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Criteria for hospital admission of febrile infants may need re-examination
Garcia S. Pediatr Infect Dis J. 2011;doi:10.1097/INF.0b013e318247b9f2.
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Ambulatory management of young infants with fever has been described for selected patients older than one month. Decreasing this cut-off age to 15 days has been considered, but acccording to a study published online, this cut-off point may not be the best option.
Silvia Garcia, MD, and other researchers from Basque Country, Spain, conducted a cross-sectional descriptive study of 1,575 febrile infants to determine whether 15 days of age is a suitable cut-off age for considering ambulatory management. Garcia and colleagues noted that 311 of the babies in their study had a serious bacterial infection.
The rate of serious bacterial infection was one-third among babies between 15 and 21 days. This rate was “similar to that among infants who were 7-14 days (31.9%, CI 95% 21.1-42.7%) and higher than among those older than 21 days old (18.3%, CI 95% 16.3-20.3%).” These results prompted the researchers to conclude that it is not appropriate to use 15 days of age as a marker for managing infants with fever. The current standard of care is to admit all febrile infants younger than the age of 28 days, but the age cut-off point may be 3 weeks, according to this study findings.
“Normally, fever is caused by self-limiting viral infections, but some infants with fever who appear well and with no relevant findings on physical examination have a bacterial infection that could potentially be serious,” making longer monitoring a better choice, the researchers noted.
The researchers noted some study limitations, specifically that it was not a prospective design, nor was it multicenter, so the results may have limited generalizability.
Disclosure: The researchers report no relevant financial disclosures. No funding was received for this work from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI); and other(s).
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Management of neonates and infants with fever continues to generate angst for practitioners who must balance the risk of a potentially severe infection with the knowledge that most of the infants we evaluate will have mild, self-limited illnesses. Numerous algorithms attempt to distinguish infants with a high risk of serious bacterial infection (SBI) from those with a low risk of SBI, who could be managed as an outpatient. Most algorithms recommend admission for all neonates less than 1 month of age.
This study addresses the importance of age in assessing risk by age-stratifying a large number of neonates. In this single-center study, the rate of SBI was highest in infants 8-14 days old and 15-21 days old. The rate of SBI in infants 22-28 days old was found to be no higher than in infants 29-90 days old. Based on the lower SBI rate in infants older than 22 days, the authors suggest an age of 21 days is a more appropriate cutoff than 28 days for mandatory inpatient management of patients. The ability to identify and appropriately manage additional low risk infants as outpatients would decrease potential complications and costs associated with hospitalization and antimicrobial therapy. It is important to note that infants in this study were observed for an average of 15 hours before discharge, a capability that many busy ERs may not have. Finally, it is critical to ensure a family can promptly and reliably follow-up as directed before allowing outpatient management of any febrile infant.
The perfect test to determine which neonate has an SBI remains elusive. We are incrementally increasing our ability to distinguish low versus high risk patients, but will probably never be able to identify patients at "no risk" for SBI. This study presents important initial data, but further study is warranted regarding the week-by-week risk of SBI in our youngest patients before recommending changes in current protocols.
Allison H. Bartlett, MD, MS
Assistant Professor,
Pediatric Infectious Disease
University of Chicago
Chicago
Disclosure: Dr. Bartlett reports no relevant financial disclosures.
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