Introductions: In most children aged 1-36 months, the cause of a febrile illnessis a self limiting viral infection. It is very difficult to distinguish these fromserious bacterial infection. Objective of this study is to assess the efficacy ofthe Yale Observation Scale (YOS) to detect serious bacterial infection in febrilechildren aged 1-36 months.Methods: YOS scores were assigned as a part of a cross- sectional study in100 children presenting in Tribhuvan University teaching hospital with fever todivide the child into well- looking if YOS â‰¤10 or ill- looking if YOS &gt;10. Then theÂ history, examination and necessary investigation was performed to come to aÂ diagnosis of non- serious illness and serious bacterial infection.Results: Serious bacterial infection was found in 33(33%) of the patients. Thesensitivity, specificity, positive and negative predictive values for a YOS scoregreater than 10 to detect serious bacterial infection were 45.45%, 88.05%%,65.21% and 76.62%, respectively.Conclusions: A YOS â‰¤10 predicts non-serious illness while a YOS&gt;10 does notnecessarily indicate serious bacterial infection and should undergo furtherevaluation to confirm serious bacterial infection.Keywords: febrile children, serious bacterial infection, yale observation scal

Kansakar, Prerana

Shrestha, Merina

Shrestha, Prakash Sundar

English

Journal of Patan Academy of Health Sciences

Prerana Kansakar: Yale scale to detect serious bacterial infectionJournal of Patan Academy of Health Sciences. 2014 Dec;1(2):23-2623Efficacy of Yale observation scale to detect serious bacterial infection in febrile children aged one to 36 months Prerana Kansakar,1 Prakash Sundar Shrestha,2 Merina Shrestha31 Lecturer Department of Pediatrics, Patan Academy of Health Sciences, Lalitpur, Nepal 2Professor, 3Assistant Professor Department of Child Health, Tribhuwan University Teaching Hospital, Kathmandu, NepalABSTRACTIntroductions: In most children aged 1-36 months, the cause of a febrile illness is a self limiting viral infection.  It is very difficult to distinguish these from serious bacterial infection. Objective of this study is to assess the efficacy of the Yale Observation Scale (YOS) to detect serious bacterial infection in febrile children aged 1-36 months.Methods: YOS scores were assigned as a part of a cross- sectional study in 100 children presenting in Tribhuvan University teaching hospital with fever to divide the child into well- looking if YOS ≤10 or ill- looking if YOS >10. Then the history, examination and necessary investigation was performed to come to a diagnosis of non- serious illness and serious bacterial infection.Results: Serious bacterial infection was found in 33(33%) of the patients. The sensitivity, specificity, positive and negative predictive values for a YOS score greater than 10 to detect serious bacterial infection were 45.45%, 88.05%%, 65.21% and 76.62%, respectively. Conclusions: A YOS ≤10 predicts non-serious illness while a YOS>10 does not necessarily indicate serious bacterial infection and should undergo further evaluation to confirm serious bacterial infection. Keywords: febrile children, serious bacterial infection, yale observation scaleCorrespondenceDr. Prerana KansakarLecturer, Department of Pediatrics, Patan Academy of Health Sciences, Lalitpur, NepalEmail: preranakansakar@hotmail.com   Phone: 9841226376Peer reviewed byProf. Dr. Jay N ShahPatan Academy of Health Sciences Dr. Sumana Bajracharya Patan Academy of Health Sciences Plain Language Summary This study was done to see efficacy of Yale observation score in detecting serious bacterial infection. Lower score was helpful in predicting no serious bacterial infection however higher score was not helpful in predicting serious bacterial infection.GENERAL SECTION ORIGINAL ARTICLEISSN: 2091-2749 (Print)2091-2757 (Online)Vol. 01 | No. 02 | Issue 02, Dec 2014Prerana Kansakar: Yale scale to detect serious bacterial infectionJournal of Patan Academy of Health Sciences. 2014 Dec;1(2):23-2624INTRODUCTIONSFever is a common presenting complaint1,2 and cause of acute hospital admission3 in children aged 1 to 36 month. Fever is usually benign but serious bacterial illness may be present. Difficulty to distinguish may lead to unnecessary investigations, admissions, irrational use of antibiotics as well as serious consequences when diagnosis is delayed or missed.4 Observation scales helps to predict the risk of significant illness. The Yale Observation Scale (YOS) is an illness severity scale using simple observations which is easily applicable.5-12The objective of this study was to observe the efficacy of YOS in detecting serious bacterial infection in febrile children 1 to 36 months of age.  