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Validating clinical practice guidelines for the management of febrile infants presenting to the emergency department in the UK and Ireland
  1. Thomas Waterfield1,
  2. Mark D Lyttle2,3,
  3. Charlotte Munday2,
  4. Steven Foster4,
  5. Marc McNulty4,
  6. Rebecca Platt5,
  7. Michael Barrett6,7,
  8. Emma Rogers6,
  9. Sheena Durnin8,9,
  10. Nida Jameel10,
  11. Julie-Ann Maney11,
  12. Claire McGinn11,
  13. Lisa McFetridge12,
  14. Hannah Mitchell12,
  15. Deepika Puthucode13,
  16. Damian Roland14,15
  17. On behalf of Paediatric Emergency Research in the UK and Ireland (PERUKI)
  1. 1Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
  2. 2Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
  3. 3Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
  4. 4Emergency Department, Royal Hospital for Children, Glasgow, UK
  5. 5Emergency Department, Barts Health NHS Trust, London, UK
  6. 6Emergency Department, Children's Health Ireland at Crumlin, Crumlin, Ireland
  7. 7Women’s and Children’s Health, School of Medicine, University College Dublin, Dublin, Ireland
  8. 8Emergency Department, Children’s Health Ireland at Tallaght, Dublin, Ireland
  9. 9Discipline of Paediatrics, Trinity College, University of Dublin, Dublin, Ireland
  10. 10Emergency Department, Children's Health Ireland at Tallaght, Dublin, Ireland
  11. 11Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
  12. 12Mathematical Sciences Research Centre, Queen's University Belfast, Belfast, UK
  13. 13Children’s Emergency Department, Leicester Royal Infirmary, Leicester, UK
  14. 14Department of Health Sciences, University of Leicester, Leicester, UK
  15. 15Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK
  1. Correspondence to Dr Thomas Waterfield, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK; t.waterfield{at}


Objective To report the performance of clinical practice guidelines (CPG) in the diagnosis of serious/invasive bacterial infections (SBI/IBI) in infants presenting with a fever to emergency care in the UK and Ireland. Two CPGs were from the National Institutes for Health and Care Excellence (NICE guidelines NG51 and NG143) and one was from the British Society for Antimicrobial Chemotherapy (BSAC).

Design Retrospective multicentre cohort study.

Patients Febrile infants aged 90 days or less attending between the 31 August 2018 to 1 September 2019.

Main outcome measures The sensitivity, specificity and predictive values of CPGs in identifying SBI and IBI.

Setting Six paediatric Emergency Departments in the UK/Ireland.

Results 555 participants were included in the analysis. The median age was 53 days (IQR 32 to 70), 447 (81%) underwent blood testing and 421 (76%) received parenteral antibiotics. There were five participants with bacterial meningitis (1%), seven with bacteraemia (1%) and 66 (12%) with urinary tract infections. The NICE NG51 CPG was the most sensitive: 1.00 (95% CI 0.95 to 1.00). This was significantly more sensitive than NICE NG143: 0.91 (95% CI 0.82 to 0.96, p=0.0233) and BSAC: 0.82 (95% 0.72 to 0.90, p=0.0005). NICE NG51 was the least specific 0.0 (95% CI 0.0 to 0.01), and this was significantly lower than the NICE NG143: 0.09 (95% CI 0.07 to 0.12, p<0.0001) and BSAC: 0.14 (95% CI 0.1 to 0.17, p<0.0001).

Conclusion None of the studied CPGs demonstrated ideal performance characteristics. CPGs should be improved to guide initial clinical decision making.

Trial registration number NCT04196192.

  • emergency care
  • infectious disease medicine
  • paediatrics
  • paediatric emergency medicine
  • sepsis

Data availability statement

Data are available in a public, open access repository.

Statistics from

Data availability statement

Data are available in a public, open access repository.

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  • Twitter @julieannmaney, @damian_roland

  • Collaborators Performed on behalf of the Paediatric Emergency Research in the UK and Ireland (PERUKI)

  • Contributors TW, MDL, DR and J-AM contributed to the design of the study. TW and CM coordinated the running of the study including data management and site training. MDL and TW designed the electronic CRFs. MDL, J-AM, DR, RP, SD and MB were site leads. LM and HM provided statistical expertise and performed the statistical analysis. All authors contributed to data collection and the writing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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