Efficacy of a Protocol to Distinguish Risk of Serious Bacterial Infection in the Outpatient Evaluation of Febrile Young Infants

Abstract

A study of 534 febrile infants ages 4 to 8 weeks evaluated for sepsis assessed the efficacy of the Milwaukee Protocol (MP) for selecting patients at low risk for serious bacterial infection (SBI) who might benefit from outpatient management. Two groups were compared: 1) Infants with uncompromised presentation (UP) who met all MP criteria received ceftriaxone 50 mg/kg and were discharged, then reevaluated within 24 hours. 2) Infants with compromised presentation (CP) who did not meet MP criteria were hospitalized for antibiotic therapy pending culture results. Of 391 CP patients, 23 (5.9%) had SBI; of 143 UP patients, 1 (0.7%) had SBI (P < .02). The MP criteria had a sensitivity of 96% and a 99% negative predictive value for distinguishing SBI outcome. The only UP patient with SBI was afebrile and had a negative repeat blood culture after 24 hours, and recovered with no complications. Managing UP infants as outpatients avoided 48 to 72 hours of hospitalization, decreasing health-care costs by an estimated total of $465,170.

Evaluation and Management of Febrile, Well-appearing Young Infants

“…There are limited data describing outcomes relating to harms associated with delayed SBI management; however, the available data suggest that lowrisk infants less than 90 days old who have delayed treatment of SBI have similar outcomes to infants hospitalized on presentation, particularly those with UTI. 2,9,14 …”

Predictive Model for Serious Bacterial Infections Among Infants Younger Than 3 Months of Age

“…The following pathogens were isolated from the blood: group B streptococci (21), Escherichia coli (20), Staphylococcus aureus (5), Streptococcus pneumoniae (4), Enterococcus faecalis (2), Enterobacter cloacae (1), group A streptococci (2), Salmonella spp. (2), Neisseria meningitidis (1), and Citrobacter koseri (1).…”

Aetiology and Management of Children With Acute Fever of Unknown Origin

“…[17] There has been a marked change from the traditional approach, especially with regard to hospitalisation and antibiotic therapy. Several criteria [139,[146][147][148][149] have been proposed for identifying the high risk infant. The sensitivities of these criteria for bacteraemia/serious bacterial infections range from 95.6 to 100% and NPVs from 94.6 to 100%.…”

“…The sensitivities of these criteria for bacteraemia/serious bacterial infections range from 95.6 to 100% and NPVs from 94.6 to 100%. [139,[146][147][148][149] The criteria are aimed at maximising the sensitivity and negative predictive value of screening tests while minimising the costs and risks of testing, hospitalisation and empiric antibiotic therapy. [101] However, usefulness of the criteria differs between centres.…”