Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections

doi:10.1016/S0022-3476(88)80312-3

The Journal of Pediatrics

Volume 112, Issue 3, March 1988, Pages 355-360

https://doi.org/10.1016/S0022-3476(88)80312-3 Get rights and content

We prospectively examined whether febrile infants younger than 2 months of age who were defined as being at low risk for having bacterial infection could be observed as outpatients without the usual complete evaluation for sepsis and without antibiotic treatment. A total of 237 previously healthy febrile infants were seen at the Pediatric Emergency Room over 17 1/2 months. One hundred forty-eight infants (63%) fulfilled the criteria for being at low risk: no physical findings consisting of soft tissue or skeletal infections, no purulent otitis media, normal urinalysis, <25 white blood cells per high-power field on microscopic stool examination, peripheral leukocyte count 5000 to 15,000/mm³ with <1500 band cells/mm³. One infant appeared too ill to be included, and had sepsis and meningitis. None of the 148 infants at low risk had bacterial infections, versus 21 of 88 (24%) of those at high risk (P<0.0001); eight of 88 (9%) had bacteremia. Of the 148 infants classified as being at low risk for having bacterial infection, 62 (42%) were discharged to home, and 72 (49%) were initially observed for ≤24 hours and then discharged. Seventeen infants (11%) were hospitalized: in six, low risk became high risk; six had indications other than fever; and five because the study physicians could not be found. The 137 nontreated infants were closely observed as outpatients. The duration of fever was <48 hours in 42%, and less than 96 hours in 91%. All infants were observed for at least 10 days after the last examination. The fever resolved spontaneously in all infants but two, with otitis media, who were treated as outpatients. Our data suggest that management of fever in selected young infants as outpatients is feasible if meticulous follow-up is provided.

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To assess the incidence rate of invasive bacterial infections in preterm infants and compare invasive bacterial infection rates and pathogens between preterm and full-term infants at age 7-90 days.
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Between January 1, 2005, and December 31, 2017, a total of 479 729 infants were born at KPNC, including 440 070 full-term infants and 39 659 preterm infants. There were 283 cases of bacteremia in 282 infants. The incidence rate of invasive bacterial infection was significantly higher for preterm infants compared with full-term infants. The highest incidence rates of invasive bacterial infection were in preterm infants at chronological age 7-28 days and/or 37-39 weeks PMA. There was a trend toward lower rates of invasive bacterial infection with increasing PMA in preterm infants aged 61-90 days. Preterm infants aged 29-60 days or at ≥40 weeks PMA and those aged 61-90 days or at ≥43 weeks PMA had a rate of invasive bacterial infection equivalent to the overall rate seen in full-term infants of the same chronological age group. The distribution of pathogens causing bacteremia and meningitis did not differ between preterm and full-term infants.
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Cost Analysis of Emergency Department Criteria for Evaluation of Febrile Infants Ages 29 to 90 Days
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To compare the medical costs associated with risk stratification criteria used to evaluate febrile infants 29-90 days of age.
A cost analysis study was conducted evaluating the Boston, Rochester, Philadelphia, Step-by-Step, and PECARN criteria. The percentage of infants considered low risk and rates of missed infections were obtained from published literature. Emergency department costs were estimated from the Centers for Medicare and Medicaid Services. The Health Care Cost and Utilization Project databases were used to estimate the number of infants ages 29-90 days presenting with fever annually and costs for admissions related to missed infections. A probabilistic Markov model with a Dirichlet prior was used to estimate the transition probability distributions for each outcome, and a gamma distribution was used to model costs. A Markov simulation estimated the distribution of expected annual costs per infant and total annual costs.
For low-risk infants, the mean cost per infant for the criteria were Rochester: $1050 (IQR $1004-$1092), Philadelphia: $1416 (IQR, $1365-$1465), Boston: $1460 (IQR, $1411-$1506), Step-by-Step $942 (IQR, $899-$981), and PECARN $1004 (IQR, $956-$1050). An estimated 18 522 febrile 1- to 3-month-old infants present annually and estimated total mean costs for their care by criteria were: Rochester, $127.3 million (IQR, $126.1-$128.5); Philadelphia, $129.9 million (IQR, $128.7-$131.1); Boston, $128.7 million (IQR, $127.5-$129.9); Step-by-Step, $ 126.6 million (IQR, $125.4-$127.8); and PECARN, $125.8 million (IQR, $124.6-$127).
The Rochester, Step-by-step, and PECARN criteria are the least costly when evaluating infants 29-90 days of age with a fever.
Practice Variation in the Evaluation and Disposition of Febrile Infants ≤60 Days of Age
2019, Journal of Emergency Medicine
Citation Excerpt :
Recent studies have confirmed that 5% to 10% of febrile infants in this age group presenting to the ED will have serious bacterial infections (SBIs) (defined here as urinary tract infections, bacterial meningitis, or bacteremia) as the cause of their fever, with <2% having bacteremia (2,3). Because of the absence of any single or combination of clinical variables or laboratory tests that can detect the presence of SBI with high degrees of sensitivity and specificity, several guidelines have been developed over the years to risk-stratify young febrile infants to determine who might be at low enough risk to safely forego invasive testing, empirical antibiotics, or hospitalization (4–7). These guidelines recommend obtaining screening tests including urinalysis for urinary tract infections (UTIs), complete blood cell counts for bacteremia, and cerebrospinal fluid analysis for bacterial meningitis along with respective cultures for a definitive diagnosis of SBI.
Febrile infants commonly present to emergency departments for evaluation.
We describe the variation in diagnostic testing and hospitalization of febrile infants ≤60 days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network.
We enrolled a convenience sample of non-critically ill–appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60 days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0–28 days of age) and older (29–60 days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age group using chi-square tests and by site using analysis of variance.
Four thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0–28 days of age. Rates of lumbar puncture and hospitalization were high (>90%) among infants ≤28 days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29–60 days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%.
The evaluation and disposition of febrile infants ≤60 days of age is highly variable, particularly among infants who are 29–60 days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization.
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To evaluate the epidemiology, microbiology, Streptococcus pneumoniae serotypes distribution and serious bacterial infections (SBIs) occurrence in infants <2 months of age with tympanocentesis-documented acute otitis media (AOM), before and after the introduction of pneumococcal conjugate vaccines (PCVs).
The medical records of all hospitalized infants with AOM who underwent tympanocentesis during 2005–2014 were reviewed.
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Original articleAmbulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections

J Pediatr

J Pediatr

Lancet

J Pediatr

J Pediatr

J Pediatr

Septicemia in the newborn

Am J Dis Child

Sepsis of obscure origin in the newborn

Pediatrics

Septicemia of the newborn: current status of the problem

Pediatrics

Neonatal meningitis

N Engl J Med

Septicemia of the newborn

Pediatrics

The serious implications of high fever in infants during their first three months: six years' experience at the Yale—New Haven Hospital Emergency Room

Clin Pediatr

Blood neutrophil response to bacterial infection in the first month of life

Arch Dis Child

The evaluation and treatment of the febrile infant

Pediatr Infect Dis

The febrile infant

Pediatr Rev

Fever in the first eight weeks of life

John Hopkins Med J

Fever in infants less than two months of age: spectrum of disease and predictors of outcome

Pediatr Emerg Care

Original article
Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections