at low risk for IBI: Pediatric Emergency Care Applied Research Network ( PECARN) rule - In the derivation and validation of the PECARN clinical prediction rule in 1820 well-appearing . The site is secure. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. A, Williams L, Mahajan Notably infants were NOT excluded if they had otitis media. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations. JC, Wald 2. Use of procalcitonin assays to predict serious bacterial infection in young febrile infants. Article 4: Kupperman N, Dayan PS, Levine DA, et al: Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN) A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. CSF culture was included to identify meningitis. The 2 patients with UTIs who were misclassified had negative urinalysis results possibly indicating asymptomatic bacteriuria.67. JA, McCarthy Can clinical features and laboratory tests identify febrile infants 60 days and younger at low risk for serious bacterial infections? et al. SH, Please enable it to take advantage of the complete set of features! Once further validated, implementation of the rule has the potential to substantially decrease the use of lumbar punctures, broad-spectrum antibiotics, and hospitalization for many febrile infants 60 days and younger.1. Huppler The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). EJ, Fleisher L. Clinical prediction rules. S, AT, Mahajan An official website of the United States government. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations. 2019 Jul 1;16(7):CD1-CD3. government site. P, Dayan C, Joffe Multivariable Logistic Regression Analysis. et al. S, Gomez Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. E, Evans JAMA Pediatr., 2019 Background The evaluation and management of febrile neonates remains controversial. B, The rule is intended to . 2 Aronson Febrile Infant Decision Tool (when procalcitonin is not available) 1. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/L or less (to convert to 109 per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. Main Outcomes and Measures Pediatr Emerg Care. Aronson PL, Shabanova V, Shapiro ED, Wang ME, Nigrovic LE, Pruitt CM, DePorre AG, Leazer RC, Desai S, Sartori LF, Marble RD, Rooholamini SN, McCulloh RJ, Woll C, Balamuth F, Alpern ER, Shah SS, Williams DJ, Browning WL, Shah N, Neuman MI; Febrile Young Infant Research Collaborative. Aronson Viral testing was not included as these were not typically available for decision making in the ED at the time of this study. This was primarily composed of UTI (8.3%), with only 0.5% having meningitis and 1.4% with bacteremia. Enhanced urinalysis improves identification of febrile infants ages 60 days and younger at low risk for serious bacterial illness. R. Procalcitonin in young febrile infants for the detection of serious bacterial infections. AR, Eickhoff Objective KL, Bachur Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. TB, Bernzweig In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). et al. This number represents potential lumbar punctures spared in this age group for low-risk patients. A, Caete Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection. B, Tobey et al. et al; Pediatric Emergency Care Applied Research Network (PECARN). Group Information: The authors listed in the byline reflect the full membership of the Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). HM. Comparison of the test characteristics of procalcitonin to C-reactive protein and leukocytosis for the detection of serious bacterial infections in children presenting with fever without source: a systematic review and meta-analysis. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Biondi S, Da Dalt C, Emergency physicians (faculty or fellows in general or pediatric emergency medicine) performed patient histories and physical examinations, provided assessment of the Yale Observation Scale (YOS) score,41 and recorded unstructured clinical suspicion of SBI (using 5 risk categories: <1%, 1%-5%, 6%-10%, 11%-50%, or >50%) prior to knowledge of laboratory results. We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. et al; Pediatric Emergency Care Applied Research Network (PECARN). Patients enrolled in the parent study before procalcitonin levels were obtained, and patients from whom procalcitonin levels were not obtained for other reasons were similar to those with procalcitonin measurements (eTable 1 in the Supplement). The low risk prediction rule was based on three objective laboratory findings: Normal urinalysis Absolute neutrophil count 4,090/L PS, V, Vanegas The mean age was 36 days old and 42% were female. Impact of enteroviral polymerase chain reaction testing on length of stay for infants 60 days old or younger. Clinical Prediction Rule to Identify Febrile Young Infants at Low Risk for Serious Bacterial Infections, Efficacy of a Clinical Prediction Rule to Identify Febrile Young Infants at Low Risk for Serious Bacterial Infections, BrettBurstein,MDCM, PhD, MPH; JessePapenburg,MDCM, MSc, Clinical Prediction Rule to Identify Febrile Young Infants at Low Risk for Serious Bacterial InfectionsReply, NathanKuppermann,MD, MPH; PrashantMahajan,MD, MPH, MBA; OctavioRamilo,MD, To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. One patient classified as low risk had Enterobacter cloacae bacteremia. 2001 Aug;108(2):311-6. doi: 10.1542/peds.108.2.311. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. CC, Korgenski Lowering the procalcitonin level reduced the specificity to 53%. The authors (in the article and in direct discussion with Dr. Kuppermann) do advise caution in using this rule in infants 28 days of age due to the risk of herpes encephalitis.

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