Validating and updating a prediction rule for serious bacterial infection in patients with fever without source

AIM: To externally validate and update a previously developed rule for predicting the presence of serious bacterial infections in children with fever without apparent source. METHODS: Patients, 1-36 mo, presenting with fever without source, were prospectively enrolled. Serious bacterial infection included bacterial meningitis, sepsis, bacteraemia, pneumonia, urinary tract infection, bacterial gastroenteritis, osteomyelitis/ethmoiditis. The generalizability of the original rule was determined. Subsequently, the prediction rule was updated using all available data of the patients with fever without source (1996-1998 and 2000-2001, n = 381) using multivariable logistic regression. RESULTS: the generalizability of the rule appeared insufficient in the new patients (n = 150). In the updated rule, independent predictors from history and examination were duration of fever, vomiting, ill clinical appearance, chest-wall retractions and poor peripheral circulation (ROC area (95%CI): 0.69 (0.63-0.75)). Additional independent predictors from laboratory were serum white blood cell count and C-reactive protein, and in urinalysis > or = 70 white bloods (ROC area (95%CI): 0.83 (0.78-0.88). CONCLUSIONS: A previously developed prediction rule for predicting the presence of serious bacterial infection in children with fever without apparent source was updated. Its clinical score can be used as a first screening tool. Additional laboratory testing may specify the individual risk estimate (range: 4-54%) further.     

Prediction of bacterial meningitis in children with meningeal signs: reduction of lumbar punctures

Physicians often have to perform a lumbar puncture to ascertain the diagnosis in patients with meningeal signs, because of the serious consequences of missing bacterial meningitis The aim of this study was to derive and validate a clinical rule to predict bacterial meningitis in children with meningeal signs, to guide decisions on the performance of lumbar punctures. Information was collected from records of patients (aged 1 mo to 15 y) consulting the emergency department of the Sophia Children's Hospital between 1988 and 1998 with meningeal signs. Bacterial meningitis was defined as cerebrospinal fluid (CSF) leucocyte count >5 cells μl^?1 with a positive bacterial culture of CSF or blood. The diagnostic value of predictors was judged using multivariate logistic modelling and area under the receiver operating characteristic curves (ROC area). In the derivation set (286 patients, years 1988–1995) the duration of the main complaint, vomiting, meningeal irritation, cyanosis, petechiae and disturbed consciousness were independent clinical predictors of bacterial meningitis. The ROC area of this model was 0.92. The only independent predictor from subsequent laboratory tests was the serum C‐reactive protein concentration, increasing the ROC area to 0.95. Without missing a single case, this final model identified 99 patients (35%) without bacterial meningitis. Validation on 74 consecutive patients in 3 subsequent years (1996–1998) yielded similar results. Conclusion: This prediction rule identifies about 35% of the patients with meningeal signs in whom a lumbar puncture can be withheld without missing a single case of bacterial meningitis. For the individual patient this prediction rule is valuable in deciding whether or not to perform a lumbar puncture.     

Risk of serious bacterial infection in children with fever without a source in the post-Haemophilus influenzae era when antibiotics are reserved for culture-proven bacteremia

OBJECTIVE: To determine the rate of serious bacterial infection in children aged 2 to 36 months with fever without a source in the post-Haemophilus influenzae era, when antibiotic therapy is reserved until blood culture results turn positive. DESIGN AND SETTING: Retrospective review of emergency department, urgent care center, and hospital medical records from an urban children's hospital. PARTICIPANTS: Eligible participants were identified from hospital medical record and microbiology laboratory databases. Immunocompetent individuals aged 2 to 36 months with fever without a source were eligible for enrollment. Exclusion criteria were temperature less than 39.0 degrees C, identifiable focus of infection, current or recent antibiotic use, and hospital admission. INTERVENTIONS AND OUTCOME MEASURES: Enrolled participants were assigned to group 1 (blood culture obtained) or group 2 (no blood culture) and did not receive empiric antibiotic treatment in the emergency department, in the urgent care center, or for home use. Demographic and outcome data were collected on all enrolled patients. RESULTS: During the study, 9241 febrile children were identified; 2641 (29%) met the enrollment criteria. Blood cultures (group 1) were performed on 1202 patients (46%), and 37 (3%) had culture-proven occult bacteremia (95% confidence interval, 2.2%-4.2%). Streptococcus pneumoniae was the most prevalent organism (84%). The mean +/- SD time for reporting a positive blood culture finding was 17.5 +/- 8.5 hours. Two patients (0.08%; 95% confidence interval, 0.009%-0.27%) developed serious bacterial infection, and both recovered completely. CONCLUSION: Reserving antibiotic therapy for culture-proven occult bacteremia was not associated with increased risk of developing serious bacterial infection compared with previously published data.     

