Screening for Serious Bacterial Illness in Febrile Neonates
ABSTRACT & COMMENTARY
Source: Baker MD, Bell LM. Unpredictability of serious bacterial illness in febrile infants from birth to 1 month of age. Arch Pediatr Adolesc Med 1999;153:508-511.
Reliable screening tools have been developed and validated to identify selected groups of febrile infants 1-2 months of age who are at low risk for serious bacterial illness (and therefore safe to manage as outpatients). One commonly applied screening tool is the "Philadelphia Protocol." The Philadelphia Protocol identifies the low risk 1-2-month-old baby as having a well appearance; no obvious source of bacterial infection on physical exam; WBC less than 15 K; band/neutrophil ratio less than 0.2; UA with less than 10 cells/hpf and no bacteria; CSF with less than 8 cells and normal gram stain; a normal CXR; and no WBC or blood in stool.
Can the Philadelphia Protocol accurately identify febrile babies younger than 1 month of age who are at low risk of serious bacterial infection? The authors of the Philadelphia Protocol report on applying it to this population. Over a recent 36-month period, 254 febrile neonates 3-28 days of age who were admitted to the Children’s Hospital of Philadelphia were enrolled in the current study. All of these neonates were treated with empiric antibiotics pending culture results. The study investigators reviewed the medical records, applied the Philadelphia Protocol, and retrospectively judged its safety and efficacy. The incidence of serious bacterial illness in the 254 neonates was 12.6% (30 of 254). The bacterial diseases diagnosed were: 17 urinary tract infections, eight cases of bacteremia, four cases of meningitis, two cases of gastroenteritis, and five other.
When the Philadelphia Protocol was applied to the 254 febrile neonates, 109 met the criteria for "low risk" for serious bacterial disease. Of these 109, five were diagnosed with serious bacterial disease (2 with urinary tract infection, 2 with meningitis, and 1 with gastroenteritis). The performance of the Philadelphia Protocol as a screening tool to identify serious bacterial illness in this population shows a sensitivity of 84% (5 of 32) with a 95% confidence interval of 67-95%, and a negative predictive value of 95% (104 of 109) with a 95% confidence interval of 90-99%.
Comment by Leonard Friedland, MD
The Philadelphia Protocol cannot safely identify febrile neonates at low risk for serious bacterial illness (and, therefore, safe to manage as outpatients). Applying this screening tool would have missed five patients (with 95% confidence up to 10% of patients) with serious bacterial illness. These data support that the initial management of the febrile baby younger than 1 month of age should include a complete evaluation for serious bacterial illness, hospitalization, and the administration of empiric antibiotics.
In young infants with fever, all of the following are correct except:
a. reliable screening tools have been developed and validated to identify selected groups of febrile babies 1-2 months of age who are at low risk for serious bacterial illness.
b. reliable screening tools have been developed and validated to identify selected groups of febrile babies younger than 1 month of age who are at low risk for serious bacterial illness.
c. urinary tract infections account for the largest proportion of serious bacterial illness in the febrile neonate.
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