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186 CRITERIA FOR EVALUATING FEBRILE 29- TO 60-DAY-OLD INFANTS: A 3-YEAR RETROSPECTIVE REVIEW FROM BIRMINGHAM.
  1. T. M. Madiwale1,
  2. K. W. Monroe1,
  3. W. D. King1
  1. 1Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL.

Abstract

Purpose This retrospective study examines 29- to 60-day-olds who presented to an emergency department (ED) between 1/1/02 and 12/31/04 with a chief complaint of fever. A set of criteria can predict which patients will not have serious bacterial infections (SBI).

Methods Fever is defined as ≥ 100.4°F rectally. Exclusion criteria: previous vaccination (other than hepatitis B), surgeries (other than circumcision), antibiotics, immune deficiency syndromes, non-well appearance, and signs of bacterial infection. Inclusion criteria were well appearance with a complete blood count (CBC) with a white blood cell count (WBC) of 5,000 to 20,000 with a band/neutrophil ratio of < 0.2; urinalysis WBC < 10, negative leukocyte esterase and nitrate; cerebrospinal fluid (CSF) WBC < 10, protein < 120, glucose > 40, and negative Gram stain. A univariate analysis of each variable against predictability of positive cultures and SBIs was performed using EPISTAT. The chi-square of each variable was used to calculate a two-tailed p value.

Results Of 552 charts, there were 565 diagnoses; 434 had a fever by our definition. Of these 434, 111 met the inclusion criteria. Of these 111 patients, 110 did not have an SBI (one patient had a urinary tract infection). Of the 323 patients with fever who failed to meet the inclusion criteria, 187 had either a bacterial or serious viral infection. The prevalence of SBI in our study is 15% (83/552) from all causes and 10% (56/552) culture proven. The inclusion criteria have a positive predictive value of 99.1% (110/111), specificity of 98.6% (70/71), sensitivity of 31.2% (110/352), and negative predictive value of 22.4% (70/312) for predicting negative SBI. The inclusion criteria have a positive predictive value of 99.1% (110/111), specificity of 97.8% (44/45), sensitivity of 29.1% (110/378), and negative predictive value of 14.1% (44/312) at predicting negative cultures. Of the criteria, well appearance (p < .001), history of no previous antibiotics (p = .004), and negative urine WBC (p < .001), nitrite (p < .001), and leukocyte esterase (p < .001) were predictive of negative SBI. Negative band:neutrophil ratio (p = .0088) and negative urine WBC (p < .001), nitrite (p < .001), and leukocyte esterase (p < .001) were predictive of negative cultures.

Conclusion A large number of patients are seen in the ED for fever. Many may be safely discharged home without antibiotics.

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