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Immunization Status and the Management of Febrile Children in the Pediatric Emergency Department: What Are We Doing?
Molly Curtis1, Jessica Kanis1, Brian Wagers1
1From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN.
Insights
Febrile children who are unimmunized or underimmunized receive more diagnostic tests and interventions in pediatric emergency departments. This highlights a need for evidence-based guidelines for managing these vulnerable pediatric patients.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Disease Management
- Immunization Practices
Background:
- Widespread immunization has reduced rates of invasive bacterial infections like occult bacteremia and meningitis.
- Pediatric emergency department practices have shifted towards less testing and empiric treatment for invasive bacterial infections.
- Evidence-based guidelines are lacking for evaluating and treating unimmunized or underimmunized febrile children.
Purpose of the Study:
- To investigate the impact of parental report of immunization status on diagnostic testing, interventions, and hospital admissions for febrile pediatric emergency department patients.
- To compare evaluation and treatment strategies for unimmunized (UnI), underimmunized (UnderI), and fully immunized (FI) febrile children.
Main Methods:
- Retrospective cohort study of children aged 3-36 months presenting to a pediatric emergency department with fever (≥38°C) and well appearance.
- Data collected via chart review, categorizing encounters by provider-documented immunization status (UnI, UnderI, FI).
- Statistical analysis using Fischer exact test and logistic regression to compare rates of diagnostic tests, interventions, and hospital admissions.
Main Results:
- Unimmunized and underimmunized children showed significantly higher rates of laboratory evaluations, including complete blood count and blood culture.
- These groups also received medical interventions and antibiotic prescriptions at higher rates within the pediatric emergency department.
- No significant differences were found in chest radiograph rates, hospital admissions, or 72-hour return visits between immunization status groups.
Conclusions:
- Pediatric emergency departments exhibit increased clinical suspicion and intervention for unimmunized/underimmunized febrile children compared to fully immunized ones.
- This disparity in care exists despite the absence of national guidelines for managing these patient groups.
- Further research is crucial to develop evidence-based management strategies for febrile unimmunized and underimmunized children due to ongoing vaccine hesitancy.
Objectives:
Widespread Haemophilus influenzae and Streptococcus pneumoniae immunization has decreased occult bacteremia and bacterial meningitis rates. Practice has evolved in pediatric emergency departments (PEDs) to favor fewer diagnostic tests for and empiric treatment of invasive bacterial infection. We lack evidence-based guidance on evaluation and treatment of unimmunized (UnI) or underimmunized (UnderI) febrile children. This study aims to determine how parental report of immunization status in febrile PED patients impacts rates of diagnostic testing, interventions, and hospital admissions.
Methods:
This is a retrospective cohort study with chart review of encounters of children aged 3 to 36 months presenting to an academic, tertiary care PED in 2019 using International Classification of Diseases-10 code for fever (R50.9). Inclusion criteria were documented fever of 38°C and higher and well appearance. Encounters were excluded if there was a history of chronic illness or documentation of ill appearance or hemodynamic instability. Encounters were grouped by provider-documented immunization status. Fischer exact test and logistic regression compared rates of diagnostic testing (serum, urine or cerebrospinal fluid laboratory studies, and chest radiographs), interventions (intravenous fluid bolus, intravenous antibiotic or steroid administration, respiratory support, or breathing treatment), and hospital admissions between UnderI, UnI, and fully immunized (FI) groups.
Results:
Of the 1813 encounters reviewed, 1093 (60%) included provider-documented immunization status and 788 (43%) met final inclusion criteria: 23 (2.1%) UnI, 44 (5.8%) UnderI, and 721 (92.1%) FI. The UnderI and UnI children experienced significantly higher rates of laboratory evaluation including complete blood count and blood culture, medical intervention, and antibiotic prescriptions while in the PED. No significant differences were observed for rates of chest radiographs, hospital admissions, or 72-hour PED return visits.
Conclusions:
Higher rates of laboratory testing and interventions were observed in UnderI and UnI versus FI febrile patients at a PED, likely demonstrating increased clinical suspicion for invasive bacterial infection in this group despite lacking national guidelines. Given continued vaccine hesitancy, further studies are needed for guiding management of febrile UnI and UnderI children presenting for emergency care.
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