Applying Outpatient Protocols in Febrile Infants 1-28 Days of Age: Can the Threshold Be Lowered?

Abstract

The purpose of this study was to determine the applicability of two accepted outpatient management protocols for the febrile infant 1-2 months of age (Boston and Philadelphia protocols) in febrile infants 1-28 days of age. We retrospectively reviewed charts of patients 1-28 days of age with a temperature greater than or equal to 38.0 degrees C. Criteria from each of the above-cited management protocols were applied to the patients to determine their applicability in screening for serious bacterial infection (SBI). An SBI was defined as bacterial growth in cultures from blood, urine, cerebrospinal fluid (CSF), stool, or any aspirated fluid. Overall, 372 febrile infants were included in the study. Ages ranged from 1 to 28 days of age. The mean age was 15 days. SBI occurred in 45 patients (12%). The mean age of the patients with an SBI was 13 days. Thirty-two infants (8.6%) had a urinary tract infection; 12 (3.2%), bacteremia; five (1.3%), bacterial meningitis; three (0.8%), cellulitis; one (0.3%), septic arthritis; one (0.3%), bacterial gastroenteritis; and one (0.3%), pneumonia. Ten infants had more than one SBI. Of 372 patients, 231 (62%) met the Boston's laboratory low-risk criteria; eight (3.5%) would have been sent home with an SBI with these criteria. Philadelphia's laboratory low-risk criteria would have been met by 186 patients (50%); six (3.2%) would have been sent home with an SBI with these criteria. The negative predictive value of both the Boston and Philadelphia protocols for excluding an SBI was 97%. We conclude that current management protocols for febrile infants 1-2 months of age when applied to febrile infants 1 to 28 days of age would allow 3% of febrile infants less than 28 days of age to be sent home with an SBI. Current guidelines recommending admitting all febrile infants less than 28 days of age should be followed until the outcome of those 3% of febrile infants with an SBI treated as outpatients can be determined.

Clinical profile of fever in newborn and predictors of outcome

“…12 In our study, 62% of the febrile neonates had a total count between 5000-15000 cells/mm 3 and around 29 children had a count more than 15000 cells/mm 3 . Platelet count of less than 185000 cells/mm3 or haematocrit of less than 38.85% or polymorph of greater than 65.5% or haemoglobin of less than 12.95 g/dL in febrile neonates predicted a high chance of mortality.…”

“…62 percent of the febrile neonates had a total count between 5000-15000 cells/mm 3 . 9% had a count less than 5000 cells/mm 3 . Around 29 children had a count more than 15000 cells/mm 3 .…”

“…9% had a count less than 5000 cells/mm 3 . Around 29 children had a count more than 15000 cells/mm 3 . Platelet count was normal in 79% of febrile neonates.…”

“…1 The incidence of serious bacterial infections ranges from 4-28%. [2][3][4] The presenting symptoms are often indirect and clinically it is difficult in distinguishing serious bacterial infection from those occurring in non-infectious conditions, including every sign of neonatal distress. 5 The common causes of fever during first days of life include cesarean section, high birth weight, breast feeding, dehydration fever and possibly early onset of sepsis due to bacterial infections which needs careful observation and immediate conservative and /or antibiotic treatment.…”

Costs and Infant Outcomes After Implementation of a Care Process Model for Febrile Infants

“…[12][13][14] CPMs are designed to decrease variation, improve quality, and support local preferences. 15 The EB-CPM for febrile infants incorporated evidence derived from local institutions 1,4,5,[16][17][18][19][20][21][22][23] and others. 2,7,8,[24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42] We defined 6 quality measures by consensus of representatives serving on the IPCP and their constituents.…”