PEDIATRICS Vol. 108 No. 4 October 2001, pp. 866-871
Enhanced Urinalysis Improves Identification of Febrile Infants Ages 60 Days and Younger at Low Risk for Serious Bacterial Illness
Received Oct 11, 2000; accepted Feb 22, 2001.
From the Department of Pediatrics, Children's Hospital of
Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania.
Objective. Investigators have sought
to establish "low-risk" criteria to identify febrile young infants
who can be observed safely without antibiotics. Previous studies have
used criteria for standard urinalysis to identify suspected urinary
tract infection; however, cases of urinary tract infection have been
missed. Enhanced urinalysis, using hemocytometer cell count and Gram
stain performed on uncentrifuged urine, has been shown to have greater
sensitivity and negative predictive value than standard urinalysis. The
objective of this study was to evaluate the ability of criteria that
incorporate enhanced urinalysis to identify febrile young infants who
are at low risk for serious bacterial illness (SBI).
Methods. Institutional guidelines were established in 1999 to evaluate in a retrospective cohort study infants who were Results. During the study period, 434 infants presented to
the emergency department for evaluation of fever. Thirty patients were
excluded from additional analysis because of incomplete data; 60 patients were identified immediately as "not low risk" on the basis
of history or physical examination. Of the 344 remaining infants, 127 were identified as "low risk" on the basis of laboratory criteria; 83 (65.4%) were observed without antibiotics. None of the
"low-risk" infants had an SBI. A total of 217 well-appearing
infants were classified as "not low risk" on the basis of
laboratory criteria; 28 (12.9%) had an SBI. The overall incidence of
SBI in infants with complete data was 10.1%, whereas the incidence of
SBI in all "not low-risk" infants was 14.8%. The negative
predictive value for the "Pittsburgh" criteria was 100% (95%
confidence interval: 96.7%-100%); the sensitivity was 100% (95%
confidence interval: 89.7%-100%).
Conclusions. The application of low-risk criteria using
enhanced urinalysis improves identification of infants who are at low
risk for SBI.
60 days
of age with temperature 
38.0°C. "Low-risk" criteria included 1) well appearance without focal infection (excluding otitis media); 2) no
history of prematurity, illness, or previous antibiotics; 3) peripheral
white blood cell count (WBC) between 5 and 15 000/mm3; 4)
absolute band count 1500/mm3; 5) cerebrospinal fluid WBC
5/mm3 with a negative Gram stain; 6) enhanced urinalysis
with WBC 9/mm3 with a negative Gram stain; 7) stool WBC
<5/high power field in infants with diarrhea; and 8) chest radiograph
without lobar infiltrate(s) in infants with respiratory signs or
symptoms. SBI was defined as a lobar infiltrate on chest radiograph or
presence of a bacterial pathogen in blood, urine, cerebrospinal fluid, stool, or culture obtained from the soft tissue. The hospital records
of all infants who presented to the emergency department for evaluation
of fever after January 1999, including those who did not meet low-risk
criteria, were reviewed; data were collected regarding history,
physical examination, laboratory test results, treatment, and clinical
course.
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