Outcomes Among Well-appearing Infants Initially Deferred Antibiotics for Fever

The 2021 American Academy of Pediatrics guideline on well-appearing febrile infants recommends deferral of lumbar puncture and/or initial antibiotics in certain patients 22 to 60 days old, along with shared decision-making with the patient's caregivers. This study sought to compare the incidence of invasive bacterial infection and/or need for escalation of care in febrile infants in this age group who did and did not receive initial empiric antibiotics before and after implementation of the guideline.

This was a single-center, retrospective cohort evaluation of admitted patients before and after guideline implementation. Well-appearing infants 22 to 60 days old who presented to the emergency department with fever and met guideline criteria were included. The primary outcome compares the incidence of invasive bacterial infections and escalation of care among patients who did and did not defer initial antibiotics. Secondary outcomes include rate of positive bacterial cultures, length of stay, and mortality. Patient demographics, antibiotic initiation, culture data, inflammatory markers, urinalysis, lumbar puncture and cerebrospinal fluid cell counts, readmission within 7 days of discharge, length of stay, and mortality within 30 days were collected and analyzed.

Sixty-one patients were included: 21 in the pre-guideline group and 40 in the post-guideline group. There was no difference in the incidence of invasive bacterial infections or escalation of care between groups. There was no difference in rate of positive bacterial cultures, length of stay, or mortality. More patients in the pre-guideline group received a lumbar puncture compared to the post-guideline group.

Our results affirm guideline recommendations suggesting deferral of antibiotics in well-appearing infants meeting select criteria results in decreased antibiotic use and lumbar punctures without affecting the rate of invasive bacterial infections or need for escalation of care.