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Rochester Criteria and Yale Observation Scale Score to Evaluate Febrile Neonates with Invasive Bacterial Infection

  • Neh D. Molyneaux
    Correspondence
    Reprint Address: Neh Molyneaux, MD, MPH, Department of Emergency Medicine, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203.
    Affiliations
    State University of New York Downstate Medical Center, Brooklyn, New York

    Kings County Hospital New York Health and Hospitals, Brooklyn, New York
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  • Tian Z. Liang
    Affiliations
    State University of New York Downstate Medical Center, Brooklyn, New York

    Kings County Hospital New York Health and Hospitals, Brooklyn, New York
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  • Jennifer H. Chao
    Affiliations
    State University of New York Downstate Medical Center, Brooklyn, New York

    Kings County Hospital New York Health and Hospitals, Brooklyn, New York
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  • Richard H. Sinert
    Affiliations
    State University of New York Downstate Medical Center, Brooklyn, New York

    Kings County Hospital New York Health and Hospitals, Brooklyn, New York
    Search for articles by this author

      Abstract

      Background

      Febrile neonates undergo lumbar puncture (LP), empiric antibiotic administration, and admission for increased risk of invasive bacterial infection (IBI), defined as bacteremia and meningitis.

      Objective

      Measure IBI prevalence in febrile neonates, and operating characteristics of Rochester Criteria (RC), Yale Observation Scale (YOS) score, and demographics as a low-risk screening tool.

      Methods

      Secondary analysis of healthy febrile infants < 60 days old presenting to any of 26 emergency departments in the Pediatric Emergency Care Applied Research Network between December 2008 and May 2013. Of 7334 infants, 1524 met our inclusion criteria of age ≤ 28 days. All had fevers and underwent evaluation for IBI. Receiver operator characteristic (ROC) curve and transparent decision tree analysis were used to determine the applicability of reassuring RC, YOS, and age parameters as an IBI low-risk screening tool.

      Results

      Of 1524 neonates, 2.9% had bacteremia and 1.5% had meningitis. After applying RC and YOS, 15 neonates were incorrectly identified as low risk for IBI (10 bacteremia, 4 meningitis, 1 bacteremia, and meningitis). Age ≤ 18 days was a statistically significant variable ROC (area under curve 0.63, p < 0.05). Incorporating age > 18 days as low-risk criteria with reassuring RC and YOS misclassified 7 IBI patients (6 bacteremia, 1 meningitis).

      Conclusion

      Thirty percent of febrile neonates met low-risk criteria, age > 18 days, reassuring RC and YOS, and could avoid LP and empiric antibiotics. Our low-risk guidelines may improve patient safety and reduce health care costs by decreasing lab testing for cerebrospinal fluid, empiric antibiotic administration, and prolonged hospitalization. These results are hypothesis-generating and should be verified with a randomized prospective study.

