Management of Febrile Neonates in US Pediatric Emergency Departments

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Recommended management of febrile neonates (#28 days) includes blood, urine, and cerebrospinal fluid cultures with hospital admission for antibiotic therapy. No study has reported adherence to standard recommendations in the management of febrile neonates in US pediatric emergency departments. WHAT THIS STUDY ADDS:There is wide variation in adherence to recommended management of febrile neonates. High rates of serious infections in admitted patients but low return rates for missed infections in discharged patients suggest additional studies needed to understand variation from current recommendations. abstract BACKGROUND: Blood, urine, and cerebrospinal fluid cultures and admission for antibiotics are considered standard management of febrile neonates (0-28 days). We examined variation in adherence to these recommendations across US pediatric emergency departments (PEDs) and incidence of serious infections (SIs) in febrile neonates. METHODS:Cross-sectional study of neonates with a diagnosis of fever evaluated in 36 PEDs in the 2010 Pediatric Health Information System database. We analyzed performance of recommended management (laboratory testing, antibiotic use, admission to hospital), 48-hour return visits to PED, and diagnoses of SI. RESULTS:Of 2253 neonates meeting study criteria, 369 (16.4%) were evaluated and discharged from the PED; 1884 (83.6%) were admitted. Recommended management occurred in 1497 of 2253 (66.4%; 95% confidence interval, 64.5-68.4) febrile neonates. There was more than twofold variation across the 36 PEDs in adherence to recommended management, recommended testing, and recommended treatment of febrile neonates. There was significant variation in testing and treatment between admitted and discharged neonates (P , .001). A total of 269 in 2253 (11.9%) neonates had SI, of whom 223 (82.9%; 95% confidence interval, 77.9-86.9) received recommended management.CONCLUSIONS: There was wide variation across US PEDs in adherence to recommended management of febrile neonates. One in 6 febrile neonates was discharged from the PED; discharged patients were less likely to receive testing or antibiotic therapy than admitted patients. A majority of neonates with SI received recommended evaluation and management. High rates of SI in admitted patients but low return rates for missed infections in discharged patients suggest a need for additional studies to understand variation from the current recommendations.

Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants

“…First, the prevalence of SBI obtained in our study was similar to those reported in other recent European publications, 17,25,33 5 only 62% of the respondents reported using some set of published guidelines and among them, 20% cited using the Philadelphia protocol, 15% the Rochester criteria, and 13% the Boston criteria. As there seems to be no predominant criteria used in the United States and none of these classic risk criteria are frequently used in Europe, we chose the Rochester criteria for the reasons previously mentioned.…”

“…Regardless of the protocol used, current adherence to any of them in clinical practice is low. 4,5 Changes in the epidemiology of bacterial pathogens in the last decades 6,7 and introduction of biomarkers such as C-reactive protein (CRP) and, more recently, procalcitonin (PCT) could justify this low adherence rate and make several authors advocate for a more individualized approach. The latter includes new biomarkers and a reduction in lumbar puncture rates, antibiotic treatments, or in-hospital admission for many well-appearing infants outside the neonatal period.…”

Etiology and Causative Pathogens of Febrile Neonates

“…On the other hand, UTI was found higher and reported that 14-21.3 percent in febrile neonatesthat means UTI affects approximately 1 in 6 febrile neonates [2][3][4][5][6][7][8][9][10][11]18]. In our study, UTI incidence was found similarly the most common etiology of fever in neonatal period.…”

“…The causes of fever in these neonates vary from dehydration, mild viral infection to serious bacterial infections which are progressive and lead to severe morbidity or mortality. Evaluation and treatment of febrile neonatesvaried widely among the different centers [11]. These differences demonstrate the deficiency of and highlight the necessity for national or international guidelines for the assessment of fever in this age group.…”

“…Previous studies on <90 days old babies reported the rate of bacterial meningitis and aseptic meningitisas 0.2% and 14.4%, respectively [25]. In the studies, where only neonates were included, the rate of bacterial meningitis was 0.5-4.4% [2,[11][12][13]. Lumbar puncture and CSF analysis werenot done routinely in the mentioned studies.…”