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Using AAP Guidelines for Managing Febrile Infants Without C-Reactive Protein and Procalcitonin
Tran H P Nguyen1,2, Beverly R Young1,2, Amy Alabaster3
1Department of Hospital Pediatrics, Kaiser Permanente Northern California, Roseville, California.
Insights
The American Academy of Pediatrics guideline effectively detects invasive bacterial infections (IBI) in febrile infants without C-reactive protein (CRP) or procalcitonin (PCT). However, it shows high sensitivity but low specificity, potentially leading to unnecessary interventions.
Area of Science:
- Pediatrics
- Infectious Diseases
- Clinical Practice Guidelines
Background:
- The 2021 American Academy of Pediatrics (AAP) Clinical Practice Guideline (CPG) aids in managing febrile infants aged 8 to 60 days.
- The guideline often incorporates inflammatory markers like C-reactive protein (CRP) and procalcitonin (PCT), which may not be readily available in all clinical settings.
Purpose of the Study:
- To evaluate the performance of the AAP CPG in identifying invasive bacterial infections (IBI) in infants aged 8 to 60 days.
- To assess the diagnostic accuracy of the AAP CPG without utilizing CRP and PCT values.
Main Methods:
- A retrospective cohort study was conducted on 1433 infants aged 8 to 60 days with fever (≥38°C) presenting to Kaiser Permanente emergency departments (2010-2019).
- Infants meeting AAP CPG criteria underwent complete blood counts, blood cultures, and urinalyses.
- Performance characteristics for IBI detection were calculated across different age strata.
Main Results:
- Among 1433 infants, 57 (4.0%) had bacteremia and 9 (0.6%) had bacterial meningitis.
- Using absolute neutrophil count >5200/mm³ and temperature >38.5°C, 3 (5%) infants with IBI were misidentified.
- Sensitivities and specificities varied by age group: 8-21 days (100% sensitivity, 0% specificity), 22-28 days (88.9% sensitivity, 40.4% specificity), and 29-60 days (93.3% sensitivity, 32.1% specificity).
- Invasive interventions were recommended for 100% of infants aged 8-21 days, 58%-100% for 22-28 days, and 0%-69% for 29-60 days.
Conclusions:
- The AAP CPG demonstrates high sensitivity for detecting IBI in young, febrile infants when CRP and PCT are unavailable.
- The guideline exhibits low specificity in these cases, potentially leading to over-treatment.
- Age-specific performance analysis is crucial for refining management strategies for febrile infants.
Background And Objectives:
In 2021, the American Academy of Pediatrics (AAP) published the Clinical Practice Guideline (CPG) for management of well-appearing, febrile infants 8 to 60 days old. For older infants, the guideline relies on several inflammatory markers, including tests not rapidly available in many settings like C-reactive protein (CRP) and procalcitonin (PCT). This study describes the performance of the AAP CPG for detecting invasive bacterial infections (IBI) without using CRP and PCT.
Methods:
This retrospective cohort study included infants aged 8 to 60 days old presenting to Kaiser Permanente Northern California emergency departments between 2010 and 2019 with temperatures ≥38°C who met AAP CPG inclusion criteria and underwent complete blood counts, blood cultures, and urinalyses. Performance characteristics for detecting IBI were calculated for each age group.
Results:
Among 1433 eligible infants, there were 57 (4.0%) bacteremia and 9 (0.6%) bacterial meningitis cases. Using absolute neutrophil count >5200/mm3 and temperature >38.5°C as inflammatory markers, 3 (5%) infants with IBI were misidentified. Sensitivities and specificities for detecting infants with IBIs in each age group were: 8 to 21 days: 100% (95% confidence interval [CI] 83.9%-100%) and 0% (95% CI 0%-1.4%); 22 to 28 days: 88.9% (95% CI 51.8%-99.7%) and 40.4% (95% CI 33.2%- 48.1%); and 29 to 60 days: 93.3% (95% CI 77.9%-99.2%) and 32.1% (95% CI 29.1%- 35.3%). Invasive interventions were recommended for 100% of infants aged 8 to 21 days; 58% to 100% of infants aged 22 to 28 days; and 0% to 69% of infants aged 29 to 60 days.
Conclusions:
When CRP and PCT are not available, the AAP CPG detected IBI in young, febrile infants with high sensitivity but low specificity.
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