Incidence of serious infections in afebrile neonates with a history of fever

A retrospective analysis was performed of 109 previously well infants younger than 4 weeks of age with a history of fever who were evaluated for sepsis in an emergency department. The objective was to assess whether infants who were afebrile at the time of evaluation were at similar risk for serious bacterial infection compared with infants with documented fever at the time of evaluation. Of 109 infants evaluated 54 were afebrile and 55 had fever (rectal temperature, greater than 38 degrees C). Serious bacterial infection occurred in 8 (14.5%) infants with documented fever and in none of those who were afebrile at the time of presentation (P = 0.003). An initial complete blood count profile of the two groups showed that nearly all (96%) in the afebrile group had a complete blood count differential ratio [% of lymphocytes + % of monocytes)/(% of polymorphonuclear leukocytes + % band forms] of greater than 1, whereas the majority (87.5%) of febrile infants with serious infection had a differential ratio of less than 1. The neonate with a history of fever who is afebrile upon presentation should receive a complete evaluation for possible bacterial infection. The neonate who appears well, has no focal source of infection on examination and whose laboratory data do not reveal any abnormality represents a low risk for serious bacterial infection.     

Bacteremia and bacterial infections in highly febrile children without apparent focus.

To find the incidence of bacteremia and serious bacterial infections in febrile children without an apparent focus of infection, we prospectively studied 100 febrile children aged 1 month-3 years with a rectal temperature > or = 39 degrees C. Ten children had a blood culture positive bacteremia and nine had serology positive for bacteremia; 6 had urinary tract infection, 5 otitis media and 8 meningitis. A diagnosis of non bacterial illness was made in 62 patients. Staphylococcus aureus was the most common bacteriologic isolate on blood culture (five) and by serology (eight). TLC > or = 15,000/cu mm m-ESR > or = 25 mm and temperature > or = 39 degrees C had high specificity (95-100%) but low sensitivity for diagnosis of bacteremia.     

Children after renal transplantation hospitalized for fever: Is empirical antibiotic treatment always justified?

Infections are a major cause of morbidity and mortality after renal transplantation. However, data focusing on children are scarce. The objective of this study was to investigate the frequency and predictors of bacterial infection in pediatric renal transplant recipients in a specific setting of hospitalization due to fever. Clinical and laboratory data were retrospectively collected for all pediatric renal transplant recipients hospitalized for fever in a national renal transplantation center from 2004 to 2012. One hundred and sixty‐eight hospital admissions for fever of 52 children were analyzed. A bacterial etiology was diagnosed in 85 admissions (50.6%); 49 cases (57.6%) were documented microbiologically and 36 (42.4%) clinically. Risk factors and markers of bacterial infection included older age, presence of a central venous catheter, sonographic findings, and elevated inflammatory indices. C‐reactive protein level was a more sensitive marker than white blood cell count and absolute neutrophil count. In patients without identified risk factors, no bacterial infections were diagnosed. Pediatric renal transplant recipients hospitalized for fever are at high risk of bacterial infections and usually require empirical antibiotic treatment at admission. However, there is a minority of low‐risk patients in whom clinicians may consider withholding antibiotic treatment with close follow‐up.     