Permission was taken from hospital authority.METHODSThis was a hospital based cross-sectional study conducted in the emergency, pediatric out-patient and pediatric in-patient department of Tribhuvan University Teaching Hospital over six months period from January 1 to June 30, 2010. Children aged 1 to 36 months with fever of less than or equal to seven days were included in the study. Children who received antibiotics or immunization 48 hours prior to presentation, who received sedatives before 24 hours of presentation and whose parents did not give consent were excluded. Before start of treatment children were scored in the six components of YOS.7Table 1. Components of Yale Observation Scale (YOS)7  for severity of illnessObservation item 1(Normal)3(Moderate impairment)5(Severe impairment)Quality of cryStrong with normal tone or content and not cryingWhimpering or sobbingWeak or moaning or high pitchedReaction to parent stimulationCries briefly then stops or content and not cryingCries off and onContinual cry or hardly respondsState variationIf awake, stays awake or if asleep and stimulated, wakes up quicklyEyes close briefly awake or awakes with prolonged stimulationFalls to sleep or will not rouseColor Pink Pale extremities or acrocyanosisPale or cyanotic or mottled or ashenHydrationSkin and eyes normal and mucous membrane moistSkin and eyes normal and mouth slightly drySkin doughy or tented & dry mucous membrane &  or sunken eyesResponse (talk, smile) to social overturesSmiles or alert(≤2mo)Brief smile or alerts briefly(≤2mo) No smile or face anxious, dull, expressionless or no alerting (≤2mo)The cause of the fever was diagnosed with the help of history, physical examination and necessary investigations. The final diagnosis was divided into serious and non- serious illness. Serious bacterial infections included diseases like bacterial meningitits, septicaemia, bacteremia , pneumonia, urinary tract infection, septic arthritis/ osteomyelitis, bacillary dysentery. Other illnesses besides these illnesses were termed non- serious illness. The SPSS 16 was used for data entry and analysis. The sensitivity, specificity, positive predictive value and negative predictive value were calculated. Mean of continuous variables between two groups were analyzed using Students’ t-test. P value < 0.05 was considered significant.RESULTSThere were total 100 children aged 1 to 36 months with fever.  Twenty eight were in age group 7 to 12 months. Male were 59. Fifty six children were from out-patient department. Fifty eight had symptoms involving respiratory tract. There was only one significant blood culture positive with staphylococcus aureus.Table 2. Severity of illness in children (n=100) with feverSeverity of illness Diagnosis FrequencySerious (33) Bacterial meningitis 1Bronchiolitis with secondary bacterial infection 1Enteric fever (Culture negative) 1Infective endocarditis 1Pneumonia 19Sepsis( Assumed) 2Septic arthritis 1Urinary tract infection 7Non-serious (67) Abscess 2Acute tonsillitis 5Aseptic meningitis 2Atropine induced hyperpyrexia 1Bronchiolitis 9Cellulitis 1Superficial skin infection 3Acute gastroenteritis- viral 8Non-specific febrile illness 19Upper respiratory tract infection- viral 17Prerana Kansakar: Yale scale to detect serious bacterial infectionJournal of Patan Academy of Health Sciences. 2014 Dec;1(2):23-2625Table 3. YOS versus serious bacterial infectionYOS score Serious bacterial infectionNon- serious illness Total≤10 18 59 77>1011-15 9 5 14≥16 6 3 9Total 33 67 100The mean YOS score in children with serious illness was 10.58±3.929. In children with non- serious illness, mean YOS was 7.88± 3.150. The mean difference of YOS between children with serious bacterial infection and non- serious illness was significant (p-0.001) The sensitivity, specificity, positive predictive value and negative predictive value of YOS >10 to detect serious bacterial illness in febrile children aged 1-36 months was 45.45%, 88.05%, 65.21% and 76.62%, respectively. DISCUSSIONSIn the present study, serious bacterial infection was 33% but bacteremia was only 3.5% as only 28% had their blood culture sent according to the hospital protocol. Earlier studies have shown the prevalence of serious bacterial infection to be 11 to 29% 13-15 and