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Northern ED registrar Teaching March 20 2013

Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study BMJ 2013;346:f866 doi : 10.1136/bmj.f866. Northern ED registrar Teaching March 20 2013. Significance. Common diagnostic challenge

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Northern ED registrar Teaching March 20 2013

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  1. Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children withfever: a retrospective cohort studyBMJ 2013;346:f866 doi: 10.1136/bmj.f866 Northern ED registrar Teaching March 20 2013

  2. Significance • Common diagnostic challenge • Majority self-limiting • infections remain the leading cause of death in children under the age of 5 years. • Previous attempts have been made to identify low risk patients and avoid invasive procedures with limited success • Not applicable

  3. Feverish illness in children - Assessment and initial management in children younger than 5 years Nice Clinical guidelines, CG47 - Issued: May 2007 This advice in this guideline covers the care and treatment of children aged under 5 years with fever in the NHS in England and Wales. http://www.nice.org.uk/nicemedia/live/11010/30524/30524.pdf

  4. - high-risk group for serious illness: unable to rouse or if roused does not stay awake weak, high-pitched or continuous cry pale/mottled/blue/ashen reduced skin turgor bile-stained vomiting moderate or severe chest indrawing respiratory rate greater than 60 breaths per minute grunting bulging fontanelle appearing ill to a healthcare professional

  5. - intermediate-risk group for serious illness: wakes only with prolonged stimulation decreased activity poor feeding in infants not responding normally to social cues/no smile dry mucous membranes reduced urine output a new lump larger than 2 cm pallor reported by parent or carer nasal flaring.

  6. low-risk group for serious illness: strong cry or not crying content/smiles stays awake normal colour of skin, lips and tongue normal skin and eyes moist mucous membranes normal response to social cues.

  7. The tool • Colour, activity, respiratory, hydration, and other features to give a low-, intermediate-, or high-risk assessment. • ‘Simple and Attractive’ • Further investigations determined by category • attempted validation by retrospectively applying it to a prospective registry of over 15,000 febrile children aged less than 5 years • primary outcome?

  8. Method • Used patients retrospectively enrolled in an earlier study (FEVER) 2004-2006 • Any nitrate or leucocyte esterase = UTI

  9. Results • 85.8% sensitivity and 28.5% specificity overall • 108 of the 157 missed cases of SBI were urinary tract infections • Adding urinalysis (UA) sensitivity 92.1%, specificity 22.3% – • PPV increased UTI = SBI? • AUC for SBI was 0.64 without the UA and 0.61 with the UA

  10. Discussion/Conclusion • Moderate sensitivity • Low specificity • Conclusion – addition of UA improved performance significantly ? • What do you want in a screening tool? • What other screening tools are there? • Doesn’t meet criteria for useful tool here

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