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Application of the Rochester Criteria to Identify Febrile Infants With Bacteremia and Meningitis

Aronson, Paul L., MD*; McCulloh, Russell J., MD; Tieder, Joel S., MD, MPH‡§; Nigrovic, Lise E., MD, MPH; Leazer, Rianna C., MD; Alpern, Elizabeth R., MD, MSCE#; Feldman, Elana A., MD§**; Balamuth, Fran, MD, PhD, MSCE††; Browning, Whitney L., MD‡‡; Neuman, Mark I., MD, MPH for the Febrile Young Infant Research Collaborative

doi: 10.1097/PEC.0000000000001421
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Objectives The Rochester criteria were developed to identify febrile infants aged 60 days or younger at low-risk of bacterial infection and do not include cerebrospinal fluid (CSF) testing. Prior studies have not specifically assessed criteria performance for bacteremia and bacterial meningitis (invasive bacterial infection). Our objective was to determine the sensitivity of the Rochester criteria for detection of invasive bacterial infection.

Methods Retrospective cohort study of febrile infants aged 60 days or younger with invasive bacterial infections evaluated at 8 pediatric emergency departments from July 1, 2012, to June 30, 2014. Potential cases were identified from the Pediatric Health Information System using International Classification of Diseases, Ninth Revision diagnosis codes for bacteremia, meningitis, urinary tract infection, and fever. Medical record review was then performed to confirm presence of an invasive bacterial infection and to evaluate the Rochester criteria: medical history, symptoms or ill appearance, results of urinalysis, complete blood count, CSF testing (if obtained), and blood, urine, and CSF culture. An invasive bacterial infection was defined as growth of pathogenic bacteria from blood or CSF culture.

Results Among 82 febrile infants aged 60 days or younger with invasive bacterial infection, the sensitivity of the Rochester criteria were 92.7% (95% confidence interval [CI], 84.9%–96.6%) overall, 91.7% (95% CI, 80.5%–96.7%) for neonates 28 days or younger, and 94.1% (95% CI, 80.9%–98.4%) for infants aged 29 to 60 days old. Six infants with bacteremia, including 1 neonate with bacterial meningitis, met low-risk criteria.

Conclusions The Rochester criteria identified 92% of infants aged 60 days or younger with invasive bacterial infection. However, 1 neonate 28 days or younger with meningitis was classified as low-risk.

From the *Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, CT;

Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospital, University of Missouri–Kansas City School of Medicine, Kansas City, MO;

Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital; and

§University of Washington School of Medicine, Seattle, WA;

Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA;

Division of Hospital Medicine, Department of Pediatrics, Children's Hospital of the King's Daughters, Norfolk, VA;

#Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL;

**Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA;

††The Center for Pediatric Clinical Effectiveness and Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; and

‡‡Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN.

This project funded in part by The Gerber Foundation Novice Researcher Award (ref 1827-3835) and the National Center for Advancing Translational Sciences of the National Institutes of Health (under award UL1TR000423 and TL1TR000422). The funders were not involved in design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

Disclosure: The authors declare no conflict of interest.

Reprints: Paul L. Aronson, MD, Section of Pediatric Emergency Medicine, Yale School of Medicine, 100 York St, Suite 1F, New Haven, CT 06511 (e-mail: paul.aronson@yale.edu).

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