Prediction of vesico-ureteric reflux in childhood urinary tract infection: a multivariate approach

In this study, independent predictors obtained from patient history, physical examination and laboratory results for vesico-ureteric reflux (VUR) in children of 0-5 y with a first urinary tract infection (UTI) were assessed and the added value of renal ultrasound (US) investigated. Information was collected from children visiting the paediatric outpatient department with a first proven UTI, defined as a urine monoculture with ≥105 organism/ml, with clinical symptoms and possible white cell count ≥20 per high-power field of spun fresh urine. Children with neurologic bladder dysfunction were excluded. VUR was determined by voiding cystourethrography (VCUG) and graded from I to V. The diagnostic value of predictors was judged using multivariate logistic modelling with the area under the receiver operating characteristic (ROC area). A risk score was derived based on the regression coefficients of the independent predictors in the logistic model. In 140 children (51 boys and 89 girls) VUR was diagnosed in 37. Independent predictors for VUR were male gender, age, family history for uropathology, serum C-reactive protein level (CRP) and dilatation of the urinary tract on US. The ROC area of this model was 0.78 (95% CI: 0.69-0.87). This prediction model identified 12% (95% CI: 7-18) of the patients without VUR without missing one case of VUR. If we used VUR ≥ grade 3 as a threshold, the model assessed VUR to be absent in 34% (95% CI: 26-42). Conclusion: A prediction rule based on age, gender, family history, CRP and US results is useful in assessing the probability of VUR in the individual child with a first UTI and may help the physician to make decisions about performing additional imaging techniques. Prospective validation of the model in future patients, however, will be necessary before applying the rule in practice.     

Early prediction of neurological sequelae or death after bacterial meningitis

This study determined independent predictors of the occurrence of permanent neurological sequelae or death after childhood bacterial meningitis. Data were used from a large study on children (aged 1 mo to 15 y) initially presenting with meningeal irritation. A nested case-control study was performed on children with (n = 23) and without (n = 70) permanent neurological sequelae (hearing impairment, locomotor dysfunction, mental retardation or epilepsy) or death after bacterial meningitis. Predictors obtained from clinical evaluation and laboratory tests at presentation and during the clinical course were identified by multivariate logistic regression and receiver operating characteristic (ROC) curve analyses. The study population comprised 23 cases and 70 controls (52% boys, median age 2.8 y). Independent predictors for an adverse outcome after bacterial meningitis were male gender, atypical convulsions in history, low body temperature at admission and the pathogen Streptococcus pneumoniae. The area under the ROC curve of this prediction rule was 0.87 (95% confidence interval: 0.78-0.96), which was not improved by adding other characteristics. A score including these independent predictors could classify patients into categories with increasing risk for an adverse outcome. Conclusion: Clinical characteristics available early in the clinical course, such as gender, atypical convulsions in history, low body temperature at admission and the pathogen, are predictive for the occurrence of permanent neurological sequelae or death after bacterial meningitis in childhood. The pathogen type, in particular, is the main prognostic determinant of childhood bacterial meningitis.     

Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis

During a 2-year period, 233 infants younger than 3 months were prospectively studied to determine whether physical examination, white blood cell and band count, and urinalysis could identify infants unlikely to have serious bacterial infections. Only previously healthy infants (born at term, no perinatal complications, no previous or underlying diseases, no previous antibiotic therapy) were studied. One hundred forty-four (62%) of the 233 infants were considered unlikely to have serious bacterial infections, because they did not have physical findings consistent with ear, soft tissue, or skeletal infection, had between 5000 and 15,000 white blood cells/mm3, had less than 1500 bands/mm3, and urinalysis yielded normal findings. Eighty-nine (38%) infants did not meet one or more of these criteria and were classified as being at high risk for serious bacterial infection. Only one (0.7%) of the 144 infants in the low-risk group had a serious infection, compared with 22 (25%) of the 89 infants in the high risk group (P less than 0.0001). None of the infants in the low-risk group had bacteremia, compared with nine (10%) of the 89 infants in the high-risk group (P less than 0.0005). Neither traditional risk factors, such as age, sex, and temperature, nor other signs, symptoms, or laboratory findings were adequate predictors of serious bacterial infection. We conclude that previously healthy infants younger than 3 months with an acute illness are unlikely to have serious bacterial infection if they have no findings consistent with ear, soft tissue, or skeletal infections and have normal white blood cell and band form counts and normal urine findings.     

