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Clinical prediction model to aid emergency doctors managing febrile children at risk of serious bacterial infections: diagnostic study

BMJ 2013; 346 doi: (Published 02 April 2013) Cite this as: BMJ 2013;346:f1706
  1. Ruud G Nijman, PhD student1,
  2. Yvonne Vergouwe, methodologist2,
  3. Matthew Thompson, clinical reader3,
  4. Mirjam van Veen, resident1,
  5. Alfred H J van Meurs, paediatrician4,
  6. Johan van der Lei, professor5,
  7. Ewout W Steyerberg, professor2,
  8. Henriette A Moll, professor1,
  9. Rianne Oostenbrink, paediatrician1
  1. 1Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, 3015 GJ, Rotterdam, Netherlands
  2. 2Department of Public Health, Center for Medical Decision Making, Erasmus MC, Rotterdam
  3. 3Department of Primary Care Health Sciences, Oxford University, Oxford, UK
  4. 4Department of Paediatrics, Haga-Juliana Children’s Hospital, The Hague, Netherlands
  5. 5Department of Medical Informatics, Erasmus MC, Rotterdam
  1. Correspondence to: R Oostenbrink r.oostenbrink{at}
  • Accepted 1 March 2013


Objective To derive, cross validate, and externally validate a clinical prediction model that assesses the risks of different serious bacterial infections in children with fever at the emergency department.

Design Prospective observational diagnostic study.

Setting Three paediatric emergency care units: two in the Netherlands and one in the United Kingdom.

Participants Children with fever, aged 1 month to 15 years, at three paediatric emergency care units: Rotterdam (n=1750) and the Hague (n=967), the Netherlands, and Coventry (n=487), United Kingdom. A prediction model was constructed using multivariable polytomous logistic regression analysis and included the predefined predictor variables age, duration of fever, tachycardia, temperature, tachypnoea, ill appearance, chest wall retractions, prolonged capillary refill time (>3 seconds), oxygen saturation <94%, and C reactive protein.

Main outcome measures Pneumonia, other serious bacterial infections (SBIs, including septicaemia/meningitis, urinary tract infections, and others), and no SBIs.

Results Oxygen saturation <94% and presence of tachypnoea were important predictors of pneumonia. A raised C reactive protein level predicted the presence of both pneumonia and other SBIs, whereas chest wall retractions and oxygen saturation <94% were useful to rule out the presence of other SBIs. Discriminative ability (C statistic) to predict pneumonia was 0.81 (95% confidence interval 0.73 to 0.88); for other SBIs this was even better: 0.86 (0.79 to 0.92). Risk thresholds of 10% or more were useful to identify children with serious bacterial infections; risk thresholds less than 2.5% were useful to rule out the presence of serious bacterial infections. External validation showed good discrimination for the prediction of pneumonia (0.81, 0.69 to 0.93); discriminative ability for the prediction of other SBIs was lower (0.69, 0.53 to 0.86).

Conclusion A validated prediction model, including clinical signs, symptoms, and C reactive protein level, was useful for estimating the likelihood of pneumonia and other SBIs in children with fever, such as septicaemia/meningitis and urinary tract infections.


  • We thank the emergency department nursing staff of the Erasmus MC-Sophia children’s hospital and the Haga-Juliana children’s hospital and the medical and nursing staff at the paediatric assessment unit at the Walsgrave Hospital (now University Hospital of Coventry and Warwickshire NHS Trust) for their participation and collection of data.

  • Contributors: All authors substantially contributed to the drafting or critical revision of the manuscript. RGN developed the protocol and analysed the data and is the main author of the paper. YV developed the protocol and analysed and interpreted the data. MT, MvV, and AHJvM developed the protocol and acquired the data. JvdL developed the protocol, provided technical support, and acquired the data. EWS developed the protocol and analysed the data analysis. HAM and RO supervised the protocol development, and were responsible for inclusion of patients, writing the manuscript, obtaining funding, and act as guarantors of this paper. All authors have read and approved the final manuscript, had full access to all of the data in the study, and can take full responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding: This study received no funding.

  • Competing interest: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; RGN is supported by ZonMW, a Dutch organisation for health research and development, and Erasmus MC Doelmatigheid; RO is supported by an unrestricted grant from Europe Container Terminals and a fellowship grant from the European Society of Paediatric Infectious Diseases in 2010; this report is independent research arising from MT’s career development fellowship supported by the National Institute for Health Research and the views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the Institute for Health Research, or Department of Health; no other relationships or activities that could have influenced the submitted work.

  • Ethical approval: This study was approved by the institutional review boards of the Erasmus MC-Sophia and Haga-Juliana children’s hospitals and University Hospital Coventry and Warwickshire NHS Trust local research ethics committee (04/Q2802/115). Informed consent for both the development populations and the validation population patient was obtained.

  • Data sharing: No additional data available.

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