在无血清降钙素原情况下优化发热幼儿的管理

Optimizing Management of Febrile Young Infants Without Serum Procalcitonin.

作者信息

Burstein Brett, Wolek Caroline, Poirier Cassandra, Yannopoulos Alexandra, Charles Casper T, Kaouache Mohammed, Kuppermann Nathan

机构信息

Montreal Children's Hospital, Division of Pediatric Emergency Medicine, McGill University Health Centre, and the Department of Biostatistics, Epidemiology and Occupational Health, McGill University, Montreal, Quebec, Canada.

McGill University, Montreal, Quebec, Canada.

出版信息

Pediatrics. 2025 Feb 1;155(2). doi: 10.1542/peds.2024-068200.

DOI:10.1542/peds.2024-068200

PMID:39749980

Abstract

BACKGROUND

Febrile young infants are at risk of invasive bacterial infections (IBIs; bacteremia or bacterial meningitis). American Academy of Pediatrics (AAP) guidelines recommend that when procalcitonin testing is unavailable, C-reactive protein (CRP), absolute neutrophil count (ANC) and temperature should be used to identify low-risk infants. We sought to determine the optimal combination of these inflammatory markers to predict IBI when procalcitonin is unavailable.

METHODS

This was a secondary analysis of prospectively collected data for all febrile infants aged 60 days or younger evaluated at a tertiary pediatric emergency department (January 2018 to July 2023). Previously healthy term infants aged 8 to 60 days with rectal temperatures of 38.0°C or greater meeting AAP inclusion/exclusion criteria were analyzed. A decision rule was derived by classification and regression tree analysis with 10-fold cross-validation then compared to AAP-recommended thresholds of ANC ≤ 5200/mm3, CRP ≤ 20 mg/L, and temperature ≤ 38.5°C.

RESULTS

Among 1987 infants, 38 (1.9%) had IBIs. The AAP-recommended thresholds missed no IBIs (sensitivity: 100.0% [95% CI, 88.6%-100.0%]; negative predictive value (NPV): 100.0% [95% CI, 99.5%-100.0%]; specificity: 50.7% [95% CI, 48.5%-53.0%]). Optimal derived thresholds were CRP ≤ 22.2mg/L, temperature ≤ 39.0°C, and ANC ≤ 4500/mm3; urinalysis and age were not selected. The derived rule also missed no IBIs (sensitivity: 100.0% [95% CI, 88.6%-100.0%]; NPV: 100.0% [95% CI, 99.7%-100.0%]); however, specificity improved to 83.8% (95% CI, 82.1%-85.4%). Area under the receiver operating curve for the cross-validated rule (91.9% [95% CI, 91.1%-92.7%]) was higher than at AAP-recommended thresholds (75.4% (95% CI, 74.3%-76.5%]).

CONCLUSIONS

The combination of ANC, CRP, and temperature at statistically derived thresholds improved diagnostic accuracy for identifying infants at low risk of IBIs compared to AAP-recommended thresholds.

摘要

背景

发热的小婴儿有发生侵袭性细菌感染（IBIs，即菌血症或细菌性脑膜炎）的风险。美国儿科学会（AAP）指南建议，当无法进行降钙素原检测时，应使用C反应蛋白（CRP）、绝对中性粒细胞计数（ANC）和体温来识别低风险婴儿。我们试图确定在无法进行降钙素原检测时，这些炎症标志物预测IBIs的最佳组合。

方法

这是一项对在一家三级儿科急诊科评估的所有60日龄及以下发热婴儿的前瞻性收集数据的二次分析（2018年1月至2023年7月）。分析了年龄在8至60日龄、先前健康的足月儿，其直肠温度为38.0°C或更高，符合AAP纳入/排除标准。通过分类和回归树分析及10倍交叉验证得出决策规则，然后与AAP推荐的ANC≤5200/mm³、CRP≤20mg/L和体温≤38.5°C的阈值进行比较。

结果

在1987名婴儿中，38名（1.9%）患有IBIs。AAP推荐的阈值未漏诊任何IBIs（敏感性：100.0%[95%CI，88.6%-100.0%]；阴性预测值（NPV）：100.0%[95%CI，99.5%-100.0%]；特异性：50.7%[95%CI，48.5%-53.0%]）。得出的最佳阈值为CRP≤22.2mg/L、体温≤39.0°C和ANC≤4500/mm³；未选择尿液分析和年龄。得出的规则也未漏诊任何IBIs（敏感性：100.0%[95%CI，88.6%-100.0%]；NPV：100.0%[95%CI，99.7%-100.0%]）；然而，特异性提高到了83.8%（95%CI，8