Outpatient Management without Antibiotics of Fever in Selected Infants

Baker, M. Douglas; Bell, Louis M.; Avner, Jeffrey R.

doi:10.1056/nejm199311113292001

Cited by 426 publications

(371 citation statements)

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“…Several management protocols have been published. 9,10,15,[17][18][19] Some studies have shown that selected febrile infants may safely be managed as outpatients without the use of antibiotics. 10,18,19 Those infants had to meet more stringent risk criteria than ours to qualify for outpatient management, and 75% of the most recent study population of infants 29 to 60 days old using this strategy were admitted.…”

Section: Discussionmentioning

confidence: 99%

“…9,10,15,[17][18][19] Some studies have shown that selected febrile infants may safely be managed as outpatients without the use of antibiotics. 10,18,19 Those infants had to meet more stringent risk criteria than ours to qualify for outpatient management, and 75% of the most recent study population of infants 29 to 60 days old using this strategy were admitted. 19 In our population, the strategy of Baskin et al 15 was used, so all children were treated with antibiotics but only 39% (42% of 28-to 60-day-old infants and 34% of 61-to 90-day-old infants) were admitted.…”

Section: Discussionmentioning

confidence: 99%

“…Other authors, using more stringent risk criteria, advocate outpatient management of low-risk febrile infants without antibiotic treatment, and inpatient management of the rest. 10,18,19 We sought to determine the time to detection of positive cultures so that optimal strategies for management and follow-up can be devised and implemented. …”

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confidence: 99%

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Time to Detection of Positive Cultures in 28- to 90-Day-Old Febrile Infants

Kaplan¹,

Harper²,

Baskin³

et al. 2000

Pediatrics

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ABSTRACT. Objective. To determine the time to detection of positive blood, urine, and cerebrospinal fluid (CSF) cultures among febrile 28-to 90-day-old infants.Study Design. Retrospective cohort of consecutive 28-to 90-day-old infants presenting with a temperature of >38°C to an urban pediatric emergency department. Positive cultures and times to detection were noted. Patients were categorized as being at high risk for serious bacterial illness (SBI) based on clinical and laboratory criteria.Results. Of the 3166 febrile infants seen in the emergency department during the study, 2733 had blood (86%), 2517 had urine (80%), and 2361 had CSF (75%) specimens obtained for culture, and 2190 had all 3 cultures (69%) sent. There were 224 positive cultures in 214 patients; of these, 191 had all 3 cultures (89%) sent. Subsequent analyses were confined to those who had all 3 cultures sent. The detected rate of SBI was 8.7% ( Conclusions. The risk of identifying SBI after 24 hours is 1.1% among all 28-to 90-day-old febrile infants and .3% in low-risk infants. Pediatrics 2000;106(6). URL: http://www.pediatrics.org/cgi/content/full/106/6/e74; serious bacterial illness, febrile infants.ABBREVIATIONS. SBI, serious bacterial illness; CSF, cerebrospinal fluid; ED, emergency department; CI, confidence interval; CBC, complete blood cell count. U p to 15% of 28-to 90-day-old febrile infants may have serious bacterial illness (SBI). 1-8 The patient's physical examination and laboratory evaluation may not detect all SBIs. 9 -19 No definitive data have been reported establishing the timing of detection of positive cultures. The practice guidelines by Baraff et al 17 for the management of infants and children 0 to 36 months of age with fever without source include recommendations that were made in the absence of these data. In 2 studies, low-risk infants were treated as outpatients with empiric antibiotics. 9,15 Baskin et al 15 showed that lowrisk febrile infants 28 to 89 days of age can be managed safely with the administration of a parenteral dose of ceftriaxone and discharged from the hospital with a scheduled follow-up within 24 hours for clinical reevaluation and a second dose of ceftriaxone to provide antibiotic coverage while the blood, urine, and cerebrospinal fluid (CSF) cultures incubate. This strategy is based on the assumptions that most pathogens are identified within 48 hours and 2 doses of ceftriaxone will provide sufficient protection for those children whose pathogens are identified later. Other authors, using more stringent risk criteria, advocate outpatient management of low-risk febrile infants without antibiotic treatment, and inpatient management of the rest. 10,18,19 We sought to determine the time to detection of positive cultures so that optimal strategies for management and follow-up can be devised and implemented. METHODS Design, Setting, and SubjectsThe investigation was a retrospective cohort study. Subjects were febrile infants seen in the emergency department (ED) of an urban pediatric teaching hospital. T...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Time to Detection of Positive Cultures in 28- to 90-Day-Old Febrile Infants

Kaplan¹,

Harper²,

Baskin³

et al. 2000

Pediatrics

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“…Therefore, most studies on evaluation and treatment of febrile young infants place neonates in a separate category. [1][2][3][4][5] Widely followed guidelines recommend a complete evaluation of febrile neonates, even if well appearing, for SIs and admission to the hospital for presumptive antibiotics. 6 A few authors have attempted to define low-risk criteria for treating these patients less conservatively.…”

