Validating clinical practice guidelines for the management of febrile infants presenting to the emergency department in the UK and Ireland

Abstract

ObjectiveTo report the performance of clinical practice guidelines (CPG) in the diagnosis of serious/invasive bacterial infections (SBI/IBI) in infants presenting with a fever to emergency care in the UK and Ireland. Two CPGs were from the National Institutes for Health and Care Excellence (NICE guidelines NG51 and NG143) and one was from the British Society for Antimicrobial Chemotherapy (BSAC).DesignRetrospective multicentre cohort study.PatientsFebrile infants aged 90 days or less attending between the 31 August 2018 to 1 September 2019.Main outcome measuresThe sensitivity, specificity and predictive values of CPGs in identifying SBI and IBI.SettingSix paediatric Emergency Departments in the UK/Ireland.Results555 participants were included in the analysis. The median age was 53 days (IQR 32 to 70), 447 (81%) underwent blood testing and 421 (76%) received parenteral antibiotics. There were five participants with bacterial meningitis (1%), seven with bacteraemia (1%) and 66 (12%) with urinary tract infections. The NICE NG51 CPG was the most sensitive: 1.00 (95% CI 0.95 to 1.00). This was significantly more sensitive than NICE NG143: 0.91 (95% CI 0.82 to 0.96, p=0.0233) and BSAC: 0.82 (95% 0.72 to 0.90, p=0.0005). NICE NG51 was the least specific 0.0 (95% CI 0.0 to 0.01), and this was significantly lower than the NICE NG143: 0.09 (95% CI 0.07 to 0.12, p<0.0001) and BSAC: 0.14 (95% CI 0.1 to 0.17, p<0.0001).ConclusionNone of the studied CPGs demonstrated ideal performance characteristics. CPGs should be improved to guide initial clinical decision making.Trial registration numberNCT04196192.

Diagnostic test accuracy of dipstick urinalysis for diagnosing urinary tract infection in febrile infants attending the emergency department

“…Young febrile infants (under 90 days of age) are at high risk of serious bacterial infections (SBI) [1][2][3][4]. The most commonly encountered SBI are urinary tract infections, accounting for 80% to 90% of all SBI in this age group [1][2][3][4][5][6][7].…”

“…Young febrile infants (under 90 days of age) are at high risk of serious bacterial infections (SBI) [1][2][3][4]. The most commonly encountered SBI are urinary tract infections, accounting for 80% to 90% of all SBI in this age group [1][2][3][4][5][6][7]. The features of urinary tract infection in young infants are typically non-specific and include fever, vomiting, lethargy, irritability and poor feeding [8][9][10].…”

Systematic review and meta-analysis assessing the diagnostic test accuracy of procalcitonin in the diagnosis of invasive bacterial infections in febrile infants: a study protocol

“…Young febrile infants (defined as 90 days of age or younger with a history of fever) are at a relatively high risk of invasive bacterial infections (IBIs) compared with older children. [1][2][3] Invasive bacterial infections include bacterial meningitis and symptomatic bacteraemia and are reported in 1%-3% of young febrile infants. [1][2][3][4][5] In addition to IBI, a further 10%-15% of young febrile infants will be diagnosed with other serious bacterial infections (SBIs); typically urinary tract infections (UTIs) requiring antibiotic treatment.…”

“…[1][2][3] Invasive bacterial infections include bacterial meningitis and symptomatic bacteraemia and are reported in 1%-3% of young febrile infants. [1][2][3][4][5] In addition to IBI, a further 10%-15% of young febrile infants will be diagnosed with other serious bacterial infections (SBIs); typically urinary tract infections (UTIs) requiring antibiotic treatment. 1 3 6 Unfortunately, it is clinically difficult to differentiate those infants with an evolving IBI from those with a self-limiting viral infection, particularly in the prodrome of their illness and in the youngest of this cohort.…”

“…Young febrile infants (defined as 90 days of age or younger with a history of fever) are at a relatively high risk of invasive bacterial infections (IBIs) compared with older children 1–3. Invasive bacterial infections include bacterial meningitis and symptomatic bacteraemia and are reported in 1%–3% of young febrile infants 1–5.…”