Introduction: Most children with fever without source will have a self limited viral infection though a small percent will develop a serious bacterial infection (SBI) like urinary tract infection, pneumonia, bacteraemia, meningitis or sepsis. The challenge facing practitioners is to distinguish between these two groups and currently biomarkers, like C-reactive protein (CRP) and Procalcitonin (PCT), are available for this purpose. The aim of the current study was to identify SBI in infants with fever without an identifiable cause using the recently introduced “Lab-score” combining C-reactive protein, procalcitonin and urine dipstick results.
Methods: This survey is part of an observational study aimed at identifying children with fever without source at risk of SBI. Patients were recruited from the Emergency Department of Tirgu Mures Emergency Clinical County Hospital, Romania, during 2013. SBI diagnosis was based on urine, blood and cerebrospinal fluid cultures and chest radiographs. For infants, aged 7 days to 12 months, CRP and PCT were determined and the “Lab-score” was calculated. Positive and negative likelihood ratios and post test probabilities were calculated for each parameter and score.
Results: Of the ninety infants included in the study, SBI was diagnosed in nineteen (21.11%). Ten had a urinary tract infection, seven had pneumonia, one had a urinary tract infection and bacteraemia, and one had sepsis. Positive and negative likelihood ratios for CRP (.40.0 mg/L) and PCT (.0.5 ng/mL) were 10.27/0.45 and 7.07/0.24 and post-test probabilities 73%/65%. For a “Lab-score1” (.3), positive and negative likelihood ratios were 10.43/0.28, and the posttest probability was 73%.
Conclusions: In our survey the “Lab-score” proved a strong predictor for the identification of febrile infants at risk of SBI, but showed no significant difference compared with CRP and PCT which both proved equally good predictors for SBI.
If the inline PDF is not rendering correctly, you can download the PDF file here.
1. Baraff LJ. Management of infants and young children with fever without source. Pediatr Ann. 2008;37:673-9.
2. Galetto Lacour A Zamora SA Gervaix A. Bedside procalcitonin and C-reactive protein tests in children with fever without localizing signs of infection seen in a referralcenter. Paediatrics. 2003;112:1054-60.
3. Craig JC Williams GJ Jones M et al. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses. BMJ. 2010;340:c1594. doi: 10.1136/ bmj.c1594.
4. Van den Bruel A Haj-Hassan T Thompson M Buntinx F Mant D. Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review. Lancet. 2010;375:834-45.
5. Van den Bruel A Thompson MJ Haj-Hassan T et al. Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ. 2011;342:d3082.
6. Yo CH Hsieh PS Lee SH et al. 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. Ann Emerg Med. 2012;60:591-600.
7. De S Williams GJ Hayen A et al. Value of white cell count in predicting serious bacterial infection in febrile children under 5 years of age. Arch Dis Child. 2014;99:493-9.
8. Galetto Lacour A Gervaix A Zamora SA et al. Procalcitonin IL-6 IL-8 IL-1 receptor antagonist and C-reactive protein as identificators of serious bacterial infections in children with fever without localising signs. Eur J Pediatr. 2001;160:95-100.
9. Andreola B Bressan S Callegaro S Liverani A Plebani M Da Dalt L. Procalcitonin and C-reactive protein as diagnostic markers of severe bacterial infections in febrile infants and children in the emergency department. Pediatr Infect Dis J. 2007;26:672-7.
10. Pratt A Attia MW. Duration of fever and markers of serious bacterial infections in young febrile children. Pediatr Int. 2007;49:31-5.
11. Maniaci V Dauber A Weiss S Nylen E Becker KL Bachur R. Procalcitonin in young febrile infants for the detectin of serious bacterial infections. Pediatrics. 2008;122:701-10.
12. Olaciregui I Hernandez U Munoz JA Emparanza JI Landa JJ. Markers that predict serious bacterial infection in infants under 3 months of age presenting with fever of unknown origin. Arch Dis Child. 2009;94:501-5.
13. Manzano S Bailey B Gervaix A Cousineau J Delvin E Girodias JB. Markers for bacterial infection in children with fever without source. Arch Dis Child. 2011;96:440-6.
14. Mahajan P Grzybrowski M Chen X et al. Procalcitonin as a marker of serious bacterial infections in febrile children younger than 3 years old. Acad Emerg Med. 2014;21:171-9.
15. Nijman RG Vergouwe Y Thompson M et al. Clinical prediction model to aid emergency doctors managing febrile children at risk of serious bacterial infections: diagnostic study. BMJ. 2013:346:f1706.
16. Galetto-Lacour A Zamora SA Gervaix A. A score identifying serious bacterial infections in children with fever without source. Pediatr Infect Dis. 2008;27:654-6.
17. Galetto-Lacour A Zamora SA Andreola B et al. Validation of a laboratory index score for the identification of severe bacterial infection in children with fever without source. Arch Dis Child. 2010;95:968-73.
18. Bressan S Gomez B Mintegi S et al. Diagnostic performance of the “Lab-score” in predicting severe and invasive bacterial infections in well-appearing young febrile infants. Pediatr Infect Dis J. 2012;31:1239-44.
19. Nijman RG Moll HA Smit FJ et al. C-reactive Protein Procalcitonin and the“Lab-score” for Detecting Serious Bacterial Infections in Febrile Children at the Emergency Department: A Prospective Observational Study. Pediatr Infect Dis J. 2014;33:273-9.
20. Herz AM Greenhow TL Alcantara J et al. Changing epidemiology of outpatient bacteraemia in 3 - to 36 -months -old children after the introduction of the heptavalent-conjugated pneumococcal vaccine. Pediatr Infect Dis J. 2006;25:293-300.
21. NICE Clinical Guideline 47. Feverish illness in children: assessment and initial management in children younger than 5 years. National Collaborating Center for Women's and Child Health; 2007.
22. Levy MM Fink MP Marshall JC et al. 2001 SCCM/ESICM/ACCP/ ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250-6.
23. Thayyil S Shenoy M Hamaluba M Gupta A Frater J Verber IG. Is procalcitonin useful in early diagnosis of serious bacterial infections in children? Acta Pediatrica. 2005;94:155-8.
24. Shaw KN Gorelick M McGowan KL Yakscoe NM Schwartz JS. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics. 1998;102:e16.
25. Mintegi S Benito J Pijoan JI et al. Occult pneumonia in infants with high fever without source: a prospective multicenter study. Pediatr Emerg Care 2010;26:470-4.
26. Dandona P Nix D Wilson MF et al. Procalcitonin increase after endotoxin injection in normal subjects. J Clin Endocrinol Metab. 1994;79:1605-8.
27. Gendrel D Bohuon C. Procalcitonin as a marker of bacterial infection. Pediatr Infect Dis J. 2000;19:679-8.
28. Gras-Le Guen C Delmas C Launay E et al. Contribution of procalcitonin to occult bacteraemia detection in children. Scand J Infect Dis. 2007;39:1063-6.
29. Bressan S Andreola B Cattelan F et al. Predicting severe bacterial infections in well-appearing febrile neonates: laboratory markers accuracy and duration of fever. Pediatr Infect Dis J. 2008;27:227-32.