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confidence: 99%

Management of Febrile Neonates in US Pediatric Emergency Departments

et al. 2014

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WHAT'S KNOWN ON THIS SUBJECT: Recommended management of febrile neonates (#28 days) includes blood, urine, and cerebrospinal fluid cultures with hospital admission for antibiotic therapy. No study has reported adherence to standard recommendations in the management of febrile neonates in US pediatric emergency departments. WHAT THIS STUDY ADDS:There is wide variation in adherence to recommended management of febrile neonates. High rates of serious infections in admitted patients but low return rates for missed infections in discharged patients suggest additional studies needed to understand variation from current recommendations. abstract BACKGROUND: Blood, urine, and cerebrospinal fluid cultures and admission for antibiotics are considered standard management of febrile neonates (0-28 days). We examined variation in adherence to these recommendations across US pediatric emergency departments (PEDs) and incidence of serious infections (SIs) in febrile neonates. METHODS:Cross-sectional study of neonates with a diagnosis of fever evaluated in 36 PEDs in the 2010 Pediatric Health Information System database. We analyzed performance of recommended management (laboratory testing, antibiotic use, admission to hospital), 48-hour return visits to PED, and diagnoses of SI. RESULTS:Of 2253 neonates meeting study criteria, 369 (16.4%) were evaluated and discharged from the PED; 1884 (83.6%) were admitted. Recommended management occurred in 1497 of 2253 (66.4%; 95% confidence interval, 64.5-68.4) febrile neonates. There was more than twofold variation across the 36 PEDs in adherence to recommended management, recommended testing, and recommended treatment of febrile neonates. There was significant variation in testing and treatment between admitted and discharged neonates (P , .001). A total of 269 in 2253 (11.9%) neonates had SI, of whom 223 (82.9%; 95% confidence interval, 77.9-86.9) received recommended management.CONCLUSIONS: There was wide variation across US PEDs in adherence to recommended management of febrile neonates. One in 6 febrile neonates was discharged from the PED; discharged patients were less likely to receive testing or antibiotic therapy than admitted patients. A majority of neonates with SI received recommended evaluation and management. High rates of SI in admitted patients but low return rates for missed infections in discharged patients suggest a need for additional studies to understand variation from the current recommendations.

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“…Recently, a comprehensive review of the literature (9) suggested that children 29 to 90 days old at low risk can also be investigated without a lumbar puncture and be discharged with no empirical treatment and follow-up based on the results of the blood and urine tests in the emergency department (ED). It is important to note that children in the Philadelphia study did not receive antibiotics if they were considered to be at low risk (8). Also note that in their study, low-risk criteria mandated a lumbar puncture.…”

Section: Management Of 29-to 90-day-old Infantsmentioning

confidence: 98%

Clinical management of fever in children younger than three years of age

Pusic¹

2007

Paediatrics &Amp; Child Health

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MV Pusic. Clinical management of fever in children younger than three years of age. Paediatr Child Health 2007;12(6):469-472.The clinical management of febrile children continues to evolve, especially in the light of vaccines against Haemophilus influenzae type B and more recently, Streptococcus pneumoniae. These vaccines have decreased the risk of serious bacterial illness in most children, allowing for a more selective approach to investigation and empirical treatment. However, children younger than three months of age still require an aggressive approach to investigation and careful follow-up. Certain laboratory criteria can allow safe management of even young infants on an outpatient basis. The present article outlines an age-based approach to investigation and management of children with fever.Key Words: Bacteremia; Fever; Meningitis; Occult bacteremia; Urinary tract infection La prise en charge clinique de la fièvre chez les enfants de moins de trois ans La prise en charge clinique des enfants fébriles continue d'évoluer, notamment depuis l'adoption des vaccins contre l'Haemophilus influenzae de type B et, plus récemment, contre le Streptococcus pneumoniae. Ces vaccins réduisent le risque de maladie bactérienne grave chez la plupart des enfants, ce qui permet d'adopter une approche plus sélective des explorations et du traitement empirique. Toutefois, il faut toujours privilégier une approche plus musclée des explorations et un suivi attentif auprès des enfants de moins de trois mois. Certains critères de laboratoire permettent la prise en charge sécuritaire des nourrissons très jeunes en consultations externes. Le présent article propose une approche adaptée à l'âge des explorations et de la prise en charge des enfants fébriles.

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Outpatient Management without Antibiotics of Fever in Selected Infants

Abstract: With the use of strict screening criteria, a substantial number of febrile one-to-two-month-old infants can be cared for safely as outpatients and without antibiotics.

Cited by 426 publications

References 12 publications

Time to Detection of Positive Cultures in 28- to 90-Day-Old Febrile Infants

Time to Detection of Positive Cultures in 28- to 90-Day-Old Febrile Infants

Management of Febrile Neonates in US Pediatric Emergency Departments

Clinical management of fever in children younger than three years of age

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