Risk Stratification of Febrile Infants 60 Days old without LP
This study looked to see how both the ROCHESTER and Philadelphia Criteria do at catching INVASIVE bacterial infections. Most of the risk stratifications scores in patient between 28-60 days look for serious infections which include UTI amongst others, but none actually specify for bacteremia or meningitis. This study uses a case-control method to retroactively look at its ability to predict low-risk infants using these scores to detect invasive infections.
The charts were selected based on certain criteria: + blood cultures, + LP, or pleocytosis after Abx and meningitis. These patients could only be ED arrivals, no transfers, and no documentation that they were “Ill appearing”. These patients were then matched to two similar febrile infants with negative blood and CSF cultures.
The results showed that both had concerning misses for potential invasive bacterial infections. Rochester marked 25 patients with IBI as low risk, while the philadelphia criteria marked 11. That said, Rochester missed 2 cases of confirmed meningitis (by their definition) and Philadelphia did not miss any. Therefore, the paper suggests the Philadelphia Criteria can be used to safely rule out invasive bacterial infections without the use of an LP. They acknowledge that a potential to miss a blood stream infection exists; however, the LP would not add to the work up in these patients that are missed.
Pediatrics is a hard population to study, and even harder to study sick kids due to such a low prevalence for disease. Regardless, this study did a strong job attempting to justify the no LP argument in the 28-59 day old infant with a fever. As long as you have a long discussion and ensure proper contact information and follow up with the patient and their caregivers, one could argue that this paper provides some good evidence to discharge a patient who fits this criteria.
Aronson PL, et al. Febrile Young Infant Research Collaborative. Risk Stratification of Febrile Infants ≤60 Days Old Without Routine Lumbar Puncture. Pediatrics. 2018 Dec;142(6)