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Observational Study
. 2017 Nov 6;171(11):e172927.
doi: 10.1001/jamapediatrics.2017.2927. Epub 2017 Nov 6.

Accuracy of Complete Blood Cell Counts to Identify Febrile Infants 60 Days or Younger With Invasive Bacterial Infections

Andrea T Cruz  1 , Prashant Mahajan  2 , Bema K Bonsu  3 , Jonathan E Bennett  4 , Deborah A Levine  5 , Elizabeth R Alpern  6 , Lise E Nigrovic  7 , Shireen M Atabaki  8 , Daniel M Cohen  3 , John M VanBuren  9 , Octavio Ramilo  10 , Nathan Kuppermann  11 ; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network
Affiliations
Observational Study

Accuracy of Complete Blood Cell Counts to Identify Febrile Infants 60 Days or Younger With Invasive Bacterial Infections

Andrea T Cruz et al. JAMA Pediatr. .

Erratum in

  • Error in Key Points.
    [No authors listed] [No authors listed] JAMA Pediatr. 2018 Mar 1;172(3):302. doi: 10.1001/jamapediatrics.2017.5387. JAMA Pediatr. 2018. PMID: 29309481 Free PMC article. No abstract available.

Abstract

Importance: Clinicians often risk stratify young febrile infants for invasive bacterial infections (IBIs), defined as bacteremia and/or bacterial meningitis, using complete blood cell count parameters.

Objective: To estimate the accuracy of individual complete blood cell count parameters to identify febrile infants with IBIs.

Design, setting, and participants: Planned secondary analysis of a prospective observational cohort study comprising 26 emergency departments in the Pediatric Emergency Care Applied Research Network from 2008 to 2013. We included febrile (≥38°C), previously healthy, full-term infants younger than 60 days for whom blood cultures were obtained. All infants had either cerebrospinal fluid cultures or 7-day follow-up.

Main outcomes and measures: We tested the accuracy of the white blood cell count, absolute neutrophil count, and platelet count at commonly used thresholds for IBIs. We determined optimal thresholds using receiver operating characteristic curves.

Results: Of 4313 enrolled infants, 1340 (31%; 95% CI, 30% to 32%) were aged 0 to 28 days, 2412 were boys (56%), and 2471 were white (57%). Ninety-seven (2.2%; 95% CI, 1.8% to 2.7%) had IBIs. Sensitivities were low for common complete blood cell count parameter thresholds: white blood cell count less than 5000/µL, 10% (95% CI, 4% to 16%) (to convert to 109 per liter, multiply by 0.001); white blood cell count ≥15 000/µL, 27% (95% CI, 18% to 36%); absolute neutrophil count ≥10 000/µL, 18% (95% CI, 10% to 25%) (to convert to × 109 per liter, multiply by 0.001); and platelets <100 × 103/µL, 7% (95% CI, 2% to 12%) (to convert to × 109 per liter, multiply by 1). Optimal thresholds for white blood cell count (11 600/µL), absolute neutrophil count (4100/µL), and platelet count (362 × 103/µL) were identified in models that had areas under the receiver operating characteristic curves of 0.57 (95% CI, 0.50-0.63), 0.70 (95% CI, 0.64-0.76), and 0.61 (95% CI, 0.55-0.67), respectively.

Conclusions and relevance: No complete blood cell count parameter at commonly used or optimal thresholds identified febrile infants 60 days or younger with IBIs with high accuracy. Better diagnostic tools are needed to risk stratify young febrile infants for IBIs.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Ramilo reports personal fees from Abbvie, Janssen, Regeneron, and Pfizer, and grants from Janssen. All these fees and grants are not related to the current work. No other disclosures are reported.

Figures

Figure.
Figure.. Receiver Operating Characteristic Curves and Optimal Complete Blood Cell Count Parameter Thresholds
Total white blood cell count (A), absolute neutrophil count (B), and platelet count (C) for identifying young febrile infants aged 0 to 28 days and 29 to 60 days with invasive bacterial infections. Black squares represent the optimal cutoffs; counts are in  × 103 cells/µL. To convert absolute neutrophil count and white blood cell count to × 109 per liter, multiply by 0.001; to convert platelet count to × 109 per liter, multiply by 1.
See this image and copyright information in PMC

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