This guideline addresses the evaluation and management of wellappearing, term infants, 8 to 60 days of age, with fever $38.0 C. Exclusions are noted. After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active investigators, 21 key action statements were derived. For each key action statement, the quality of evidence and benefit-harm relationship were assessed and graded to determine the strength of recommendations. When appropriate, parents' values and preferences should be incorporated as part of shared decision-making. For diagnostic testing, the committee has attempted to develop numbers needed to test, and for antimicrobial administration, the committee provided numbers needed to treat. Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. BACKGROUNDEfforts to develop an evidence-based approach to the evaluation and management of young febrile infants have spanned more than 4 decades. 1 In the 1970s, concerns arose about the emergence and rapid progression of group B Streptococcus (GBS) infection in neonates, whose clinical appearance and preliminary laboratory evaluations did not always reflect the presence of serious disease. 2 Such concerns led to extensive evaluations, hospitalizations, and antimicrobial treatment of all febrile infants younger than 60 days, 3 with many institutions extending complete sepsis workups to 90 days. However, the seminal

IMPORTANCE The incidence of human papillomavirus (HPV)-related cancers is more than 35 000 cases in the United States each year. Effective HPV vaccines have been available in the United States for several years but are underused among adolescents, the target population for vaccination. Interventions to increase uptake are needed. OBJECTIVE To evaluate the effect of a 5-component health care professional HPV vaccine communication intervention on adolescent HPV vaccination. DESIGN, SETTING, AND PARTICIPANTS A cluster randomized clinical trial using covariate-constrained randomization to assign study arms and an intent-to-treat protocol was conducted in 16 primary care practices in the Denver, Colorado, metropolitan area. Participants included 188 medical professionals and 43 132 adolescents. INTERVENTIONS The 5 components of the intervention were an HPV fact sheet library to create customized information sheets relevant to each practice's patient population, a tailored parent education website, a set of HPV-related disease images, an HPV vaccine decision aid, and 2½ hours of communication training on using a presumptive vaccine recommendation, followed by motivational interviewing if parents were resistant to vaccination. Each practice participated in a series of 2 intervention development meetings over a 6-month period (August 1, 2014, to January 31, 2015) before the intervention. MAIN OUTCOMES AND MEASURES Differences between control and intervention changes over time (ie, difference in differences between the baseline and intervention period cohorts of patients) in HPV vaccine series initiation (Ն1 dose) and completion (Ն3 doses) among patients aged 11 to 17 years seen at the practices between February 1, 2015, and January 31, 2016. Vaccination data were obtained from the practices' records and augmented with state immunization information system data. RESULTS Sixteen practices and 43 132 patients (50.3% female; median age, 12.6 years [interquartile range, 10.8-14.7 years] at the beginning of the study period) participated in this trial. Adolescents in the intervention practices had significantly higher odds of HPV vaccine series initiation (adjusted odds ratio [aOR], 1.46; 95% CI, 1.31-1.62) and completion (aOR, 1.56; 95% CI, 1.27-1.92) than those in the control practices (a 9.5-absolute percentage point increase in HPV vaccine series initiation and a 4.4-absolute percentage point increase in HPV vaccine series completion in intervention practices). The intervention had a greater effect in pediatric practices compared with family medicine practices and in private practices compared with public ones. Health care professionals reported that communication training and the fact sheets were the most used and useful intervention components. CONCLUSIONS AND RELEVANCE A health care professional communication intervention significantly improved HPV vaccine series initiation and completion among adolescent patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02456077

At the community level, evidence-based communication strategies to address vaccine hesitancy are needed. The practice of dismissing families from pediatric practices who refuse to vaccinate is common, although widely criticized. Other controversial and rapidly evolving topics include statewide vaccination mandates and school exemption policies. Electronic interventions, such as text-messaging services and social media, have recently emerged as effective methods of communication and may become more important in coming years.

Providing Web-based vaccine information with social media applications during pregnancy can positively influence parental vaccine behaviors.