Rochester Criteria for Febrile Infants

Julie Jaskiewicz, MD, is a pediatrician affiliated with HealthSource of Ohio, the Cincinnati Children’s Hospital Medical Center, and Mercy Health Anderson Hospital. She is also a fellow of the American Academy of Pediatrics. Dr. Jaskiewicz's research interests include evaluation and management of febrile infants as well as impact of night shift work on pediatric residents.

Why did you develop the Rochester Criteria? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

Prior to the development of the Rochester Criteria, the consensus was that there was no way to predict which child under 3 months of age will have serious bacterial infection (SBI). Too many children that obviously did not have much risk to have SBI were hospitalized, submitted to sepsis workup, and treated with antibiotics for 2-3 days at least. My thought was that instead of looking for who has SBI, we needed to look at those who are very likely NOT to have SBI.

I have used my clinical experience from my residency in Israel to set a list of criteria that would suggest no SBI and tested them first in Rochester (during my fellowship) and then submitted them for validation later in Israel. These criteria were proved to be able to rule out more than 2/3 of the "suspected" children under 3 months of age, and thus only ~1/3 needed to be subjected to sepsis workup.

What pearls, pitfalls and/or tips do you have for users of the Rochester Criteria? Do you know of cases when it has been applied, interpreted, or used inappropriately?

1. Remember that part of these criteria is the absence of previous history that suggests SBI (previously healthy!).
2. Remember that any real sick looking baby (i.e., toxic) should be treated anyhow.
3. Remember that very low risk is still not 100% proof! The group of neonates under 2-3 weeks was the minority in these studies, so be even more careful with this group before you decide they are low risk.
4. Remember to follow all those who are not treated very carefully!

What recommendations do you have for doctors once they have applied the Rochester Criteria? Are there any adjustments or updates you would make to the score based on new data or practice changes?

Just remember that infants <2-3 months may show a dynamic disease, so follow up very carefully.

How do you use the Rochester Criteria in your own clinical practice? Can you give an example of a scenario in which you use it?

In our pediatric emergency room at the Soroka University Medical Center in Beer-Sheva, Israel, the Rochester criteria are the gold standard guidelines for suspected sepsis or febrile children <2-3 months. However, we always warn that in doubt, treat. Low risk infants can be sent home if there is no other reason for hospitalization (e.g. dehydration, hypoxemia).

Ron Dagan, MD, is a distinguished professor of pediatrics and infectious diseases at the Ben-Gurion University of the Negev in Beer-Sheva, Israel. He also created the pediatric infectious disease unit at the Soroka University Medical Center, where he was director until 2014. Dr. Dagan is an active researcher, primarily focusing on new conjugate vaccines, epidemiology of vaccine-preventable diseases, and other infectious disease topics.