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Study Group I

Evaluation of fever in infants age <2 Months: An international survey

By Efraim Bilavsky, MD and Shai Ashkenazi, MD, MSc

Schneider Children’s Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Israel

Although relatively common, the management of febrile infants age <2 months, varies considerably among medical institutions, thus, it is a highly debatable issue. Since young infants with bacterial infections are often difficult to identify on the basis of clinical presentation alone and because of the relatively high prevalence of serious bacterial infections (SBIs), the approach to these children has traditionally been very careful. Traditional management includes a comprehensive work-up which consists of blood cultures, urine and cerebrospinal fluid (CSF), hospitalization, and empiric antibiotic treatment. However, while SBIs indeed occur more frequently in young infants than in older children, the actual rate is still fairly low and this approach has had many disadvantages such as iatrogenic complications, nosocomial infections, overuse of antibiotics, and adverse effects.  In addition, there are emotional and financial burdens on the family as well as a rise in the cost of healthcare services.

The Rochester criteria was introduced in 1985 as an attempt to help clinicians to identify young infants who are at a low risk for SBIs and thus, the young infants do not need to be hospitalized or empirically treated. Subsequent prospective studies deemed much of the Rochester criteria discriminating consequently, the criteria were modified.

Practice guidelines for the management of febrile infants were published by Baraff et al. in 1993. While the recommendations of the research by Baraff et al. were based on the high and low risk criteria that was originally presented in the Rochester criteria, they were not identical For example, while the original Rochester criteria recommended that all low risk infants be discharged without antibiotic therapy (regardless of age), the practice guidelines by Baraff et al. recommended hospitalization and empirical antibiotic treatment of neonates younger than one month.

Moreover, since the introduction of the high and low risk criteria, other laboratory markers such as C-reactive protein (CRP) and procalcitonin were introduced into common practice. Later on, C-reactive protein (CRP) and procalcitonin were found to have better discriminative powers than a white blood cell (WBC) count with regards to distinguishing bacterial infections from viral infections. As a consequence of the late presentation of these markers, they were not included in any of the protocols even though these markers routinely serve to help many clinicians in daily practice.

Unfortunately, no single protocol has been universally accepted regarding the preferred management for young febrile infants age <2 months. As clinicians face cases like this on a daily basis, the lack of clear clinical guidelines has led to inconsistent and variable management approaches.

We conducted a national survey using all twenty-five in-patient pediatric hospitals in Israel based on the fever evaluation practices of febrile infants’ age ≤60 days (Acta Paediatrica 2014; 103:379-85).  With the use of a structured questionnaire, considerable variability was found. Our first interesting finding was that only 36% of the center had written protocols concerning the way to approach young febrile infants in this age group. Moreover, in only 13 (52%) of the hospitals, a normal WBC count was defined as 5000-15000 cells/ml, 20 (80%) of the centers use CRP, and procalcitonin was not used routinely in any of the pediatric centers. Hospitalization was mandatory in most of the centers (96%) for all febrile neonates age 28 days or less. In contrast, low risk febrile infants age 29-60 days were hospitalized in most (68.4%) of the primary and secondary hospitals in Israel, while 66.7% were discharged from tertiary centers. A combination of an antibiotic regimen of ampicillin and gentamicin was the routine empiric antibiotic treatment for febrile infants when no sepsis or meningitis was suspected in 92% of centers.

Table: Management of low-risk febrile infants’ age 29 to 60 days in Israel by medical centers’ characteristics:

Type of medical center Partial fever evaluation & discharge Partial fever evaluation & hospitalization without treatment Partial fever evaluation & hospitalization for empiric antibiotic treatment Other
Primary (N=8) 2 (25%) 4 (50%) 1 (12.5%) 1* (12.5%)
Secondary (N=11) 4 (36.4%) 7 (63.6%)
Tertiary (N=6) 5** (83.3%) 1*** (16.7%)
Total (N=25) 11** (44%) 11 (44%) 1 (4%) 2 (8%)

*≤6 weeks – full fever evaluation and hospitalization for empiric antibiotic treatment, 6 to 8 weeks – partial fever evaluation and hospitalization without treatment
**In two centers hospitalization for observation for 24h without antibiotic treatment was equally accepted, in one center a full fever evaluation was mandatory before the patient could be discharged
***≤6 weeks – full fever evaluation and hospitalization for empiric antibiotic treatment; 6 to 8 weeks – partial fever evaluation and discharge without antibiotic treatment

To broaden the scope of the study, we have created an international survey. This will further highlight the gaps that exist amongst the centers and it will aid in creating national and international guidelines for the evaluation of fever in neonates and young infants.

Please complete the structured questionnaires in the below link