Professional Documents
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Clinical Predictors
Clinical Predictors
Febrile Child
Charles G. Murphy, MD, Alma C. van de Pol, MD, Marvin B. Harper, MD, Richard G. Bachur, MD
Abstract
Background: The utility of chest radiographs (CXRs) for detecting occult pneumonia (OP) among pediatric
patients without lower respiratory tract signs has been previously studied, but no predictors other than
white blood cell count (WBC) and height of fever have been investigated.
Objectives: To identify predictors of OP in pediatric patients in the postconjugate pneumococcal vaccination era.
Methods: This was a retrospective cross sectional study that was conducted in a large urban pediatric hospital. Physician records of emergency department (ED) patients of age 10 years or less who presented with
fever (R38 C) and had a CXR obtained for suspected pneumonia were reviewed. Patients were classified
into two groups: signs of pneumonia and no signs of pneumonia on the basis of the presence or absence of respiratory distress, tachypnea, or lower respiratory tract findings. Occult pneumonia was defined
as radiographic pneumonia in a patient without signs of pneumonia.
Results: Two thousand one hundred twenty-eight patients were studied. Among patients categorized as
having no signs of pneumonia (n = 1,084), 5.3% (95% CI = 4.0% to 6.8%) had OP. Presence of cough and
longer duration of cough (greater than 10 days) had positive likelihood ratios (LR+) of 1.24 (95% CI =
1.15 to 1.33) and 2.25 (95% CI = 1.21 to 4.20), respectively. Absence of cough had a negative likelihood ratio
(LR) of 0.19 (95% CI = 0.05 to 0.75). The likelihood of OP increased with increasing duration of fever
(LR+ for more than three days and more than five days of fever, respectively: 1.62; 95% CI = 1.13 to 2.31
and 2.24; 95% CI = 1.35 to 3.71). When obtained (56% of patients), WBC was a predictor of OP, with a
LR+ of 1.76 (95% CI = 1.40 to 2.22) and 2.17 (95% CI = 1.58 to 2.96) for WBC of >15,000/mm3 and
>20,000/mm3, respectively.
Conclusions: Occult pneumonia was found in 5.3% of patients with fever and no lower respiratory tract
findings, tachypnea, or respiratory distress. There is limited utility in obtaining a CXR in febrile children
without cough. The likelihood of pneumonia increased with longer duration of cough or fever or in the
presence of leukocytosis.
ACADEMIC EMERGENCY MEDICINE 2007; 14:243249 2007 by the Society for Academic Emergency
Medicine
Keywords: occult pneumonia, febrile child
ISSN 1069-6563
PII ISSN 1069-6563583
243
244
Murphy et al.
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Figure 1. Distribution of eligible patients on the basis of the presence or absence of clinical signs of pneumonia and chest
radiograph (CXR) results. Grayed boxes are the study patients who are compared for predictors of occult pneumonia.
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Murphy et al.
Table 1
Comparison of Clinical and Laboratory Characteristics of
Patients without Signs of Pneumonia by Physical Examination
Positive CXR
Negative
(Occult Pneumonia)
CXR
pvalue
Parameter
Age (yr)
Temperature
at home ( C)
Triage temp ( C)
WBC count
( 103 per mm3)
Respiratory rate
(respirations/
min)
901
658
3.14 (2.3)
39.5 (0.7)
2.50 (2.3)
39.4 (0.8)
893
508
38.5 (1.0)
21.5 (8.8)
828
31.6 (9.2)
30.5 (9.4)
0.05*
0.40
0.44
pneumonia were statistically older in age. Fifty-six percent of the patients had a WBC count obtained; patients with occult pneumonia had higher mean WBC
count as compared with those without pneumonia (21.5 vs.
14.6 103/mm3, respectively, p < 0.01).
