What are the Rochester criteria for pediatric patients?

From the Guidelines

The Rochester criteria are a reliable tool for identifying low-risk febrile infants aged 0-60 days who may not require hospitalization or extensive workup, as supported by the clinical policy for well-appearing infants and children younger than 2 years of age presenting to the emergency department with fever 1. The criteria include:

• infant appears generally well
• previously healthy (born at term, no perinatal antibiotics, no previous hospitalizations, no chronic or underlying illness)
• no evidence of skin, soft tissue, bone, joint, or ear infection
• normal laboratory values (white blood cell count 5,000-15,000/mm³, absolute band count ≤1,500/mm³, normal urinalysis with <10 WBC/hpf, and if diarrhea is present, <5 WBC/hpf in stool) Infants meeting all criteria may receive a single dose of ceftriaxone (50 mg/kg) and be discharged with close follow-up within 24 hours, as this approach has been shown to reduce unnecessary hospitalizations while ensuring appropriate care for those who need it 1. Key considerations when applying the Rochester criteria include:
• Clinical judgment should always be used alongside these criteria
• Parental reliability and access to follow-up care must be considered before choosing outpatient management
• The criteria are not applicable to neonates (aged 28 days) or infants with specific risk factors, such as uncircumcised male infants, who may require more thorough evaluation and management 1.

From the Research

Overview of Rochester Criteria

• The Rochester criteria were developed to identify febrile infants aged 60 days or younger at low-risk of bacterial infection 2.
• The criteria do not include cerebrospinal fluid (CSF) testing and are based on medical history, symptoms or ill appearance, results of urinalysis, complete blood count, and blood, urine, and CSF culture 2.

Application of Rochester Criteria

• A study published in 2019 found that the sensitivity of the Rochester criteria for detection of invasive bacterial infection was 92.7% overall, 91.7% for neonates 28 days or younger, and 94.1% for infants aged 29 to 60 days old 2.
• Another study published in 2018 noted that the old Rochester criteria remain effective for identifying young infants between 29 and 60 days old who do not have severe bacterial infections (SBIs), but the addition of laboratory tests such as C-reactive protein (CRP) and procalcitonin (PCT) can significantly improve the identification of children with SBI 3.

Limitations and Variations

• A study from 1997 found that employing the Rochester criteria to fully cultured neonates who could be risk-stratified, the sensitivity, specificity, positive predictive value, and negative predictive value were 86.4%, 46.4%, 26.8%, and 93.8%, respectively 4.
• A 2005 study reappraised the Philadelphia protocol and the Rochester criteria for identifying infants at low risk for serious bacterial illness (SBI) and found that the negative predictive value (NPV) of the Rochester criteria was 97.3% (95% CI = 90.5% to 99.2%) 5.

Clinical Decision Making

• The Rochester criteria can be used to determine whether or not febrile infants are at low risk for serious bacterial infection, but should be used in conjunction with clinical judgment and other diagnostic tools 6.
• The approach in evaluating neonates is significantly more complicated, as their risk of SBIs, including bacteremia and meningitis, remains relevant and none of the suggested approaches can reduce the risk of dramatic mistakes 3.