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Boston Febrile Infant Algorithm 2.0: Improving Care of the Febrile Infant 1-2 Months of Age

Kate Dorney1, Mark I Neuman1, Marvin B Harper1

  • 1Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston Mass.

Pediatric Quality & Safety
|November 7, 2022
PubMed

Insights

A revised clinical pathway for febrile infants 1-2 months old safely reduced lumbar punctures and antibiotic use. This updated algorithm incorporates procalcitonin (PCT) testing to improve management of invasive bacterial infection (IBI).

Area of Science:

  • Pediatrics
  • Infectious Diseases
  • Clinical Quality Improvement

Background:

  • Management of febrile infants aged 1-2 months shows significant variation.
  • A long-standing algorithm guided care, but new evidence on procalcitonin (PCT) emerged.
  • Existing practices included frequent lumbar punctures (LPs) and antibiotic use.

Purpose of the Study:

  • To revise the clinical algorithm for febrile infants 1-2 months old.
  • To decrease lumbar punctures (LPs) and antibiotic administration.
  • To ensure no increase in hospitalizations, revisits, or missed invasive bacterial infections (IBI).

Main Methods:

  • Revised the algorithm's risk stratification based on PCT test performance for IBI.
  • Disseminated the revised algorithm using quality improvement strategies.
  • Monitored LPs, antibiotic use, hospitalizations, revisits, and missed IBIs as primary and balancing outcomes.

Main Results:

  • A total of 616 infants were studied, with 326 after algorithm revision.
  • Lumbar punctures (LPs) decreased from 66.2% to 31.9% (34.3% absolute reduction, P < 0.001).
  • Antibiotic administration fell from 62.4% to 36.2% (26.2% decrease, P < 0.001), and hospitalizations dropped by 8.1% (P = 0.03).
  • No cases of missed invasive bacterial infections (IBI) were reported post-revision.
  • Sustained reduction in LPs and antibiotic use for 24 months was observed.

Conclusions:

  • The revised clinical pathway incorporating PCT safely reduced LPs and antibiotic use in febrile infants.
  • The updated algorithm demonstrates sustained effectiveness in managing febrile infants aged 1-2 months.
  • This approach balances the need to detect invasive bacterial infection with minimizing invasive procedures and antibiotic exposure.

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