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Original research
Prevalence of serious bacterial infections and performance of inflammatory markers in febrile infants with and without proven viral illness
  1. Zhao Xiang Choa1,
  2. Gayatiri Raveentheran2,
  3. Zi Xean Khoo1,3,
  4. Gene Yong-Kwang Ong2,4,
  5. Lena Wong5,
  6. Rupini Piragasam5,
  7. Sashikumar Ganapathy2,4,
  8. Shu-Ling Chong2,4
  1. 1Department of Paediatric Medicine, Kandang Kerbau Women's and Children’s Hospital, Singapore
  2. 2Department of Children’s Emergency, Kandang Kerbau Women's and Children’s Hospital, Singapore
  3. 3Singhealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
  4. 4Singhealth-Duke NUS Paediatrics Academic Clinical Programme and SingHealth-Duke NUS Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore
  5. 5Research Centre, Kandang Kerbau Women's and Children’s Hospital, Singapore
  1. Correspondence to Dr Zi Xean Khoo; khoo.zi.xean{at}singhealth.com.sg

Abstract

Background Febrile infants ≤90 days old with proven viral infections who may have concurrent serious bacterial infections (SBIs) remain a diagnostic dilemma. We aimed to compare the prevalence of SBIs and evaluate the performance of inflammatory markers in predicting SBIs, between infants with and without proven viral illness.

Methods We conducted a secondary analysis of febrile infants ≤90 days old presenting with temperature ≥38°C to a tertiary paediatric emergency department in Singapore between 1 December 2017 and 31 July 2022. We compared SBI prevalence, performance of white blood cell (WBC), C-reactive protein (CRP), procalcitonin (PCT) and absolute neutrophil count (ANC), between infants with and without proven viral illness. We presented performance using sensitivity, specificity, positive and negative predictive values, and area under the receiver operating characteristic curve (AUC).

Results Among 1783 infants, 261 (14.6%) had SBIs, and 653 (36.6%) had proven viral infections. The prevalence of SBI was lower in infants with proven viral illness compared with those without (5.05% vs 20.2%, p<0.001, OR=0.211, 95% CI 0.144 to 0.308). In both groups, CRP >20 mg/L had the highest sensitivity (60.6%, 95% CI 42.1% to 77.1% and 67.0%, 95% CI 60.4% to 73.0% for those with proven illness and those without) and ANC >10×109/L demonstrated the highest specificity (98.1%, 95% CI 96.7% to 99.1% and 93.1%, 95% CI 91.2% to 94.8%, for those with proven illness and those without), in predicting for SBIs. Using current thresholds, WBC, ANC, CRP and PCT performed with greater specificity but lower sensitivity among those with proven viral illness compared with those without. Differences in AUCs between both groups for the four inflammatory markers were only statistically significant with ANC >10×109/L.

Conclusions Although febrile infants ≤90 days old with proven viral illnesses compared with those without were at lower risk of SBIs, current inflammatory markers thresholds may result in missed SBIs in this subgroup.

Trial registration number NCT04103151.

  • bacterial
  • viral
  • pediatrics

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/emermed-2024-214435

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Handling editor Shammi L Ramlakhan

    • Contributors ZXC, S-LC, KZX, GR, GY-KO, LW, RP and SG have made contributions to the conception, design, acquisition of data, analysis, interpretation for the manuscript. ZXC, S-LC, KZX, GR have made contributions to drafting the work and revising it critically for important intellectual content. ZXC, S-LC, KZX are involved in the final approval of the version to be published. ZXC, S-LC, KZX are in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. KZX is the guarantor.

    • Funding Supported by National Medical Research Council (Singapore), NMRC/MOH-000158-00/MOHCNIG18May-005 and MOH-CSSSP19May-0020.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.