Duration of fever and markers of serious bacterial infection inyoung febrile children

BACKGROUND: Despite the drastic change in the evaluation of the febrile young child due to the decreased incidence of serious bacterial infections (SBI) effected by Haemophilus influenza type B and pneumococcal vaccine, there remains a small role for blood work in the evaluation of these patients. Bacterial markers including white blood cell (WBC) count, absolute neutrophil count (ANC) and C-reactive protein (CRP) have been studied and are widely used as predictors of SBI in febrile children. It has been suggested that CRP values should be interpreted cautiously when fever has been present <12 h based on the kinetics of this biological marker. This limitation has not been previously addressed with CRP, nor was it described with other markers, specifically WBC and ANC, therefore the purpose of the present paper was to assess WBC, ANC and CRP values as predictors of SBI in relation to duration of fever. METHODS: Patients who presented to a pediatric emergency department between the ages of 1 and 36 months, with fever > or =39 degrees C and no source of infection had a complete blood count (CBC) blood culture, and CRP level drawn. A urinalysis and/or urine culture was obtained when age and gender appropriate. A chest X-ray was performed at the discretion of the treating physician. The study subjects were enrolled prospectively and then divided into two groups based on duration of fever of < or = or >12 h, and compared. RESULTS: One hundred and twenty-eight patients were originally enrolled. Nine patients were excluded. Seventeen patients (14%) had SBI. One patient (<1%) had bacteremia, three (3%) had pneumonia, and 13 (10%) had urinary tract infections. Forty-five patients presented with fever < or =12 h and 74 patients presented with fever >12 h. Area under the curve (AUC) for WBC, ANC and CRP was significantly larger in patients with SBI presenting with fever >12 h (0.85, 0.83, 0.92 respectively) compared to patients with SBI who presented with fever for <12 h (0.37, 0.42, 0.68 respectively). CONCLUSIONS: Bacterial markers studied were more predictive of SBI if the duration of fever was >12 h as shown by the AUC. CRP performed better than WBC and ANC in both scenarios.     

The occult bacteremia controversy

A young child with a high fever and no source for infection is a common situation confronting pediatricians and pediatric emergency medicine physicians alike. Although most febrile children with no apparent source of infection are suffering from viral illnesses, a percentage will he harboring occult bacterial infection. Whereas most cases of occult bacteremia resolve spontaneously, a small number of cases progress to serious bacterial illness, This article reviews the approach to children 3 to 36 months of age with fever mid no apparent source and reflects on practice guidelines developed to guide clinicians managing this situation, The rationale for a variety of management approaches is reviewed and data from ongoing studies which might influence care in the future are presented.     

Clinical decision rule to identify febrile young girls at risk for urinary tract infection

OBJECTIVE: To develop a clinical prediction rule to identify febrile young girls needing urine culture for evaluation of urinary tract infection (UTI). DESIGN: Prospective cohort study. SETTING: Urban children's hospital emergency department. PATIENTS: All girls younger than 2 years (N = 1469) presenting to the emergency department with fever (temperature > or =38.3 degrees C) and without an unequivocal source of fever during a 12-month period. MAIN OUTCOME MEASURES: The outcome of interest was UTI, defined as a catheterized urine culture with pure growth of 10(4) colonies/mL or greater. Candidate predictors included demographic, historical, and physical examination variables. Clinical prediction rules were developed using multiple logistic regression after screening variables for univariate association and reliability. RESULTS: The presence of 2 or more of the following 5 variables-less than 12 months old, white race, temperature of 39.0 degrees C or higher, fever for 2 days or more, and absence of another source of fever on examination-predicted UTI with a sensitivity of 0.95 (95% confidence interval, 0.85-0.99) and a specificity of 0.31 (95% confidence interval, 0.28-0.34). In the study population, with an overall prevalence of UTI of 4.3%, the positive predictive value of a score of 2 or more was 6.4% and the negative predictive value of a score of less than 2 was 0.8%. CONCLUSION: Using this clinical decision rule, a strategy of obtaining urine cultures from girls younger than 2 years with a score of 2 or more would lead to identification of 95% of children with UTI and elimination of 30% of unnecessary urine cultures.     

Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone.

