Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants

Borja Gomez, MD, Santiago Mintegi, MD, PhD, Silvia Bressan, MD, PhD, Liviana Da Dalt, MD, Alain Gervaix, MD, Laurence Lacroix, MD

Pediatrics, 2016

Links   PubMed  Pediatrics  pdf

The Bottom Line

The step-by-step approach has better accuracy in identifying patients at low risk of invasive bacterial infection than the Rochester criteria or the Lab-score.

What They Did

  • A prospective study of 2,185 infants ≤90 days with fever without a source that presented to one of 11 European Pediatric Emergency Departments
  • All patients got U/A, Urine culture, CBC, Blood culture, CRP and procalcitonin. Other tests were at the discretion of the ordering physician
  • They compared the Step-by-Step approach, the Rochester Criteria, and the Lab Score in identifying patients at low risk of Invasive bacterial infection (IBI) – bacteremia or meningitis.
  • Note that UTI was not considered to be an IBI
  • See below for the three criteria:

 

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  • There is a lot to unpack in terms of the results here – I heartily recommend that you read the entire paper. However, if you look at two tables – make then #3 and #4 – which I have conveniently posted here, as they detail the statistical characteristics

What You Can Do

  • OK, so first of all, the Step by Step appears to be more sensitive than Rochester. Sensitivity is again about “ruling out” which is mostly why we get the labs in the febrile newborn in the first place.
  • You need to think about what it would mean for you to push the “line” back to 21 days. The step by step also includes procalcitonin, which while used often in utopian settings is not as commonly employed in the States
  • I recommend that you talk with your colleagues in the ED, inpatient and the community about what this study potentially means for your patients. I think that all stakeholders should read the paper, and consider whether or not it could or should change practice.