that of bacteremia to be 2.9 to 28% 1,9,16-18 in children less than 36 months . So the present study looked into the efficacy of YOS in detecting serious bacterial infection rather than bacteremia which is similar to a study done by McCarthy et al.5 McCarthy in 1980s first attempted to quantify clues of sickness by devising an observational scoring system known as Yale Observation Score to detect serious bacterial illness7 and  various studies have compared diagnostic use of YOS (Table 4). In our study, children from in-patient ward, out- patient and emergency department were included. Bang et al did the study in the admitted patients16, while Baker and Teach et al did the study in admitted and patientsTable 4. Comparison of studies using YOSAuthor (Year) Sample size  (Site of study)Study population Outcome assessed Sensitivity Specificity PPV NPVMcCarthy et al (1982)7206(ER) 106(OPD)≤24  MonthsSerious illness (11.8%)75%93%74%60%10%28%99%98%Baker MD et al (1990)15126(ER) 29-56 days Bacterial disease (9.5%) 33% 73% 11% 91%Baker RC et al (1989)12154(OPD+ER) 3-24 months Bacteremia  (12.3%) 68% 77% 30% -Teach  et al (1995)17 6611(OPD) 3-36months Occult bacteremia  2.9%) 5.2% 96.7% 4.5% 97.1%Jamuna et al( 2000)9 100(OPD+ER) 3-36 months Occult bacteremia (4%) 100% 41.6% 6.6% 100%Bang et al( 2009)16 219(In-patients) 3-36 months Bacteremia  (28.2%) 87.9% 83.8% 68% 94.7%Present  Study100(OPD+ER+In-patients)1-36 months Serious  Bacterial illness (33%) 45.45%88.05% 64.2% 76.6%Note- (OPD- out-patient department, ER- Emergency, PPV-Positive Predictive value, NPV- Negative predictive value) presenting to emergency15,17 while McCarthy, Baker RC  and Jamuna et al included patients from the out- patients and emergency department.7,8,12In the present study, 59% of the children were males which is similar to another study by Bang et al.16 Since male is the preferred gender in our part of the world and more number of these male children are brought to health care services, it might be the reason of higher preponderance of male over female in the present study.Out of the 100 cases, about half of the children presented with fever due to involvement of the respiratory tract system. The most common disease in respiratory tract was pneumonia. This was similar to a study conducted by N. Nepali et al.19 The cause of high prevalence of infections of the respiratory tract might be because of various socio- demographic risk, nutritional and environmental risk factors.20 Out of the 33% of serious bacterial illness, the commonest cause of serious bacterial illness was pneumonia which is comparable to a study done by McCarthy et al.7   The high prevalence of serious bacterial infection in the study might be because of the fact many children with serious illnesses are referred here from all over the country for management and also that most of the non-serious illnesses are managed outside the hospitals in private clinics and other health care centers.Our study had lower sensitivity than other studies. The reason for a low sensitivity might be because of unequal distribution of patient from the emergency, out-patient department and in-patient ward. Antipyretics before YOS21 and referral of serious cases from ER to other centres might have decreased the sensitivity. The specificity is similar to other studies and is higher than sensitivity. The predictive value of the present study is similar to a study done by Bang et al16 but is high when compared to other studies.9,12,15-17 As predictive value Prerana Kansakar: Yale scale to detect serious bacterial infectionJournal of Patan Academy of Health Sciences. 2014 Dec;1(2):23-2626depends upon the prevalence of outcome assessed (serious bacterial infection) which incase of study by Bang et al16 and in my study is high.  Similar to previous studies done by other authors, the negative predictive value of YOS >10 to detect serious bacterial illness was better than the positive predictive value.7,9,15-17 This indicates that YOS is better at ruling out serious bacterial infection and bacteremia. The limitation of our study could be inadequate sample size and the inequal distribution of cases from different sites. We also could not send blood cultures of all the cases so bacteremia could not be studied. Few of our patients had antipyretics before YOS leading to decrease in sensitivity. We could not enroll very sick children who could have been referred directly from the emergency due to unavailability of intensive care unit in our institute which might have affected the result. CONCLUSIONSSerious bacterial illness is present in 1/3rd of the febrile children aged 1 to 36 months. A febrile child with YOS less than or equal to 10 is less likely to have serious bacterial illness but an elevated YOS cannot be used as predictor of serious bacterial illness.   