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Pediatrics. 2018 Dec;142(6). pii: e20181879. doi: 10.1542/peds.2018-1879. Epub 2018 Nov 13.

Risk Stratification of Febrile Infants ≤60 Days Old Without Routine Lumbar Puncture.

Author information

Departments of Pediatrics and
Emergency Medicine, Yale School of Medicine, and.
Division of Pediatric Hospital Medicine, Lucile Packard Children's Hospital Stanford and Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California.
Departments of Pediatrics and.
Department of Epidemiology of Microbial Diseases, Yale University, New Haven, Connecticut.
Divisions of Infectious Diseases and.
Hospital Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
Divisions of Hospital Medicine and.
Infectious Diseases, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri.
Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
Division of Emergency Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.
Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
Division of Hospital Medicine, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia.
Division of Hospital Medicine, Seattle Children's Hospital and Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington.
Division of Pediatric Emergency Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee; and.
Division of Emergency Medicine, and.
Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.


: media-1vid110.1542/5840460609001PEDS-VA_2018-1879Video Abstract OBJECTIVES: To evaluate the Rochester and modified Philadelphia criteria for the risk stratification of febrile infants with invasive bacterial infection (IBI) who do not appear ill without routine cerebrospinal fluid (CSF) testing.


We performed a case-control study of febrile infants ≤60 days old presenting to 1 of 9 emergency departments from 2011 to 2016. For each infant with IBI (defined as a blood [bacteremia] and/or CSF [bacterial meningitis] culture with growth of a pathogen), controls without IBI were matched by site and date of visit. Infants were excluded if they appeared ill or had a complex chronic condition or if data for any component of the Rochester or modified Philadelphia criteria were missing.


Overall, 135 infants with IBI (118 [87.4%] with bacteremia without meningitis and 17 [12.6%] with bacterial meningitis) and 249 controls were included. The sensitivity of the modified Philadelphia criteria was higher than that of the Rochester criteria (91.9% vs 81.5%; P = .01), but the specificity was lower (34.5% vs 59.8%; P < .001). Among 67 infants >28 days old with IBI, the sensitivity of both criteria was 83.6%; none of the 11 low-risk infants had bacterial meningitis. Of 68 infants ≤28 days old with IBI, 14 (20.6%) were low risk per the Rochester criteria, and 2 had meningitis.


The modified Philadelphia criteria had high sensitivity for IBI without routine CSF testing, and all infants >28 days old with bacterial meningitis were classified as high risk. Because some infants with bacteremia were classified as low risk, infants discharged from the emergency department without CSF testing require close follow-up.

[Available on 2019-12-01]

Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST: Dr Shapiro has served as an expert witness in malpractice cases involving the evaluation of febrile children; the other authors have indicated they have no potential conflicts of interest to disclose.

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