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    PECARN Rule for Low Risk Febrile Infants ≤60 Days Old

    Predicts risk of urinary tract infection, bacteremia, or bacterial meningitis in febrile infants up to 60 days old.
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    IMPORTANT

    This calculator is not yet externally validated, and as such, should be used with caution.

    INSTRUCTIONS

    Does not apply to ill-appearing infants. The rule is intended to be one-directional: it may help rule out serious bacterial infection (SBI) in patients who are “low risk”, but the converse is not true (i.e., patients who are “not low risk” by the rule do not necessarily have SBI).

    When to Use
    Pearls/Pitfalls
    Why Use

    Well-appearing infants ≤60 days old, to stratify risk of SBI (defined as urinary tract infection, bacteremia, or bacterial meningitis).

    • The majority of infants ≤60 days old are unvaccinated and have immature immune systems.

    • Infants with signs of shock or who are otherwise ill-appearing/unstable should be considered at high risk of SBI and in most cases should have blood, urine, and CSF cultures collected. This clinical prediction rule would not apply to such patients.

    • Serum procalcitonin level is required, but may not be rapidly available in all settings.

    • Most SBIs identified in the study were UTIs, so the rule may be less accurate for bacteremia and bacterial meningitis.

    • Infants <28 days old warrant special attention, as they are at elevated risk of herpes meningoencephalitis as well as a more rapid progression of disease. These patients almost always require admission for close monitoring as well as a full sepsis work-up including lumbar puncture.

    • In the study, three infants were misclassified as being low risk but did have SBIs (two UTI, and one Enterobacter cloacae bacteremia). All were treated appropriately based on culture results and had uneventful clinical courses.

    • Physical exam alone is unreliable in ruling out SBI in febrile infants.

    • May help safely avoid admission and/or lumbar puncture.

    • Helps determine disposition of some well-appearing infants who can reliably follow up with their primary pediatrician or in the ED in 24 hours and/or can be relied upon to return to the ED should a pending culture return positive.

    No
    Yes

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Some well-appearing infants ≥28 days old with low risk for SBI may be suitable for discharge from the ED with follow up with their primary pediatrician or in the same ED in 24 hours for reassessment. Infants <28 days old generally require admission for close monitoring and empiric IV antibiotics.

    Management

    • Patients deemed low risk by this rule might be safely discharged from the ED, as long as follow up with the primary pediatrician or same ED can be reasonably well assured.

    • The decision to admit a febrile infant is multifactorial. Lack of reliable follow up may necessitate admission.

    • For well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever and no obvious infectious source, ACEP recommends the following: 

      • Consider chest x-ray if cough, hypoxia, rales, high fever (≥39°C), fever duration greater than 48 hours, or tachycardia/tachypnea out of proportion to fever (level B recommendation).

      • Should not order chest x-ray if wheezing and high likelihood of bronchiolitis (level C recommendation).

      • If dipstick urinalysis is negative and UTI is still suspected, obtain urine culture (level C recommendation).

    Critical Actions

    Remember to consider a critical congenital heart defect (and empiric prostaglandin treatment) in the neonate presenting in shock.

    Formula

    Urinalysis positive
    Urinalysis positive
    Yes
    Yes
    No
    No
    ANC >4,090/μL
    ANC >4,090/μL
    Yes
    Yes
    No
    No
    Serum procalcitonin >1.71 ng/mL
    <span style="font-size: 12px">Serum procalcitonin >1.71 ng/mL</span>
    Yes
    Yes
    No
    No
    49.6% SBI risk
    <span>49.6% SBI risk</span>
    6.0% SBI risk
    [Not supported by viewer]
    27.3% SBI risk
    [Not supported by viewer]
    0.2% SBI risk
    (99.8% SBI negative)
    [Not supported by viewer]

    SBI risk from recursive partitioning analysis in Kupperman 2019.

    <p style="line-height: 100%">% SBI risk from recursive partitioning analysis in Kupperman 2019.</p>

    Evidence Appraisal

    The derivation study by Kuppermann et al (2019) included 1,896 infants aged ≤60 days old that had a procalcitonin level drawn at the time of their sepsis evaluation; 11 participants whose procalcitonin samples were lost or mislabeled were excluded. Overall n was 1,821 (908 infants in derivation sample, 913 in validation sample). The primary outcome was the presence or absence of a serious bacterial infection (SBI), defined as UTI, bacteremia, or bacterial meningitis.

    The prediction rule had a sensitivity of 98.8% (95% confidence interval [CI], 92.5-99.9) in the derivation study and 97.7% sensitivity (95% CI, 91.3-99.6) in the validation study. The NPV for SBI was 99.8% (95% CI, 98.8-100.0) and 99.6% (95% CI, 98.4-99.9) in the derivation and validation studies, respectively.

    Because the validation study was not conducted independently, there is a risk of diminished external validity.

    The benefits of this rule are: 1) unnecessary admissions may be decreased, and 2) unnecessary lumbar punctures may be avoided. A key difference in this prediction rule as compared to other similar rules is that despite the fact that lumbar puncture results were not used as criteria in the rule, the sensitivity remained high.

    However, the low prevalence of bacterial meningitis in the general population due to the Hib and pneumococcal vaccinations means that few cases of bacterial meningitis were included in this study’s data set. Thus, because most of the SBIs seen in this study were UTIs, even though the heuristic of 10 outcomes to 1 predictor was satisfied with the overall outcome of “serious bacterial infection,” this rule may be less sensitive and/or specific for meningitis and bacteremia.

    Finally, in this study, three infants were misclassified as being low risk but had SBIs. Two had UTIs and one had Enterobacter cloacae bacteremia. All were treated appropriately based on culture results and had uneventful clinical courses.

    Dr. Nate Kuppermann

    About the Creator

    Nate Kuppermann, MD, MPH, is a professor and chair of the emergency medicine department at UC Davis Children’s Hospital in Sacramento, CA. He chaired the first research network in pediatric emergency medicine and was a founding chair of the Pediatric Emergency Care Applied Research Network (PECARN). Dr. Kuppermann is a leading national investigator for studies focusing on infectious emergencies in children including the laboratory evaluation of young febrile children, the evaluation of children at risk of diabetic ketoacidosis-related cerebral injury, and the laboratory and radiographic evaluation of the pediatric trauma patient.

    To view Dr. Nate Kuppermann's publications, visit PubMed

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    About the Creator
    Dr. Nate Kuppermann
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