A5V4d

Feverish illness in children
Few studies were found looking at the usefulness of markers of bacterial infection in the management
of children with fever without apparent source presenting to the paediatric specialist who were
considered sufficiently unwell that intravenous anti-bacterial treatment should be initiated empirically.
GDG translation
‘Green’ group
Because tests such as CRP, PCT and WBC do not improve the detection of SBI in this group, the
GDG concluded that routine blood tests on well-appearing children with fever are not justified. This
would not change current practice since well-appearing children over 3 months old with fever rarely
have blood tests in the UK at present. In contrast, there is a significant risk of UTI in this group and
only by testing the urine will this be identified.
‘Amber’ and ‘Red’ groups
Although PCT is more sensitive than CRP in identifying sepsis and meningitis in young children with
fever, the GDG did not feel that this difference was sufficient to recommend PCT over CRP,
potentially changing current UK practice. The GDG noted that there was only limited evidence on the
use of PCT in children with fever without apparent source, and they decided to call for more research
in this area. In children with no symptoms or signs of pneumonia, a combination of temperature
> 39°C and a WBC > 20 × 10 9 /litre has a high specificity for bacterial pneumonia and therefore the
GDG concluded that a chest X-ray is indicated in this small group of children. In children considered
sufficiently unwell to require empiric antibiotics, the GDG acknowledged that the result of a CRP or
WBC would not influence immediate management. However, they should be measured as an aid to
ongoing management of this group.
Procalcitonin and C-reactive protein
Introduction
A review question comparing procalitonin (PCT) and C-reactive protein (CRP) was outlined as new
evidence had become available since the 2007 guideline was published.
PCTCRP are found in the bloodstream and the levels of both increase in response to the presence of
bacterial infection, but not (or less so) to viral illness. This response starts approximately 6 hours after
the start of infection with PCT and 12 hours afterwards for CRP. The tests are used to differentiate
between viral and bacterial infections, and to determine the seriousness of bacterial infection.
Review question
The clinical question set out on the scope asks for: ’The predictive value of pro-calcitonin and/or Creactive
protein markers.’ This translates into the following review question “What is the predictive
value of procalcitonin compared to C-reactive protein for detecting serious illness in fever without
apparent source in children under 5?”
Overview of review
In the 2007 guideline the use of CRP was recommended, but not the use of PCT. A research
recommendation was outlined stating the need for studies comparing PCT and CRP. The focus of this
question was to review the literature comparing PCT and CRP.
A literature search was undertaken from 2005 onwards. A total of 594 studies were identified. In
addition, studies included in the 2007 guideline were reviewed for inclusion in the updated guideline.
Description of included studies
A total of 16 observational studies were included in this review (Galetto-Lacour et al., 2003; Guen et
al., 2007; Lacour et al., 2001; Thayyil et al., 2005; Manzano et al., 2011; Olaciregui et al., 2009;
Andreola et al., 2007; Maniaci et al., 2008; Hsaio et al, 2006; Berger et al, 1996; Isaacman et a, 2002;
Pratt et al, 2007 ; Pulliam et al, 2001; Gomez et al, 2010; Luaces-Cubells et al, 2012; Woelker et al,
2012). Fifteen of these assessed CRP and ten assessed PCT. Eight of these studies directly
compared CRP with PCT (Galetto-Lacour et al., 2003; Guen et al., 2007; Lacour et al., 2001; Thayyil
et al., 2005; Manzano et al., 2011; Olaciregui et al., 2009; Andreola et al., 2007; Luaces-Cubells et al,
2012). Six studies included CRP but not PCT (Hsaio et al, 2006; Berger et al, 1996; Gomez et al,
2010; Isaacman et a, 2002; Pratt et al, 2007; Pulliam et al, 2001). Two studies examined PCT only
(Maniaci et al., 2008; Woelker et al, 2012). Fourteen studies were prospective studies and two were
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