Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study BMJ 2013;346:f866 doi: /bmj.f866 Northern ED registrar Teaching March

Significance Common diagnostic challenge Majority self-limiting infections remain the leading cause of death in children under the age of 5 years. Previous attempts have been made to identify low risk patients and avoid invasive procedures with limited success Not applicable

Feverish illness in children - Assessment and initial management in children younger than 5 years Nice Clinical guidelines, CG47 - Issued: May 2007 This advice in this guideline covers the care and treatment of children aged under 5 years with fever in the NHS in England and Wales. 4/30524.pdf

- high-risk group for serious illness: unable to rouse or if roused does not stay awake weak, high-pitched or continuous cry pale/mottled/blue/ashen reduced skin turgor bile-stained vomiting moderate or severe chest indrawing respiratory rate greater than 60 breaths per minute grunting bulging fontanelle appearing ill to a healthcare professional

- intermediate-risk group for serious illness: wakes only with prolonged stimulation decreased activity poor feeding in infants not responding normally to social cues/no smile dry mucous membranes reduced urine output a new lump larger than 2 cm pallor reported by parent or carer nasal flaring.

low-risk group for serious illness: strong cry or not crying content/smiles stays awake normal colour of skin, lips and tongue normal skin and eyes moist mucous membranes normal response to social cues.

The tool Colour, activity, respiratory, hydration, and other features to give a low-, intermediate-, or high-risk assessment. ‘Simple and Attractive’ Further investigations determined by category attempted validation by retrospectively applying it to a prospective registry of over 15,000 febrile children aged less than 5 years primary outcome?

Method Used patients retrospectively enrolled in an earlier study (FEVER) Any nitrate or leucocyte esterase = UTI

Results 85.8% sensitivity and 28.5% specificity overall 108 of the 157 missed cases of SBI were urinary tract infections Adding urinalysis (UA) sensitivity 92.1%, specificity 22.3% – PPV increased UTI = SBI? AUC for SBI was 0.64 without the UA and 0.61 with the UA

Discussion/Conclusion Moderate sensitivity Low specificity Conclusion – addition of UA improved performance significantly ? What do you want in a screening tool? What other screening tools are there? Doesn’t meet criteria for useful tool here