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Pehlivan J, Douillet D, Jérémie R, Perraud C, Niset A, Eveillard M, Chenouard R, Mahieu R. A clinical decision rule to rule out bloodstream infection in the emergency department: retrospective multicentric observational cohort study. Emerg Med J 2023; 41:20-26. [PMID: 37940371 DOI: 10.1136/emermed-2022-212987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND We aimed to identify patients at low risk of bloodstream infection (BSI) in the ED. METHODS We derived and validated a prediction model to rule out BSI in the ED without the need for laboratory testing by determining variables associated with a positive blood culture (BC) and assigned points according to regression coefficients. This retrospective study included adult patients suspected of having BSI (defined by at least one BC collection) from two European ED between 1 January 2017 and 31 December 2019. The primary end point was the BSI rate in the validation cohort for patients with a negative Bacteremia Rule Out Criteria (BAROC) score. The effect of adding laboratory variables to the model was evaluated as a second step in a two-step diagnostic strategy. RESULTS We analysed 2580 patients with a mean age of 64 years±21, of whom 46.1% were women. The derived BAROC score comprises 12 categorical clinical variables. In the validation cohort, it safely ruled out BSI without BCs in 9% (58/648) of patients with a sensitivity of 100% (95% CI 95% to 100%), a specificity of 10% (95% CI 8% to 13%) and a negative predictive value of 100% (95% CI 94% to 100%). Adding laboratory variables (creatinine ≥177 µmol/L (2.0 mg/dL), platelet count ≤150 000/mm3 and neutrophil count ≥12 000/mm3) to the model, ruled out BSI in 10.2% (58/570) of remaining patients who had been positive on the BAROC score. The BAROC score with laboratory results had a sensitivity of 100% (95% CI 94% to 100%), specificity of 11% (95% CI 9% to 14%) and negative predictive value of 100% (95% CI 94 to 100%). In the validation cohort, there was no evidence of a difference in discrimination between the area under the receiver operating characteristic for BAROC score with versus without laboratory testing (p=0.6). CONCLUSION The BAROC score safely identified patients at low risk of BSI and may reduce BC collection in the ED without the need for laboratory testing.
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Affiliation(s)
- Jonathan Pehlivan
- Service de maladies infectieuses et tropicales, Centre hospitalier universitaire d'Angers, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Delphine Douillet
- Emergency Department, Angers University Hospital, CHU Angers, Angers, France
- UMR MitoVasc CNRS 6015-INSERM 1083, University of Angers, Angers, France
| | - Riou Jérémie
- Micro et Nano médecines translationnelles, MINT, UMR INSERM 1066, UMR CNRS 6021, University of Angers, Angers, France
- Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, CHU Angers, Angers, France
| | - Clément Perraud
- Emergency Department, Angers University Hospital, CHU Angers, Angers, France
| | - Alexandre Niset
- Emergency Department, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Hopital à Bruxelles-Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Matthieu Eveillard
- Laboratoire de Bactériologie, Institut de Biologie en Santé-PBH, CHU Angers, Angers, France
| | - Rachel Chenouard
- Laboratoire de Bactériologie, Institut de Biologie en Santé-PBH, CHU Angers, Angers, France
| | - Rafael Mahieu
- Service de maladies infectieuses et tropicales, Centre hospitalier universitaire d'Angers, CHU Angers Maladies infectieuses et tropicales, Angers, France
- Faculty of Medicine, Université de Nantes, Inserm, CRCINA, SFR ICAT, University of Angers, Angers, France
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