REFERENCES1. Armon K, Stephenson T, Gabriel V. Determining the common medical presenting problems to an accident and emergency department. Archives of Diseases in Childhood. 2001;84(5):390–2.2. Stewart M, Werneke U, MacFaul R, Taylor-Meek J, Smith HE, Smith IJ, et al. Medical and social factors associated with the admission and discharge of acutely ill children. Archives of Diseases in Childhood. 1998;79(3):219–24.3. Singhal A, Morley R, Abbott R, Fairweather-Tait S, Stephenson T, Lucas A, et al. Clinical safety of iron-fortified formulas. Pediatrics. 2000;105(3):38-44.4. National Institute for Health and Clinical Excellence. Feverish illness: assessment and initial management in children younger than 5 years [Internet]. London: NICE; 2007 May [cited 2015 Jan 15]. [Available from: www.nice.org.uk/CG047]5. McCarthy PL, Lembo RM, Fink HD. Observation, history, and physical examination in diagnosis of serious illnesses in febrile children ≤24 months. Journal of Pediatrics. 1987;110(1):26–30.6. Bonado WA. The history and physical assessments of the febrile infant. Pediatric Clinics of North America. 1998;45(1):65-77.7. McCarthy PL, Sharpe MR, Spiesel SZ, Dolan TF, Forsyth BW, DeWitt TG, et al. Observation scales to identify serious illness in febrile children. Pediatrics. 1982;70(5):802-9.8. Jamuna R, Srinivasan S, Harish BN. Factors predicting occult bacteremia in young children. Indian Journal of Pediatrics. 2000;67(10):709-11.9. Bharti B, Bharti S, Verma V. Role of acute AIOS in managing severe childhood pneumonia. Indian Journal of Pediatrics. 2007;74(1):27-32.10. McCarthy PL, Sznajderman SD, Lustman- Findling K, Baron MA, Fink HD, Czarkowski N, et al. Mother’s clinical judgement: a randomized trial of the AIOS. Journal of Pediatrics. 1990;116(2):200-6.11. McCarthy P. Management of the febrile infant. Pediatrics. 1992;89(6):1251-3.12. Baker RC, Tiller T, Bausher JC, Belief PS, Cotton WH, Finley AH, et al. Severity of disease correlated with fever reduction in febrile infants. Pediatrics. 1989;83(6):1016-9.13. Kohli V, Singhi S, Sharma P. Value of serum C-reactive protein concentrations in febrile children without apparent focus. Annals of Tropical Paediatrics. 1993;13(4):373–8.14. Fernandez LA, Luaces CC, Garcia JJ. Procalcitonin in pediatric emergency departments for the early diagnosis of invasive bacterial infections in febrile infants: results of a multicenter study and utility of a rapid qualitative test for this marker. Pediatrics Infectious Disease Journal. 2003;22(10 Suppl):895–903.15.  Baker MD, Avner JR, Bell LM. Failure of an infant observation scale in detecting serious illness in febrile, 4 to 8 weeks old infants. Pediatrics. 1990;85(6):104016. Bang A, Chaturvedi P. Yale Observational Scale for prediction of bacteremia in febrile child. Indian Journal of Pediatrics. 2009;76(6):599-605. 17. Teach SJ, Fleisher GR. Duration of fever and its relationship to bacteremia in febrile outpatients three to 36 months old. The Occult Bacteremia Study Group. Pediatric Emergency Care. 1997;13(5):317–9.18. Lodha R, Mukerji N, Sinha N, Pandey RM, Jain Y. Is axillary temperature an appropriate surrogate for core temperature? Indian Journal of Pediatrics. 2000;67(8):571-4.19. Nepali N, Ghimire R, Shrestha RPBS. Review of Paediatric in-patient at Dhulikhel Hospital, Kathmandu University Teaching Hospital. Journal of Nepal Pediatric Society. 2006;1(26):16-9.20. Bonadio WA, Hennes H, Smith D, Ruffling R, Melzer-Lange M, Lye P, et al. Reliability of observation variables in distinguishing infectious outcome of febrile young infants. Pediatrics Infectious Diseases Journal. 1993;12(2):111-4.21. McCarthy PL. Controversies in pediatrics: What tests are indicated for the child under 2 with fever? Pediatrics in Review. 1979;(1):51.

Efficacy of Yale observation scale to detect serious bacterial infection in febrile children aged one to 36 months

https://www.jpahs.edu.np/index.php/jpahs/article/download/25/25

Efficacy of Yale observation scale to detect serious bacterial infection in febrile children aged one to 36 months

Abstract

Similar works

Full text

Available Versions

Journal of Patan Academy of Health Sciences