Management and Outcomes of Previously Healthy, Full-Term, Febrile Infants Ages 7 to 90 Days

Abstract

BACKGROUND: There is considerable variation in the approach to infants presenting to the emergency department and outpatient clinics with fever without a source. We set out to describe the current clinical practice regarding culture acquisition on febrile young infants and review the outcomes of infants with and without cultures obtained.

Observational Assessment in the Febrile Infant

“…The observational assessment of moderately or very ill (corresponding to YOS scores of 11-15 and ≥16) detected 36 (58%) of the 63 infants and was considered an important component of a diagnostic approach, which included appearance, age <25 days, fever >38.6°C, and had a sensitivity for bacteremia and/or bacterial meningitis of 94% (59 of 63 infants). Greenhow et al 7 reported on 1380 infants who were 7 to 90 days of age with fever seen in Northern California Kaiser Permanente over a 3-year period, 40 of whom had bacteremia and/ or meningitis. Laboratory testing was variable in frequency but more common in infants 7 to 28 days old.…”

Etiology and Causative Pathogens of Febrile Neonates

“…Fever is not uncommon in neonatal period, and the incidence rate of fever was documented as 14.4/1000 full tem births [1]. Although such fevers are typically self-limiting, it has been reported that 7.1-19.7% of affected neonate also have serious bacterial infection (SBI) [2][3][4][5].…”

Management of Fever in Young Infants: Evidence Versus Common Practice

“…Similarly, the study in this issue of Pediatrics involving febrile infants followed up by the Kaiser Permanente Northern California network found that only 59% of infants aged 7 to 28 days, 25% of infants aged 29 to 60 days, and 5% of infants aged 61 to 90 days had a full sepsis evaluation. 5 With this approach, no infant returned with bacteremia or meningitis, and only 1% of infants returned with urinary tract infection. It is important to note that the management of these infants was at the discretion of the practitioner, and 32.3% of the 1390 febrile infants studied had no bacterial cultures obtained at all.…”

“…In the current publication of Kaiser Permanente Northern California data, among the reasons cited for not obtaining cultures in febrile infants are "other diagnosis of otitis, " "upper respiratory symptoms or bronchiolitis, " "sick contacts appeared well, " and "did not believe thermometer." 5 All of these parameters have been investigated previously and have been shown to not excuse or eliminate the need for further investigation of cause of fever in young infants. Numerous publications of prospectively collected data have repeatedly found a 6% to 7% concurrence of bacterial infection in febrile infants with demonstrated viral infection.…”