Efficacy of an observation scale in detecting bacteremia in febrile children three to thirty-six months of age, treated as outpatients,☆☆,,★★

https://doi.org/10.1016/S0022-3476(95)70200-8Get rights and content

Abstract

Objective: To assess the efficacy of the Yale Observation Scale (YOS) in detecting occult bacteremia in febrile, ambulatory pediatric patients with no apparent signs or symptoms of severe infection and with no focal infection. Design: YOS scores were assigned as part of a prospective, multicenter, randomized, interventional trial of oral and intramuscular antibiotics in preventing the complications of occult bacteremia in febrile children. Setting: Pediatric emergency departments at eight urban medical centers. Participants: Children, 3 to 36 months of age with a temperature at least 39.0° C, a nonfocal, non-toxic-appearing illness (or uncomplicated otitis media), treated as outpatients. Interventions: None. Results: There were 6611 assessable patients, who had both a blood culture result and a YOS score assigned. The median YOS score for both patients with bacteremia (n = 192) and patients without bacteremia (n = 6419) was 6, but the mean rank among patients with bacteremia was significantly higher (p <0.0001). The sensitivity, specificity, and positive and negative predictive values for a YOS score greater than 10 were 5.2%, 96.7%, 4.5%, and 97.1%, respectively. Conclusions: The YOS scores are higher among patients with bacteremia than among patients without bacteremia, but the difference is not clinically useful in detecting occult bacteremia in febrile children, with nonfocal, apparently nontoxic infection, treated as outpatients in this age group. (J PEDIATR 1995; 126:877-81)

Section snippets

METHODS

The study population was drawn from 6680 patients prospectively enrolled in a prior multicenter trial of the use of parenteral versus oral antibiotics for the prevention of bacterial complications in children with occult bacteremia between November 1987 and May 1991.19 Criteria for inclusion were age from 90 days to 36 months, a temperature of at least 39.0° C, and a nonfocal febrile illness as determined by a physical examination and a blood sample taken for culture at the time of initial

Patient population

The eight study centers enrolled 6680 patients who received medication; 6329 (96%) had nonfocal febrile illness and 351 (4%) had otitis media. A detailed description of this population and of its sampling procedures has been previously reported.19 The mean age was 14.5 ± 8.3 months, and the median age was 12.4 months. The mean temperature was 39.8° ± 0.56° C, with a median of 39.7° C.

Of the 6680 patients who received medication, 43 were excluded from analysis because of lost blood cultures, 23

DISCUSSION

The YOS16 is a composite ordinal scoring system with the use of observation variables for the assessment of febrile children. The standard outcome measure used by McCarthy et al.14, 16 was the detection of serious illness (pneumonia, urinary tract infection, occult bacteremia, a focal complication of occult bacteremia, severe gastroenteritis, aseptic meningitis, and others). It was among the first attempts to recognize and to quantify the physician's overall assessment of toxicity in ill

References (22)

  • LG Rubin et al.

    Pneumococcal and Haemophilus influenzae type b antigen detection in children at risk for occult bacteremia

    Pediatrics

    (1987)
  • Cited by (65)

    • Risk stratification and management of the febrile young child

      2013, Emergency Medicine Clinics of North America
      Citation Excerpt :

      Clinical assessment as to whether a child appears to be well, ill, or toxic is important. A well appearance does not exclude bacteremia,125 but children who appear toxic are more likely to have serious illness than ill-appearing or well-appearing children (92% vs 26% vs 3%, respectively).126 Most children with fever have viral infections, and many bacterial infections can be identified by history and physical examination alone.

    • Pediatric Emergencies Associated with Fever

      2010, Emergency Medicine Clinics of North America
    • FEVER WITHOUT SOURCE AND FEVER OF UNKNOWN ORIGIN

      2009, Feigin and Cherry's Textbook of Pediatric Infectious Diseases, Sixth Edition
    • The Evolving Approach to the Young Child Who Has Fever and No Obvious Source

      2007, Emergency Medicine Clinics of North America
      Citation Excerpt :

      Clinical assessment as to whether a child appears to be well, ill, or toxic is important. A well appearance does not completely exclude bacteremia [101], but children who appear toxic are much more likely to have serious illness when compared with ill- or well-appearing children (92% versus 26% versus 3%, respectively) [102]. Many bacterial infections can be identified by history and physical examination alone, but some infections may be occult.

    View all citing articles on Scopus

    From the Division of Emergency Medicine and the Department of Pediatrics, Children's Hospital of Buffalo and the School of Medicine and Biomedical Sciences, State University of New York at Buffalo, and the Division of Emergency Medicine and the Department of Pediatrics, Children's Hospital, Boston, and Harvard Medical School, Boston, Massachusetts

    ☆☆

    aFor members of Occult Bacteremia Study Group, see list at end of text.

    Reprint requests: Stephen J. Teach, MD, MPH, Division of Emergency Medicine, Children's Hospital of Buffalo, 219 Bryant St., Buffalo, NY 14222.

    ★★

    0022-3476/95/$3.00 + 0 9/20/62984

    View full text