This prospective cohort study externally validated the Melbourne ASSET Score for predicting the need for IV antibiotics in children aged 6 months–18 years presenting to a Canadian tertiary pediatric ED with cellulitis (January 2022–January 2024, n=229). The primary outcome was IV vs. oral antibiotic use at 24 hours.
The ASSET Score showed limited discrimination (AUC 0.68; 95% CI 0.61–0.75), with 74% sensitivity and 55% specificity for IV antibiotic use. Notably, 57% of children with scores ≥4 (the threshold for IV therapy) were successfully managed with oral antibiotics. Treatment failure occurred in 12% (28/229), with severe complications only in patients already on IV therapy.
- Single tertiary pediatric center in Canada limits generalizability, especially since local high-dose oral therapy pathways heavily influenced outcomes. - The score's performance as a binary decision rule may not translate to settings without established oral high-dose antibiotic protocols. - Interrater reliability varied across individual ASSET Score components (overall κ=0.66), which may affect reproducibility.
Do not use the Melbourne ASSET Score as a standalone rule to mandate IV antibiotics in pediatric cellulitis—its PPV is only 43% and over half of high-scoring children did well on oral therapy. Use it as one input for risk stratification alongside clinical judgment, particularly in settings with reliable high-dose oral antibiotic pathways.
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