      Keywords

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      References

        • Aronson PL
        • Thurm C
        • Williams DJ
        • et al.
        Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age.
        J Hosp Med. 2015; 10: 358-365
        • Leazer R
        • Erickson N
        • Paulson J
        • et al.
        Epidemiology of cerebrospinal fluid cultures and time to detection in term infants.
        Pediatrics. 2017; 139e20163268
        • Byington CL
        • Enriquez FR
        • Hoff C
        • et al.
        Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections.
        Pediatrics. 2004; 113: 1662-1666
        • Harper MB.
        Update on the management of the febrile infant.
        Clin Pediatr Emerg Med. 2004; 5: 5-12
        • Gómez B
        • Mintegi S
        • Benito J
        • et al.
        Blood culture and bacteremia predictors in infants less than three months of age with fever without source.
        Pediatr Infect Dis J. 2010; 29: 43-47
        • Gomez B
        • Mintegi S
        • Bressan S
        • et al.
        Validation of the “Step-by-Step” approach in the management of young febrile infants.
        Pediatrics. 2016; 138e20154381
        • Mintegi S
        • Bressan S
        • Gomez B
        • et al.
        Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection.
        Emerg Med J. 2014; 31: e19-e24
        • Schwartz S
        • Raveh D
        • Toker O
        • et al.
        A week-by-week analysis of the low-risk criteria for serious bacterial infection in febrile neonates.
        Arch Dis Child. 2009; 94: 287-292
        • Jain S
        • Cheng J
        • Alpern ER
        • et al.
        Management of febrile neonates in US pediatric emergency departments.
        Pediatrics. 2014; 133: 187-195
        • Kuppermann N
        • Dayan PS
        • Levine DA
        • et al.
        A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections.
        JAMA Pediatr. 2019; 173: 342-351
        • Goldman RD.
        Analgesia for lumbar puncture in infants and children.
        Can Fam Physician. 2019; 65: 192-194
        • Huppler AR
        • Eickhoff JC
        • Wald ER.
        Performance of low-risk criteria in the evaluation of young infants with fever: review of the literature.
        Pediatrics. 2010; 125: 228-233
        • Pantell RH
        • Newman TB
        • Bernzweig J
        • et al.
        Management and outcomes of care of fever in early infancy.
        JAMA. 2004; 291: 1203-1212
        • Aronson PL
        • Thurm C
        • Alpern ER
        • et al.
        Variation in care of the febrile young infant <90 days in US pediatric emergency departments.
        Pediatrics. 2014; 134: 667-677
        • Jaskiewics JA
        • McCarthy CA
        • Richardson AC
        • et al.
        Febrile infants at low risk for serious bacterial infection—an appraisal of the Rochester criteria and implications for management.
        Pediatrics. 1994; 94: 390-396
        • Bachur RG
        • Harper MB.
        Predictive model for serious bacterial infections among infants younger than 3 months of age.
        Pediatrics. 2001; 108: 311-316
        • Lyons TW
        • Garro AC
        • Cruz AT
        • et al.
        Performance of the modified Boston and Philadelphia criteria for invasive bacterial infections.
        Pediatrics. 2020; 145e20193538
        • Aronson PL
        • Wang ME
        • Shapiro ED
        • et al.
        Risk stratification of febrile infants ≤60 days old without routine lumbar puncture.
        Pediatrics. 2018; 142e20181879
        • Aronson PL
        • McCulloh RJ
        • Tieder JS
        • et al.
        Application of the Rochester criteria to identify febrile infants with bacteremia and meningitis.
        Pediatr Emerg Care. 2019; 35: 22-27
        • Nigrovic LE
        • Mahajan PV
        • Blumberg SM
        • et al.
        The Yale Observation Scale score and the risk of serious bacterial infections in febrile infants.
        Pediatrics. 2017; 140e20170695
        • Biondi EA
        • McCulloh R
        • Staggs VS
        • et al.
        Reducing variability in the infant sepsis evaluation (REVISE): a national quality initiative.
        Pediatrics. 2019; 144e20182201
        • McCarthy PL
        • Sharpe MR
        • Spiesel SZ
        • et al.
        Observation scales to identify serious illness in febrile children.
        Pediatrics. 1982; 70: 802-809
        • Baker MD
        • Bell LM
        • Avner JR.
        Outpatient management without antibiotics of fever in selected infants.
        N Engl J Med. 1993; 329: 1437-1441
        • Baker MD
        • Bell LM.
        Unpredictability of serious bacterial illness in febrile infants from birth to 1 month of age.
        Arch Pediatr Adolesc Med. 1999; 153: 508-511
        • Kadish H
        • Loveridge B
        • Tobey J
        • et al.
        Applying outpatient protocols in febrile infants 1–28 days of age: can the threshold be lowered?.
        Clin Pediatr (Phila). 2000; 39: 81-88
        • Garcia S
        • Mintegi S
        • Gomez B
        • et al.
        Is 15 days an appropriate cut-off age for considering serious bacterial infection in the management of febrile infants?.
        Pediatr Infect Dis J. 2012; 31: 455-458
        • Powell EC
        • Mahajan PV
        • Roosevelt G
        • et al.
        Epidemiology of bacteremia in febrile infants aged 60 days and younger.
        Ann Emerg Med. 2017; 71: 211-216
        • Biondi E
        • Evans R
        • Mischler M
        • et al.
        Epidemiology of bacteremia in febrile infants in the United States.
        Pediatrics. 2013; 132: 990-996
        • Woll C
        • Neuman MI
        • Pruitt CM
        • et al.
        Epidemiology and etiology of invasive bacterial infection in infants ≤60 days old treated in emergency departments.
        J Pediatr. 2018; 200 (e1): 210-217
        • Pantell RH
        • Roberts KB
        • Adams WG
        • et al.
        Evaluation and management of well-appearing febrile infants 8 to 60 days old.
        Pediatrics. 2021; 148e2021052228
        • Yarden-Bilavsky H
        • Ashkenazi S
        • Amir J
        • et al.
        Fever survey highlights significant variations in how infants aged 60 days are evaluated and underline the need for guidelines.
        Acta Paediatr. 2014; 103: 379-385
        • Biondi EA
        • Byington CL.
        Evaluation and management of febrile, well-appearing young infants.
        Infect Dis Clin North Am. 2015; 29: 575-585