STUDY OBJECTIVE: To determine the outcome of outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. DESIGN: Prospective consecutive cohort study. SETTING: Urban emergency department. PATIENTS: Five hundred three infants 28 to 89 days of age with temperatures greater than or equal to 38 degrees C who did not appear ill, had no source of fever detected on physical examination, had a peripheral leukocyte count less than 20 x 10(9) cells/L, had a cerebrospinal fluid leukocyte count less than 10 x 10(6)/L, did not have measurable urinary leukocyte esterase, and had a caretaker available by telephone. Follow-up was obtained for all but one patient (99.8%). INTERVENTION: After blood, urine, and cerebrospinal fluid cultures had been obtained, the infants received 50 mg/kg intramuscularly administered ceftriaxone and were discharged home. The infants returned for evaluation and further intramuscular administration of ceftriaxone 24 hours later; telephone follow-up was conducted 2 and 7 days later. RESULTS: Twenty-seven patients (5.4%) had a serious bacterial infection identified during follow-up; 476 (94.6%) did not. Of the 27 infants with serious bacterial infections, 9 (1.8%) had bacteremia (8 of these had occult bacteremia and 1 had bacteremia with a urinary tract infection), 8 (1.6%) had urinary tract infections without bacteremia, and 10 (2.0%) had bacterial gastroenteritis without bacteremia. Clinical screening criteria did not enable discrimination between infants with and those without serious bacterial infections. All infants with serious bacterial infections received an appropriate course of antimicrobial therapy and were well at follow-up. One infant had osteomyelitis diagnosed 1 week after entry into the study, received an appropriate course of intravenous antimicrobial therapy, and recovered fully. CONCLUSIONS: After a full evaluation for sepsis, outpatient treatment of febrile infants with intramuscular administration of ceftriaxone pending culture results and adherence to a strict follow-up protocol is a successful alternative to hospital admission.     

Clinical signs and laboratory tests in the differential diagnosis of arthritis in children

To develop a scheme for primary diagnosis, we analyzed the clinical findings and laboratory test results in 278 children with arthritis by using univariate analysis and multivariate logistic regression analysis. An elevated C-reactive protein (CRP) value, a temperature above 38.5 degrees C, and a high white blood cell count were independent predictors for the diagnosis of septic joint infection in patients with acute monoarthritis. The presence of either of the first two signs had a sensitivity of 100% and a specificity of 87% for septic arthritis. Sixty-seven percent of all patients with arthritis were cured within two weeks from the onset of joint symptoms. In patients whose disease duration exceeded two weeks, a low CRP value, the absence of fever, and an elevated IgG value were independent predictors for the diagnosis of juvenile arthritis. Antinuclear antibodies had a specificity of 100% and a sensitivity of 25% for juvenile arthritis or other connective tissue diseases. We recommend that laboratory tests indicated for all children with joint symptoms include determinations of the erythrocyte sedimentation rate and the CRP value, both total and differential leukocyte counts, urinalysis, and a bacterial culture of a throat smear. When arthritis is prolonged or when enteroarthritis is suspected, tests for antinuclear antibodies and serum immunoglobulins, serologic tests for Yersinia and Salmonella, and stool bacterial cultures should be included.     

CD15s is a potential biomarker of serious bacterial infection in infants admitted to hospital

Early recognition of serious bacterial infection (SBI) in children is essential for better treatment outcome. Flow cytometry analysis of neutrophil surface molecules has been more frequently utilized as a tool for diagnosis of infection. The infants (n?=?105) under 6 months of age presenting to the pediatric emergency department with fever without apparent source who were hospitalized with suspicion of having SBI were enrolled in this prospective study. Sixty-nine infants were included into the training pool and were classified into bacterial or viral infection group. Validation pool consisted of 36 infants. The values of white blood cells counts, absolute neutrophil count (ANC), C-reactive protein (CRP), procalcitonin (PCT), neutrophil CD11b, CD15s and CD64 expression, and the percentage (%CD15s+) and absolute count (AC-CD15s+) of CD15s+ neutrophils were determined. In infants with SBI, %CD15s+ was 10.5 times more likely to be higher than the cut-off value. ANC, CRP, PCT, CD64, and AC-CD15s+ were also found as useful biomarkers for differentiation between bacterial and viral infection. The best fit multivariate logistic regression model included CRP, PCT, and %CD15s+ as strong predictors of SBI. The model's sensitivity (87 %) and specificity (83 %) indicated high model's accuracy. After validation on independent dataset, model's accuracy maintained high: 86 % sensitivity and 93 % specificity, confirming its reliability and supporting CRP, PCT, and %CD15s+ as real predictors. The findings of this study support assumption made in the literature on significance of CD15s in inflammation processes. Also, this study demonstrated for the first time that CD15s is potentially valuable biomarker of SBI in infants.     

