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Background:
Very young febrile infants often lack the signs and symptoms that make it possible to distinguish between serious bacterial illnesses and minor illnesses. While guidelines for the management of the young febrile infant have been developed in an attempt to ensure identification and treatment of children at high risk for serious bacterial illnesses, it is uncertain how well these guidelines perform or whether pediatric practitioners utilize these guidelines. To date, the practice patterns of office-based pediatricians in treating febrile infants and the clinical outcomes resulting from their care have not been systematically studied.
Objective:
To characterize the management of febrile infants under the age of three months in pediatric office practices in the United States, develop a clinical prediction model for the identification of serious bacterial illnesses, and compare the accuracy of existing and theoretical strategies with providers’ actual performances in the identification of serious bacterial illnesses and prevention of serious sequelae.
Design:
Prospective observational cohort study
Methods:
Practitioners from the Pediatric Research in Office Settings (PROS) network enrolled 3066 patients from March 1, 1995 through February 28, 1998. Eligible patients were infants who had been previously discharged home from the hospital after newborn care, were three months of age or younger, and had a temperature of 38°C or greater either at home or in the practitioner’s office. Clinicians recorded information about each patient episode of illness and outcomes of care while employing their usual practice in the care of these infants.
Results:
PROS clinicians hospitalized slightly more than a third of the infants, performed laboratory testing on three quarters and treated 52% with antibiotics. The strongest predictors of hospitalization and antibiotic usage were infant clinical appearance and age. Serious bacterial illnesses rates were lower than previous reports from emergency department samples, with 0.5% of infants diagnosed with bacterial meningitis and 1.7% with bacteremia. Rates of other illnesses included 9% urinary tract infection, 12% otitis media, 27% upper respiratory infection, 9% bronchiolitis, and 8% gastroenteritis. In only 44% of episodes did practitioners follow current published guidelines. However, on the initial, visit they identified and/or treated 61 of the 62 cases of bacterial meningitis and/or bacteremia.
Conclusions:
Only 2% of febrile infants were diagnosed with bacteremia or bacterial meningitis. The majority of these diagnoses occurred in infants less than 30 days of age, justifying a more aggressive approach for these patients. Pediatric practitioners in the United States appear to use individualized clinical judgement in managing febrile infants. Our results suggest that if practitioners had used current clinical guidelines, there would have been no improvement in outcomes, but greatly increased rates of hospitalizations, laboratory testing and antibiotic usage. Currently guidelines may not be completely applicable to the management of very young febrile infants seen in office practice.
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