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Can urgency classification of the Manchester triage system predict serious bacterial infections in febrile children?
  1. Ruud G Nijman1,
  2. Rob LJ Zwinkels1,
  3. Mirjam van Veen1,
  4. Ewout W Steyerberg2,
  5. Johan van der Lei3,
  6. Henriëtte A Moll1,
  7. Rianne Oostenbrink1
  1. 1Department of General Paediatrics, Erasmus MC – Sophia Children's Hospital, Rotterdam, The Netherlands
  2. 2Department of Public Health, Centre for Medical Decision Making, Erasmus MC, Rotterdam, The Netherlands
  3. 3Department of Medical Informatics, Erasmus MC, Rotterdam, The Netherlands
  1. Correspondence to Rianne Oostenbrink, Department of General Paediatrics, Erasmus MC – Sophia Children's Hospital, Dr Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands; r.oostenbrink{at}


Objective To evaluate the discriminative ability of the Manchester triage system (MTS) to identify serious bacterial infections (SBIs) in children with fever in the emergency department (ED) and to study the association between predictors of SBI and discriminators of MTS urgency of care.

Methods This prospective observational study included 1255 children with fever (1 month–16 years) attending the ED of the Erasmus MC – Sophia Children's Hospital, Rotterdam, The Netherlands in 2008–9. Triage urgency was determined with the MTS (urgency (U) level 1–5). The relationship between triage urgency and SBI was assessed with multivariable logistic regression, including effects of age, sex and temperature. Discriminative ability was assessed by receiver operating characteristic curve analysis.

Results SBI prevalence was 11% (n=131, 95% CI 9% to 12%). The discriminative value of the MTS for predicting SBI was 0.57 (95% CI 0.52 to 0.62), and the MTS did not contribute to a model including age, sex and temperature. The sensitivity of the MTS (U1–2 vs U3–5) to detect SBI was 0.42 (95% CI 0.33 to 0.51) and specificity was 0.69 (95% CI 0.66 to 0.72). MTS high urgency discriminators include several known predictors of SBI, such as fever, work of breathing, meningism and oxygen saturation, but apply to non-SBI children as well.

Conclusion The MTS has poor discriminative ability to predict the presence of SBIs in children presenting with fever to the paediatric ED. Important predictors of SBI are represented within the MTS, but are used in a different way to classify urgency.

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  • Funding RN is supported by a grant from ZonMW, the Dutch Organization for Health Research and Development, and Erasmus MC Doelmatigheid. RO is supported by an unrestricted grant from Europe Container Terminals B.V.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Ethics Committee, Erasmus MC, Rotterdam, The Netherlands.

  • Provenance and peer review Not commissioned; externally peer reviewed.