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• 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

Feverish illness in children - Assessment and initial management in children younger than 5 years

Nice Clinical guidelines, CG47 - Issued: May 2007This 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

- 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

- intermediate-risk group for serious illness:

wakes only with prolonged stimulation decreased activitypoor feeding in infants not responding normally to social cues/no smile dry mucous membranesreduced urine output a new lump larger than 2 cm pallor reported by parent or carernasal flaring.

low-risk group for serious illness:

strong cry or not cryingcontent/smilesstays awake normal colour of skin, lips and tongue normal skin and eyesmoist mucous membranes normal response to social cues.

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?

Method

• Used patients retrospectively enrolled in an earlier study (FEVER) 2004-2006

• Any nitrate or leucocyte esterase = UTI

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

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