李斯特菌败血症六例报告

目的 分析6例由血培养证实的新生儿李斯特菌病临床特征、治疗方法与转归,提高临床对本病的识别.方法 调查2004年1月1日至2006年6月30日我院分娩活产婴儿12 538例,其中6例检出李斯特菌.比较此6例中的早产儿与足月儿在发病时间、临床表现、病情严重程度、实验室指标变化、治疗措施、预后的差异.结果 李斯特菌病检出率为4.8%.6例均为早发型感染,由母亲孕期宫内感染所致.3例早产儿生后即有败血症多样临床表现,反应低下,肤色苍灰,呼吸窘迫,肝脏增大,皮疹,四肢肌张力低下;实验室指标明显异常,WBC(21.6～33.8×109)/L,N0.77～0.83;PLT(102～59×109)/L;CRP＞(160～118)mg/L.3例早产儿合并有肺部病变,需机械通气辅助呼吸,死亡1例,痊愈2例.3例足月儿发病时间较晚,分别在生后62、63、165h,仅表现为发热,精神反应欠活跃;实验室指标轻度异常,WBC(4.8～40.7×109)/L,N 0.72～0.80;PLT(202～192×109)/L;CRP(22～33)mg/L.治疗后痊愈.确诊必须依赖于细菌培养.氨苄青霉素或青霉素治疗有效.结论 我国存在成人李斯特菌病散发病例,并导致母婴传播的发生.早期发现和检测,针对性选择敏感抗生素治疗可有效降低死亡率.对孕妇进行食品安全性宣传教育,避免孕期感染,是防止新生儿李斯特菌病的重要措施.     

Clinical predictors of positive urine cultures in young children at risk for urinary tract infection

BACKGROUND:

Urinary tract infections (UTIs) are a common source of bacterial infection among young febrile children. The diagnosis of UTI is challenging because the clinical presentation is not specific.

OBJECTIVE:

To describe clinical predictors to identify young children needing urine culture for evaluation of UTI.

METHODS:

Retrospective cohort study of all children younger than two years of age (719 hospital visits for 545 patients) suspected of having a UTI during a 12-month period. The outcome was UTI, defined as a catheterized urine culture with pure growth of 10⁴ colonies/mL or greater, or suprapubic aspiration culture with 10³ colonies/mL or greater. Candidate predictors included demographic, historical and physical examination variables.

RESULTS:

The medical records of 545 children younger than two years of age were reviewed. Forty-six per cent were girls. Mean age was 9.1 months (SD 7 months). Four variables were found to predict UTI: absence of another source of fever on examination (odds ratio [OR]=41.6 [95% CI, 8.8 to 197.4]), foul smelling urine (OR=19.7 [95% CI, 5.7 to 68.2]), white blood cell count greater than 15,000/mm³ (OR=4.3 [95% CI, 2.0 to 9.3]), younger than six months old (OR=3.1 [95% CI, 1.3 to 7.1]). The sensitivity of an abnormal urine analysis was 0.77 (95% CI, 0.66 to 0.88) and the specificity was 0.31 (95% CI, 0.2 to 0.42).

CONCLUSION:

An incremental increase in risk for UTI is associated with younger age (younger than six months), having a white blood cell count higher than 15,000/mm³, parental report of malodorous or foul smelling urine and the absence of an alternative source of fever. In the present patient population, obtaining a urine culture from children with at least one of these clinical predictors would have resulted in missing one UTI (2%), and 111 negative cultures (20%) would have been avoided.     

Diagnostic markers of infection: comparison of procalcitonin with C reactive protein and leucocyte count.

