Abstract
Background
The assessment and management of febrile young infants (under 90 days of age) is challenging. Young infants are at higher risk of serious and invasive bacterial infections (SBI/IBI) compared to older children and the symptoms and signs of SBI/IBI in young infants are subtle. This leads to an appropriately cautious approach with many guidelines advocating a “just in case” strategy with all febrile infants undergoing an infection screen and receiving broad-spectrum parenteral antibiotics.
In recent years there have been a number of validated clinical practice guidelines developed including the PECARN and StepByStep. These guidelines advise a tailored approach with the lowest risk infants suitable for management in the community without parenteral antibiotics. These guidelines can only be applied in settings where procalcitonin (PCT) testing is available.
In 2021 the American Academy of Paediatrics (AAP) published a new consensus guideline for the management of febrile infants. Unlike the PECARN and StepByStep guidelines AAP guidelines can be applied without the need for PCT testing. The objective of this secondary analysis was to validate the AAP guideline in UK and Irish populations.
Methods
The data for this secondary analysis comes from the Febrile Infants Diagnostic assessment and Outcome (FIDO) study (www.clinicaltrials.gov). The FIDO study, described previously, was a multicentre cohort study conducted on behalf of the Paediatric Emergency UK and Ireland (PERUKI) network at six PERUKI sites. Infants up to 90 days of age attending between 31/08/2018 - 01/09/2019 were screened for inclusion. Infants with a recorded fever (≥38°C) at triage were eligible for inclusion. There were no exclusion criteria. Invasive bacterial infection (IBI) defined as either bacterial meningitis or bacteraemia (non-contaminant) confirmed by culture or molecular diagnostic testing of a sterile site i.e. blood or cerebrospinal fluid (CSF). The diagnostic accuracy of the AAP guideline was reported with sensitivity and specificity with 95% confidence intervals (CI).
Result
Of 1362 eligible infants, 555 met the inclusion criteria. The median age of participants was 53 days (IQR 32 to 70). There were 325 male participants (59%). The incidence of IBI was 14 (3%). The AAP guidelines had a reported sensitivity 1.0 (95%CI: 0.7 – 1.0) and specificity of 0.14 (95%CI: 0.12 – 0.18) in febrile infants < 90 days of age. For febrile infants 8 – 60 days of age (N=333, IBI-11 (3%)), the reported sensitivity and specificity were 1.0 (95%CI: 0.7 – 1.0) and 0.14 (95%CI: 0.10 – 0.18) respectively. The AAP guideline identified 78/555 (14%) of infants as low risk out of which none had an IBI.
Discussion
The APP guidance was 100% sensitive for detecting IBI when applied to our cohort. Based on AAP guidance infants who appear well, are over 28 days of age, have a maximum temperature of <38.5oC, a CRP of <20mg/l and an absolute neutrophil count of <4,000 can safely be managed without parenteral antibiotics.
The assessment and management of febrile young infants (under 90 days of age) is challenging. Young infants are at higher risk of serious and invasive bacterial infections (SBI/IBI) compared to older children and the symptoms and signs of SBI/IBI in young infants are subtle. This leads to an appropriately cautious approach with many guidelines advocating a “just in case” strategy with all febrile infants undergoing an infection screen and receiving broad-spectrum parenteral antibiotics.
In recent years there have been a number of validated clinical practice guidelines developed including the PECARN and StepByStep. These guidelines advise a tailored approach with the lowest risk infants suitable for management in the community without parenteral antibiotics. These guidelines can only be applied in settings where procalcitonin (PCT) testing is available.
In 2021 the American Academy of Paediatrics (AAP) published a new consensus guideline for the management of febrile infants. Unlike the PECARN and StepByStep guidelines AAP guidelines can be applied without the need for PCT testing. The objective of this secondary analysis was to validate the AAP guideline in UK and Irish populations.
Methods
The data for this secondary analysis comes from the Febrile Infants Diagnostic assessment and Outcome (FIDO) study (www.clinicaltrials.gov). The FIDO study, described previously, was a multicentre cohort study conducted on behalf of the Paediatric Emergency UK and Ireland (PERUKI) network at six PERUKI sites. Infants up to 90 days of age attending between 31/08/2018 - 01/09/2019 were screened for inclusion. Infants with a recorded fever (≥38°C) at triage were eligible for inclusion. There were no exclusion criteria. Invasive bacterial infection (IBI) defined as either bacterial meningitis or bacteraemia (non-contaminant) confirmed by culture or molecular diagnostic testing of a sterile site i.e. blood or cerebrospinal fluid (CSF). The diagnostic accuracy of the AAP guideline was reported with sensitivity and specificity with 95% confidence intervals (CI).
Result
Of 1362 eligible infants, 555 met the inclusion criteria. The median age of participants was 53 days (IQR 32 to 70). There were 325 male participants (59%). The incidence of IBI was 14 (3%). The AAP guidelines had a reported sensitivity 1.0 (95%CI: 0.7 – 1.0) and specificity of 0.14 (95%CI: 0.12 – 0.18) in febrile infants < 90 days of age. For febrile infants 8 – 60 days of age (N=333, IBI-11 (3%)), the reported sensitivity and specificity were 1.0 (95%CI: 0.7 – 1.0) and 0.14 (95%CI: 0.10 – 0.18) respectively. The AAP guideline identified 78/555 (14%) of infants as low risk out of which none had an IBI.
Discussion
The APP guidance was 100% sensitive for detecting IBI when applied to our cohort. Based on AAP guidance infants who appear well, are over 28 days of age, have a maximum temperature of <38.5oC, a CRP of <20mg/l and an absolute neutrophil count of <4,000 can safely be managed without parenteral antibiotics.
| Original language | English |
|---|---|
| Publication status | Published - 16 Oct 2022 |
| Event | 2022 European Society of Emergency Medicine Congress - Berlin, Germany Duration: 15 Oct 2022 → 19 Oct 2022 |
Conference
| Conference | 2022 European Society of Emergency Medicine Congress |
|---|---|
| Abbreviated title | EUSEM 2022 |
| Country/Territory | Germany |
| City | Berlin |
| Period | 15/10/2022 → 19/10/2022 |