In Table 2, we further examined specific historical variables in patients with no signs of pneumonia and
either positive (occult pneumonia) or negative CXRs. The
positive and negative likelihood ratios for each clinical
finding are shown in Table 3. The duration of cough was
found to be statistically significant in patients with a prolonged history of cough. The LR+ increased with increasing duration of fever. Although the duration of fever
Table 2
Frequencies of Symptoms or Signs by Chest Radiograph (CXR)
Results among Children without Signs of Pneumonia
Symptom
Positive CXR
(Occult Pneumonia;
n = 57)
Presence of cough
Duration of cough (d)
>1
>3
>5
>10
Presence of nasal
congestion
Ill appearance
Fevery
>39 C
>40 C
Duration of fever (d)
>1
>3
>5
WBC count (per mm3)
>15,000
>20,000
Negative
CXR
(n = 844)
pvalue
95.7 (44/46)z
78.8
48.5
42.4
27.3
64.5
78.3
40.0
26.2
12.1
69.9
(26/33)
(16/33)
(14/33)
(9/33)
(20/31)
(278/355)
(142/355)
(93/355)
(43/355)
(411/588)
1.0
0.36
0.07
0.03*
0.04*
1.8 (1/57)
3.0 (26/844)
1.00
71.4 (40/56)
32.1 (18/56)
63.8 (534/837)
29.3 (245/837)
0.31
0.65
68.8 (33/48)
41.7 (20/48)
27.1 (13/48)
74.2 (23/31)
61.3 (19/31)
DISCUSSION
Fever remains one of the most common chief complaints
of children presenting to the pediatric ED. The approach
to children with fever and no apparent source on physical examination continues to evolve, as rates of occult
infections change with new vaccine development and their
more widespread distribution. The CXR is an important
tool that is used in the ED for the diagnosis of pneumonia, whereas the diagnosis of pneumonia in the ambulatory setting has typically relied on suggestive physical
examination findings to help determine appropriate empiric initiation of therapy. Although the finding of an infiltrate or radiographic pneumonia cannot be directly
equated with bacterial pneumonia, the majority of clinicians will prescribe antibiotics for presumed bacterial
pneumonia in the setting of these radiographic findings.
This study investigated patients with fever and no physical examination findings suggestive of pneumonia
(auscultatory signs, tachypnea, hypoxia, or respiratory
distress) to determine the prevalence rate of occult pneumonia in the post pneumococcal vaccine era. We also examined whether clinical variables in the patients history
and physical examination might be predictive of pneumonia. Is there value in obtaining a CXR in a child with
high fever despite clear lung findings and no tachypnea?
In addition, does the duration of cough, duration of fever,
or WBC count influence this decision? This study was undertaken to examine whether there exist specific components of the patients acute illness that can help guide the
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Table 3
Percentage of Patients with Occult Pneumonia Who Have Specific Historical and Laboratory Features, with Positive (LR+) and Negative
(LR) Likelihood Ratios
Feature
% (n) of Patients
with Specific Finding
Who Have Occult Pneumonia
LR (95% CI)
7.9 (44/559)z
Presence of cough
Duration of cough (d)
>1
>3
>5
>10
Presence of nasal congestion
Ill appearance
Fevery
>39 C
>40 C
Duration of fever (d)
>1
>3
>5
WBC count (per mm3)
>15,000
>20,000
8.6
10.1
13.1
17.3
4.6
3.7
(26/304)
(16/158)
(14/107)
(9/52)
(20/431)
(1/27)
1.01
1.21
1.62*
2.25*
0.92
0.56
(0.81,
(0.83,
(1.05,
(1.21,
(0.71,
(0.08,
1.21)
1.76)
2.50)
4.20)
1.20)
4.09)
0.98
0.86
0.78
0.83
1.18
1.01
(0.49,
(0.61,
(0.58,
(0.67,
(0.72,
(0.98,
1.49)
1.21)
1.05)
1.02)
1.92)
1.05)
7.0 (40/574)
6.8 (18/263)
7.9 (33/420)
10.0 (20/201)
13.3 (13/98)
10.3 (23/224)
12.3 (19/154)
Table 4
Comparison of Respiratory Findings in Patients with Signs of Pneumonia by Physical Examination
Sign or Symptom
Wheeze
Rales
Rhonchi
Decreased breath sounds
Signs of respiratory distress
Tachypnea (age defined)
Positive CXR,
% (n; N = 132)
31.8
40.1
18.9
31.8
38.6
71.9
(42)
(53)
(25)
(42)
(51)
(95)
Negative CXR,
% (n; N = 613)
48.3
23.3
13.1
10.9
40.1
70.6
(296)
(143)
(80)
(67)
(246)
(433)
p-value
<0.01
<0.01
0.1
<0.01
0.77
1.0
(0.51,
(1.34,
(0.57,
(2.08,
(0.76,
(0.89,
0.86)
2.22)
2.18)
4.08)
1.22)
1.12)
LR (95% CI)
1.32*
0.78*
0.93
0.77*
1.02
1.01
(1.15,
(0.67,
(0.85,
(0.68,
(0.88,
(0.75,
1.52)
0.90)
1.02)
0.86)
1.19)
1.37)
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Murphy et al.
breath sounds was also found to be a significant predictor for pneumonia among patients with lower respiratory tract findings (LR+ of 1.7 and 2.9, respectively) but
with relatively low positive predictive values of 27.0%
(95% CI = 21.1% to 24.4%) and 39.1% (95% CI =
30.0% to 48.9%), respectively. Tachypnea, although significant in some past studies, was not seen at a statistically higher rate in our patients with pneumonia, when
compared with patients with negative radiographs. Our
study population included a large number of younger
patients (median age for both groups = 1.7 yr), many
of whom were tachypneic, regardless of a positive or
negative CXR. This large number of younger patients
may have made the value of tachypnea as a predictor
of pneumonia more difficult to appreciate.