BACKGROUND: Procalcitonin has been advocated as a marker of bacterial infection. OBJECTIVE: To evaluate diagnostic markers of infection in critically ill children, comparing procalcitonin with C reactive protein and leucocyte count in a paediatric intensive care unit (PICU). METHODS: Procalcitonin, C reactive protein, and leucocyte count were measured in 175 children, median age 16 months, on admission to the PICU. Patients were classified as: non-infected controls (43); viral infection (14); localised bacterial infection without shock (25); bacterial meningitis/encephalitis (10); or septic shock (77). Six children with "presumed septic shock" (without sufficient evidence of infection) were analysed separately. Optimum sensitivity, specificity, predictive values, and area under the receiver operating characteristic (ROC) curve were evaluated. RESULTS: Admission procalcitonin was significantly higher in children with septic shock (median 94.6; range 3.3-759.8 ng/ml), compared with localised bacterial infection (2.9; 0-24.3 ng/ml), viral infection (0.8; 0-4.4 ng/ml), and non-infected controls (0; 0-4.9 ng/ml). Children with bacterial meningitis had a median procalcitonin of 25.5 (7.2-118.4 ng/ml). Area under the ROC curve was 0.96 for procalcitonin, 0.83 for C reactive protein, and 0.51 for leucocyte count. Cut off concentrations for optimum prediction of septic shock were: procalcitonin > 20 ng/ml and C reactive protein > 50 mg/litre. A procalcitonin concentration > 2 ng/ml identified all patients with bacterial meningitis or septic shock. CONCLUSION: In critically ill children the admission procalcitonin concentration is a better diagnostic marker of infection than C reactive protein or leucocyte count. A procalcitonin concentration of 2 ng/ml might be useful in differentiating severe bacterial disease in infants and children.     

Fever response to acetaminophen in viral vs. bacterial infections

The effect of acetaminophen on fever in bacterial vs. viral infections was tested in 100 children ages 9 days to 17 years who presented to the Pediatric Service with a rectal or oral temperature of 102 degrees F (38.9 degrees C) or greater. All patients were given acetaminophen, 15 mg/kg, and their temperatures were rechecked at 1 hour. Laboratory tests were ordered at the discretion of the examining physician and usually included viral and bacterial cultures and total white blood cell counts. Sixteen patients had proved viral illnesses and 17 patients had serious bacterial infections. There was a significant difference (P less than 0.02) in the white blood cell count between the two groups, with the higher values in patients with bacterial infections. There was, however, no significant difference in the fever response to acetaminophen between the two groups (P = 0.37). The remaining 67 patients were then placed into one of the two groups based on their clinical illness and outcome. The mean temperature change was then calculated between the two groups, and again the difference was found to be statistically insignificant (P = not significant (t = 0.19]. We conclude that there is no correlation between a child's fever response to acetaminophen and the etiology of the fever.     

Relationship of fever magnitude to rate of serious bacterial infections in infants aged 4-8 weeks

We correlated the height of fever with underlying infectious etiology in 683 consecutive febrile infants aged four to eight weeks who received outpatient evaluation for sepsis during a five-year period. The relative number of infants with fever was inversely proportional to fever height, as 51% had a temperature 38.1-38.9 degrees C, 45% had a temperature 39-39.9 degrees C, and 4% had a temperature greater than or equal to 40 degrees C [hyperpyrexia]. There were 34 cases of serious bacterial infections [SBI], including 16 cases of urinary tract infection, 8 cases of bacteremia, 6 cases of bacterial meningitis, and 4 cases of Salmonella enteritis. The rate of SBI increased in direct proportion to fever height, being 3.2% in those with a temperature 38.1-38.9 degrees C, 5.2% in those with a temperature 39-39.9 degrees C, and 26% in those with a temperature greater than or equal to 40 degrees C. The 6.8% rate of SBI in those with fever greater than or equal to 39 degrees C was significantly greater than the 3.2% rate in those with fever less than 39 degrees C [p less than 0.035]; and the 26% rate of SBI in those with hyperpyrexia was significantly greater than the 4.1% rate in those with fever less than 40 degrees C [p less than 0.000004]. In identifying those with SBI, the presence of hyperpyrexia had a sensitivity of 21%, specificity of 97%, positive-predictive value of 25%, and negative-predictive value of 96%.(ABSTRACT TRUNCATED AT 250 WORDS)