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Value of white cell count in predicting serious bacterial infection in febrile children under 5 years of age
De S, et al. Arch Dis Child 2014;99:493–499. doi:10.1136/archdischild-2013-304754 493
David King 26.2.2015
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Clinical scenario11 month old boy
Temperature 39 C
No clear focus
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the results…WCC 24.5 (Neut 18)
CRP 54
Urine: 1 + WCC
+/- epithelial cells
no organisms
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The dilemma
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Clinical assessment…
Clinical assessment had a sensitivity of 10-50% for detecting SBI (Craig et al, 2010)
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Dr Damien Roland (Leicester consultant)
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Is a WCC clinically useful in excluding (or ruling in) a serious bacterial infection?
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Current guidelines (NICE)…• Perform FBC, CRP, blood culture, CRP, urine test, CXR (if
resp signs) if < 3 months with fever• Perform LP in febrile infants < 3 months with WCC < 5 or
>15• Start empirical antibiotics if febrile infants < 3 months with
WCC < 5 or > 15.• Perform investigations including FBC in older children
with red or amber features (unless deemed unnecessary)• CXR if WCC > 20 and temp > 39
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Results
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Performance of WCC in detecting SBI
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Performance of WCC in detecting SBI
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Performance of ANC in detecting SBI
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In summaryThe FBC in excluding serious bacterial infection in children is rubbish…
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CASP checklist
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Clearly focused issue?
• Well set out and considered research question.
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Recruitment of patients?
• Only patients having FBC included in analysis (for ethical reasons)
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Outcome accurately measured to minimise bias?
• Relatively large number of children had CXRs• ? Overdiagnosed pneumonias
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Follow-up of patients?
>95% follow-up rate
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Are the results precise and do you believe them?
• Results seem valid• Study has some weaknesses but overall findings are
convincing
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Can the results be applied locally?
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• WCC thresholds likely to be reviewed when NICE guidelines updated
• Still waiting for the “perfect test”…
The future?