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Applying outpatient protocols in febrile infants 1-28 days of age: can the threshold be lowered?
H A Kadish1, B Loveridge, J Tobey
1Department of Pediatrics, Primary Children's Medical Center, Salt Lake City, Utah 84113, USA.
Insights
Two common outpatient protocols for febrile infants are not fully applicable to newborns 1-28 days old. These protocols may miss serious bacterial infections (SBI) in 3% of young infants, necessitating continued hospitalization for this age group.
Area of Science:
- Pediatrics
- Infectious Diseases
- Neonatal Care
Background:
- Febrile infants under 28 days old present a diagnostic challenge.
- Existing outpatient management protocols (Boston, Philadelphia) are validated for infants 1-2 months old.
- The applicability of these protocols to younger neonates requires evaluation.
Purpose of the Study:
- To assess the effectiveness of the Boston and Philadelphia outpatient management protocols for identifying serious bacterial infections (SBI) in febrile infants aged 1-28 days.
- To determine the rate at which these protocols might incorrectly classify neonates with SBI as low-risk.
Main Methods:
- Retrospective chart review of 372 febrile infants aged 1-28 days (temperature ≥38.0°C).
- Application of Boston and Philadelphia protocol criteria to identify low-risk infants.
- Definition of SBI based on positive bacterial cultures from blood, urine, CSF, stool, or aspirated fluids.
Main Results:
- Serious bacterial infection (SBI) was present in 12% (45/372) of infants.
- The Boston protocol would have sent home 3.5% (8/231) of infants with an SBI.
- The Philadelphia protocol would have sent home 3.2% (6/186) of infants with an SBI.
- Both protocols demonstrated a 97% negative predictive value for excluding SBI.
Conclusions:
- Current outpatient management protocols for febrile infants aged 1-2 months are not entirely suitable for neonates aged 1-28 days.
- Approximately 3% of febrile infants under 28 days with SBI might be discharged under these protocols.
- Current guidelines recommending admission for all febrile infants under 28 days should be maintained pending further outcome data.
Abstract:
The purpose of this study was to determine the applicability of two accepted outpatient management protocols for the febrile infant 1-2 months of age (Boston and Philadelphia protocols) in febrile infants 1-28 days of age. We retrospectively reviewed charts of patients 1-28 days of age with a temperature greater than or equal to 38.0 degrees C. Criteria from each of the above-cited management protocols were applied to the patients to determine their applicability in screening for serious bacterial infection (SBI). An SBI was defined as bacterial growth in cultures from blood, urine, cerebrospinal fluid (CSF), stool, or any aspirated fluid. Overall, 372 febrile infants were included in the study. Ages ranged from 1 to 28 days of age. The mean age was 15 days. SBI occurred in 45 patients (12%). The mean age of the patients with an SBI was 13 days. Thirty-two infants (8.6%) had a urinary tract infection; 12 (3.2%), bacteremia; five (1.3%), bacterial meningitis; three (0.8%), cellulitis; one (0.3%), septic arthritis; one (0.3%), bacterial gastroenteritis; and one (0.3%), pneumonia. Ten infants had more than one SBI. Of 372 patients, 231 (62%) met the Boston's laboratory low-risk criteria; eight (3.5%) would have been sent home with an SBI with these criteria. Philadelphia's laboratory low-risk criteria would have been met by 186 patients (50%); six (3.2%) would have been sent home with an SBI with these criteria. The negative predictive value of both the Boston and Philadelphia protocols for excluding an SBI was 97%. We conclude that current management protocols for febrile infants 1-2 months of age when applied to febrile infants 1 to 28 days of age would allow 3% of febrile infants less than 28 days of age to be sent home with an SBI. Current guidelines recommending admitting all febrile infants less than 28 days of age should be followed until the outcome of those 3% of febrile infants with an SBI treated as outpatients can be determined.