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The need for a second dose of ceftriaxone in febrile infants age 4-8 weeks
S E Allen1, C M Walsh-Kelly, H H Hennes
1Emergency Medicine Section, Cincinnati Children's Hospital, OH, USA.
Insights
A second dose of ceftriaxone may not be needed for febrile infants meeting low-risk outpatient criteria. Infants with no infection source and negative cultures at 24 hours can avoid the additional antibiotic dose.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Diseases
- Antibiotic Stewardship
Background:
- Febrile infants require careful management to rule out serious bacterial infections.
- Outpatient therapy is an option for low-risk febrile infants, but optimal antibiotic dosing is debated.
Purpose of the Study:
- To evaluate the necessity of a second intramuscular ceftriaxone dose in febrile infants meeting specific low-risk outpatient criteria.
Main Methods:
- A prospective study in a hospital emergency department involving febrile infants aged 4-8 weeks.
- Infants meeting strict outpatient criteria received initial intramuscular ceftriaxone and were re-evaluated in 24 hours.
- A second ceftriaxone dose was administered if no infection source was identified and cultures were pending; all cultures were finalized at 48 hours.
Main Results:
- 172 infants were enrolled; all had normal blood counts, urinalysis, and cerebrospinal fluid (CSF) analyses.
- Chest radiographs were normal in the 30% of infants who underwent the procedure.
- Only one infant (0.05%) required admission at follow-up; two infants had positive blood or urine cultures, but all CSF cultures remained negative.
Conclusions:
- Febrile infants aged 4-8 weeks meeting outpatient criteria, with no identifiable infection source, and negative cultures at 24-hour follow-up may not need a second dose of intramuscular ceftriaxone.
- This finding supports judicious antibiotic use and potentially reduces unnecessary medication exposure in this population.
Objective:
To determine if a second intramuscular injection of ceftriaxone was necessary in febrile infants who meet low-risk criteria for outpatient therapy.
Setting:
Children's Hospital Emergency Department.
Patients:
Febrile infants 4-8 weeks of age.
Methods:
Outpatient treatment criteria included non-toxic appearance, no identifiable source for infection on physical examination, CSF WBC > or = 10/mm3, peripheral WBC < or = 15,000/mm3, normal UA, and normal chest radiograph study, if obtained. Additional requirements included a reliable caretaker and re-evaluation in 24 hours. Infants who met these criteria received intramuscular ceftriaxone 50 mg/kg with instructions to follow-up in 24 hours. At the follow-up visit, infants with no identifiable source for infection and negative cultures received a second dose of intramuscular ceftriaxone and were discharged. Cultures were read at 48 hours and at the conclusion of the study. Medical records were reviewed to identify delayed complications.
Results:
172 infants were enrolled. The mean age was 45 days. All CBC, UA, CSF analyses were normal. Chest radiographs were obtained in 56 (30%) infants; all were normal. One (.05%) patient was admitted at the follow-up visit. The mean time to follow-up was 25 hours. Two positive cultures were identified at the re-evaluation visit; one blood culture grew Salmonella and a urine culture grew E. coli. The CSF cultures were all negative at follow-up and remained negative.
Conclusion:
Febrile infants 4-8 weeks of age who meet outpatient therapy criteria and have negative cultures and no identifiable source for infection at 24 hours may not require the second dose of intramuscular ceftriaxone.