Outpatient management of selected young febrile infants without antibiotics

Objectives To determine the incidence of bacterial meningitis (BM) among all febrile infants 29–56 days old undergoing a lumbar puncture (LP) in the emergency department (ED) of a tertiary care children’s hospital and the number of low-risk FYI with BM, in order to reassess the need for routine LP in these infants. Study design Retrospective cohort study using a quality improvement registry from July 2007-April 2014. Infants included were 29–56 days old with fever and who had an LP in the ED. Low-risk criteria were adapted from the Philadelphia criteria. 4BM was defined as having a bacterial pathogen isolated from the cerebrospinal fluid (CSF). A medical record review of one-third of randomly selected patients in the cohort determined the proportion who met low-risk criteria. Results One of 1188 (0.08%) FYI had BM; this patient did not meet low-risk criteria. An additional 40 (3.4%) had positive CSF cultures; all were contaminants. Sub-analysis of one-third of the study population revealed that 45.6% met low-risk criteria; the most common reasons for failing low-risk classification included abnormal white blood cell count or urinalysis. Conclusions In a cohort of FYI, BM is uncommon and no cases of BM would have been missed had LPs not been performed in those meeting low-risk criteria.

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“…In a study performed in Spain, there was no missed case of BM among 676 febrile infants 22–90 days old who met low-risk criteria. 23 …”

Section: Discussionmentioning

confidence: 99%

Lumbar Puncture for All Febrile Infants 29-56 Days Old: A Retrospective Cohort Reassessment Study

Scarfone

Murray

Gala

et al. 2017

The Journal of Pediatrics

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“…In patients <90 days of age, increased body temperature is a matter of great concern. A fever in these patients requires emergency medical treatment due to the significant risk of serious bacterial infection (SBI) . Several clinical practice guidelines recommend a thorough investigation, including laboratory and blood and urine culture, X‐ray, and rapid viral tests to rule out serious infection SBI in febrile infants.…”

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confidence: 99%

“…A fever in these patients requires emergency medical treatment due to the significant risk of serious bacterial infection (SBI). [1][2][3][4] Several clinical practice guidelines recommend a thorough investigation, including laboratory and blood and urine culture, X-ray, and rapid viral tests to rule out serious infection SBI in febrile infants. Such an exhaustive battery of tests, however, can be expensive.…”

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confidence: 99%

“…Such an exhaustive battery of tests, however, can be expensive. 5,6 Many studies have investigated SBI predictors in febrile young infants to optimize patient care, 3,7 but most of these studies involved laboratory examinations for white blood cell count, Creactive protein, and procalcitonin to diagnose SBI, requiring extensive use of medical resources. 8,9 With the aim of optimizing the use of medical resources in the treatment of febrile young infants, some studies have reported using vital sign data to predict SBI, 10 but these studies failed to include a precise cut-off point for the variables, thus limiting the utility of their findings.…”

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confidence: 99%

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Predicting serious bacterial infection in febrile young infants utilizing body temperature

Nomura

Ihara

Sakakibara³

et al. 2019

Pediatrics International

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Background Febrile young infants have a high risk of serious infection. Although measuring vital sign parameters can serve as a rapid and effective assessment in these patients, their predictive value for serious bacterial infection (SBI) has not been fully investigated. Methods This retrospective observational study enrolled febrile (>38.0°C) infants aged <90 days at the time of presentation. Data from the emergency room triage database at Tokyo Metropolitan Children's Medical Center for the period 1 November 2011–30 November 2013, were reviewed. Variables included patient age, gender, and vital sign data, including body temperature, pulse rate, oxygen saturation, definitive diagnosis, and disposition. Results Two hundred and sixty‐nine patients were included, with a mean age of 55 days, and 158 (58.7%) were male. Of the total, 43 patients had an SBI. On logistic regression, body temperature ≥38.5°C (OR, 2.80; 95%CI: 1.37–5.74) was a significant predictor of SBI. Conclusion High‐grade fever was found to be a significant predictor of SBI in febrile young infants.

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“…Traditionally, a conservative approach was advocated with a 'full septic screen', including lumbar puncture (LP), empiric antibiotics and inpatient admission. 10,11 Published evidence exists that select infants aged 1-3 months can be risk stratified. The option to manage febrile infants less invasively has been discussed in the literature since the 1990s, [5][6][7][8] with some clinical centres recently recommending a 'watch and wait' approach in the over 1-month age group 9 or outpatient management.…”

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confidence: 99%

Fever under 3 months and the full septic screen: Time to think again? A retrospective cohort study at a tertiary‐level paediatric hospital

Aldridge

Rao

Sethumadavan

et al. 2017

J Paediatrics Child Health

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Outpatient management of selected young febrile infants without antibiotics

Abstract: Outpatient management without antibiotics and systematic lumbar puncture is appropriate for selected febrile infants younger than 3 months of age with close follow-up.

Cited by 25 publications

References 34 publications

Lumbar Puncture for All Febrile Infants 29-56 Days Old: A Retrospective Cohort Reassessment Study

Lumbar Puncture for All Febrile Infants 29-56 Days Old: A Retrospective Cohort Reassessment Study

Predicting serious bacterial infection in febrile young infants utilizing body temperature

Fever under 3 months and the full septic screen: Time to think again? A retrospective cohort study at a tertiary‐level paediatric hospital

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