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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