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6 PEM papers that could change your practice – #4 – predictors of serious bacterial infection


Simon Binks, an Emergency Medicine doc in Wollongong Hospital recently gave an awesome talk on six papers that changed his paediatric emergency medicine practice in the last year. This week we are posting one each day.

You can hear the talk on Joe Lex’s Free Emergency Medicine Talks site.

See all the papers and discussion:

  1. The downsides of codeine in kids
  2. The outcomes of absorbable sutures in facial lacerations
  3. Abdo x-rays to rule out intussusception
  4. Bloods markers as predictors of serious bacterial infection
  5. High flow nasal cannulae for acute respiratory insufficiency
  6. Getting urine from neonates

Here I summarise the fourth paper he identified and his key points.

4. Predictors of serious bacterial infection – do the blood results help us?

An Annals of Emergency Medicine 2012 paper was a meta-analysis looking at biochemical markers of serious bacterial infection in children presenting to ED with fever without a source.

Which papers and patients did they look at?

Patients were aged 7 days to 36 months.

The authors specifically looked at procalcitonin, WCC and CRP.

8 citations were found – this included over 1800 patients (between 2001-2010). There were six ED studies and two from paediatric asssessment units or paediatric wards.

Were the papers comparable?

Serious bacterial infection was defined as: urinary tract infection based on culture; pneumonia based on chest x-ray; septicaemia or bacteraemia based on blood culture; meningitis based on positive CSF; and abscesses, cellulitis and osteomyelitis.

The rates of serious bacterial infection varied between 3% and 29 %, which suggests that the papers may be looking at different populations (also the percentages seem very high).

The papers used different cut offs levels before classifying a test as positive.

What did they conclude?

Procalcitonin was the best biological marker for serious bacterial infection. Overall sensitivity was only 83% though.

This doesn’t really change practice – it is clear that we still need clinical examination and experience to decide whether or not to treat a fever with an unknown source.


Yo CH, Hsieh PS, Lee SH, Wu JY, Chang SS, Tasi KC, Lee CC.  Comparison of the test characteristics of procalcitonin to C-reactive protein and leukocytosis for the detection of serious bacterial infections in children presenting with fever without source: a systematic review and meta-analysis. Annals of Emergency Medicine 2012; 60(5): 591-600.




  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.


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