These previous studies, although helpful guides for the
patient who presents with respiratory signs that are suggestive for pneumonia, leave the clinician without clear
recommendations on the indication for a CXR in the absence of overt signs of pneumonia. The presumption for
previous studies would be that a CXR would not be indicated on the basis of an absence of these clinical signs.
However, these studies did not specifically evaluate the
prevalence rate of occult pneumonia in febrile children.
We find the rate of pneumonia to be 5.3% (95% CI =
4.0% to 6.8%), or 1 in 20 among febrile children without
any lower respiratory tract findings, signs of respiratory
distress, tachypnea, or hypoxia. A study in 1999, before
the use of the conjugate pneumococcal vaccine, reported
a high rate of occult pneumonia (no clinical evidence of
pneumonia) among febrile children with leukocytosis.
In this study, positive radiographs were found in 26%
of febrile children aged %5 years of age with no clinical
signs of pneumonia by examination, if they had fever of
R39 C and a WBC count of R20,000/mm3.7 These results
suggested a much higher incidence of occult pneumonia
in this patient population than previously realized.
With the advent of a conjugate pneumococcal vaccine,
the incidence of invasive Streptococcus pneumoniae disease has decreased significantly.8,10 Historically, the ED
evaluation of febrile children aged 336 months with no
apparent source of infection frequently included evaluation for possible occult bacteremia, with S. pneumoniae
being the most common pathogen isolated in these cases.
As the rates of invasive pneumococcal disease declined
with widespread vaccine use, the practice of evaluating
febrile young children for occult bacteremia has declined, and with that has come a reduction in the frequency in which a complete blood count is obtained in
this population. As a result, the frequency with which
the clinician will have an opportunity to identify leukocytosis to guide evaluation of young febrile children has appropriately decreased. In the absence of available WBC
counts, it is even more important to examine other variables that may guide the clinician in the evaluation of
these patients for occult pneumonia.
In our study, the prevalence of occult pneumonia was
5.3% (95% CI = 4.0% to 6.8%). Among the historical variables studied, the presence of cough was found to be a
statistically significant predictor of patients with occult
pneumonia. Conversely, in febrile children with no signs
of pneumonia on physical examination and no history of
cough, the prevalence of occult pneumonia was only
LIMITATIONS
There are several limitations of our study. First, we were
only able to review patients who had a CXR obtained;
therefore, the exact prevalence of occult pneumonia
can only be estimated. The need to have a CXR also introduces potential bias into our study, as well as limits its
possible applicability, as we are studying a population
of patients in whom the clinician has already made the
decision to obtain a CXR. Furthermore, documentation
in medical records can be incomplete or inaccurate. To
help minimize the inherent limitations of a retrospective
review, we developed strict data abstraction rules. In
the case of physical examination, findings were presumed to be absent unless specifically recorded in the
medical record. This introduces a potential source of error into our study, as the possibility exists that specific
physical examination findings were in fact present but
were not noted in the medical record. The presence
and height of fever in several cases was based on information provided from the guardian, because the patient
was afebrile on arrival in the ED. This could raise the potential concern of the accuracy of this data element. In
addition, we were unable to assess whether the radiograph result was known before documentation in the
record; this could lead to recall bias in the physicians
record. Similarly, CXR readings were based on the reading from a single attending radiologist who may not have
been blinded to the clinical presentation of the patient.
Chest radiographs were ordered on patients at the physicians discretion, rather than on the basis of prespecified criteria, raising the potential concern for possible
selection bias. We also adopted a strict definition of
what we term occult pneumonia, which may limit the applicability of our findings. Furthermore, the prevalence
of pneumonia may have been underestimated by our
exclusion of all patients with apparently equivocal CXR
readings; although many of the patients with equivocal
radiographs were treated as having pneumonia, we felt
that this would also overestimate the incidence of pneumonia. Finally, although the presence of leukocytosis
continues to be a predictor of pneumonia, it is important
to note that a WBC count was only obtained in approximately half the patients in the study.
CONCLUSIONS
Radiographic pneumonia can be identified in a subset of
febrile children, even in the absence of lower respiratory
signs by physical examination. These occult pneumonias
are more common in children with prolonged fever and
cough. Conversely, empiric CXRs have limited diagnostic
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