Validation of the Hospital for Sick Children Algorithm for Discriminating Bacteremia From Contaminants in Children With a Preliminary Positive Blood Culture - 18/06/24

Doi : 10.1016/j.annemergmed.2024.05.005

Jocelyn Gravel, MD, MSc ^a,^⁎ , Charlotte Grandjean-Blanchet, MD ^a, Alino Demean-Loghin ^b, Brandon Noyon ^b, Olivia Ostrow, MD ^c, Émilie Vallières, MD, PhD ^d
^a Department of Pediatric Emergency Medicine, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
^b Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
^c Department of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
^d Division of Microbiology, Department of Clinical Laboratory Medicine, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada

^∗Corresponding Author.

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Abstract

Study objective

Children with positive blood cultures obtained in the emergency department (ED) prompt urgent actions due to the risk of bacteremia. This study aimed to validate the Hospital for Sick Children algorithm used for discriminating bacteremia from contaminants and identified variables associated with bacteremia in children with positive blood cultures.

Methods

We conducted a retrospective cohort study of all children with positive blood cultures from a tertiary care, pediatric ED between 2018 and 2022. A 2-step standardized approach defined true bacteremia as the primary outcome based on 1) the bacteria involved and 2) the clinical outcome assessed by 2 reviewers. We evaluated multiple independent variables. We used multiple logistic regression to analyze the association between independent variables and outcome.

Results

Among the 375,428 ED visits, 574 participants were identified, including 286 (49.8%; 95% confidence interval [CI] 45.8% to 53.9%) with bacteremia and 288 (50.2%; 95% CI 46.1% to 54.3%) with contaminants. The algorithm identified 364 children (63.4%) at high risk of bacteremia, 178 (31.0%) at medium risk, and 32 (5.6%) at low risk. The corresponding bacteremia proportions were 62%, 34%, and 0%, respectively, for a sensitivity of 100% and a specificity of 11%. Suspicion of osteoarticular infection (aOR=43.6; 95% CI 16.2 to 118), presence of internal hardware (aOR=24.9; 95% CI 7.2 to 83.5), and presence of Gram-negative bacteria or Gram-positive cocci in chains/pairs (aOR=21.7; 95% CI 11.7 to 40.3) were the most significant predictors of true bacteremia.

Conclusion

The Hospital for Sick Children algorithm exhibits 100% sensitivity to detect children with bacteremia but demonstrated low specificity at 11%. We identified predictors to discriminate contaminants from bacteremia.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Methods

Study Design and Settings

Characteristics of Study Subjects

Main Results

Limitations

Discussion

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor: Steven M. Green, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: JG initiated the study, drafted the study protocol, participated in the chart review, performed the statistical analysis, drafted the first version of the manuscript, and completed the submission. CG, ADL, and BN collaborated on the design of the study, participated in the chart review, provided feedback for the initial analysis, and critically reviewed and revised the manuscript. EO and EV collaborated on the design of the study, provided feedback for the initial analysis, and critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. JG takes responsibility for the paper as a whole.
	Data sharing statement: Complete datasets and the data dictionary are available from January 2025 on request to Dr. Jocelyn Gravel at graveljocelyn@hotmail.com to investigators who provide an IRB letter of approval.
	Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). This study was conducted without financial support. The authors have no conflict of interest relevant to this article to disclose.
	Presentation information: This work was presented at the Pediatric Academic Societies conference in Toronto, Canada in May 2024, and the Canadian Pediatric Society conference in Vancouver, Canada in June 2024.