Abstract
Background
Febrile neonates undergo lumbar puncture (LP), empiric antibiotic administration,
and admission for increased risk of invasive bacterial infection (IBI), defined as
bacteremia and meningitis.
Objective
Measure IBI prevalence in febrile neonates, and operating characteristics of Rochester
Criteria (RC), Yale Observation Scale (YOS) score, and demographics as a low-risk
screening tool.
Methods
Secondary analysis of healthy febrile infants < 60 days old presenting to any of 26
emergency departments in the Pediatric Emergency Care Applied Research Network between
December 2008 and May 2013. Of 7334 infants, 1524 met our inclusion criteria of age
≤ 28 days. All had fevers and underwent evaluation for IBI. Receiver operator characteristic
(ROC) curve and transparent decision tree analysis were used to determine the applicability
of reassuring RC, YOS, and age parameters as an IBI low-risk screening tool.
Results
Of 1524 neonates, 2.9% had bacteremia and 1.5% had meningitis. After applying RC and
YOS, 15 neonates were incorrectly identified as low risk for IBI (10 bacteremia, 4
meningitis, 1 bacteremia, and meningitis). Age ≤ 18 days was a statistically significant
variable ROC (area under curve 0.63, p < 0.05). Incorporating age > 18 days as low-risk criteria with reassuring RC and
YOS misclassified 7 IBI patients (6 bacteremia, 1 meningitis).
Conclusion
Thirty percent of febrile neonates met low-risk criteria, age > 18 days, reassuring
RC and YOS, and could avoid LP and empiric antibiotics. Our low-risk guidelines may
improve patient safety and reduce health care costs by decreasing lab testing for
cerebrospinal fluid, empiric antibiotic administration, and prolonged hospitalization.
These results are hypothesis-generating and should be verified with a randomized prospective
study.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Emergency MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age.J Hosp Med. 2015; 10: 358-365
- Epidemiology of cerebrospinal fluid cultures and time to detection in term infants.Pediatrics. 2017; 139e20163268
- Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections.Pediatrics. 2004; 113: 1662-1666
- Update on the management of the febrile infant.Clin Pediatr Emerg Med. 2004; 5: 5-12
- Blood culture and bacteremia predictors in infants less than three months of age with fever without source.Pediatr Infect Dis J. 2010; 29: 43-47
- Validation of the “Step-by-Step” approach in the management of young febrile infants.Pediatrics. 2016; 138e20154381
- Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection.Emerg Med J. 2014; 31: e19-e24
- A week-by-week analysis of the low-risk criteria for serious bacterial infection in febrile neonates.Arch Dis Child. 2009; 94: 287-292
- Management of febrile neonates in US pediatric emergency departments.Pediatrics. 2014; 133: 187-195
- A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections.JAMA Pediatr. 2019; 173: 342-351
- Analgesia for lumbar puncture in infants and children.Can Fam Physician. 2019; 65: 192-194
- Performance of low-risk criteria in the evaluation of young infants with fever: review of the literature.Pediatrics. 2010; 125: 228-233
- Management and outcomes of care of fever in early infancy.JAMA. 2004; 291: 1203-1212
- Variation in care of the febrile young infant <90 days in US pediatric emergency departments.Pediatrics. 2014; 134: 667-677
- Febrile infants at low risk for serious bacterial infection—an appraisal of the Rochester criteria and implications for management.Pediatrics. 1994; 94: 390-396
- Predictive model for serious bacterial infections among infants younger than 3 months of age.Pediatrics. 2001; 108: 311-316
- Performance of the modified Boston and Philadelphia criteria for invasive bacterial infections.Pediatrics. 2020; 145e20193538
- Risk stratification of febrile infants ≤60 days old without routine lumbar puncture.Pediatrics. 2018; 142e20181879
- Application of the Rochester criteria to identify febrile infants with bacteremia and meningitis.Pediatr Emerg Care. 2019; 35: 22-27
- The Yale Observation Scale score and the risk of serious bacterial infections in febrile infants.Pediatrics. 2017; 140e20170695
- Reducing variability in the infant sepsis evaluation (REVISE): a national quality initiative.Pediatrics. 2019; 144e20182201
- Observation scales to identify serious illness in febrile children.Pediatrics. 1982; 70: 802-809
- Outpatient management without antibiotics of fever in selected infants.N Engl J Med. 1993; 329: 1437-1441
- Unpredictability of serious bacterial illness in febrile infants from birth to 1 month of age.Arch Pediatr Adolesc Med. 1999; 153: 508-511
- Applying outpatient protocols in febrile infants 1–28 days of age: can the threshold be lowered?.Clin Pediatr (Phila). 2000; 39: 81-88
- Is 15 days an appropriate cut-off age for considering serious bacterial infection in the management of febrile infants?.Pediatr Infect Dis J. 2012; 31: 455-458
- Epidemiology of bacteremia in febrile infants aged 60 days and younger.Ann Emerg Med. 2017; 71: 211-216
- Epidemiology of bacteremia in febrile infants in the United States.Pediatrics. 2013; 132: 990-996
- Epidemiology and etiology of invasive bacterial infection in infants ≤60 days old treated in emergency departments.J Pediatr. 2018; 200 (e1): 210-217
- Evaluation and management of well-appearing febrile infants 8 to 60 days old.Pediatrics. 2021; 148e2021052228
- Fever survey highlights significant variations in how infants aged 60 days are evaluated and underline the need for guidelines.Acta Paediatr. 2014; 103: 379-385
- Evaluation and management of febrile, well-appearing young infants.Infect Dis Clin North Am. 2015; 29: 575-585
Article info
Publication history
Published online: June 09, 2022
Accepted:
October 12,
2021
Received in revised form:
July 26,
2021
Received:
March 23,
2021
Identification
Copyright
Published by Elsevier Inc.
