FEVER IN INFANTS

RICHARD J. SCARFONE, MD, PAYAL K. GALA, MD, AND MARY KATE FUNARI, MSN, RN, CPEN

BACKGROUND (EPIDEMIOLOGY, EVIDENCE)

Febrile young infants (FYIs) are at higher risk for serious bacterial infection (SBI) compared to older children. Published data indicate that 8% to 12% of FYIs have an SBI, most commonly pyelonephritis. To provide high-value care, clinicians who are evaluating FYIs in the ED must be appropriately vigilant in assessing for SBI while trying to minimize the inherent risks of overtesting and overtreating including obtaining false-positive cultures, unnecessary hospitalizations, increased costs, increased lengths of stay in the ED, and parental anxiety.

To date, there is not a universally accepted evaluation and treatment strategy for this population. Rather, most clinicians follow hospital-specific guidelines that vary widely among medical institutions. For example, there is variation in practice for several fundamental clinical decision points including the age below which a lumber puncture (LP) should be performed routinely, the clinical scenarios in which herpes simplex virus (HSV) screening and/or empiric therapy should be initiated, and whether or not an LP is necessary for FYI with pyuria. A review of the literature helps to provide guidance and serves as the basis for the recommendations here. Huppler et al. published a 25-year review of 22 studies assessing the performance of low-risk criteria for SBI among this cohort. Just two neonates <4 weeks old had bacterial meningitis. None of 29- to 56-day old infants who otherwise met low-risk criteria had bacterial meningitis suggesting that an LP may be safely omitted in this setting. On the other hand, about one-third of neonates with HSV infection do not have skin vesicles and in a significant proportion of cases, their mothers have asymptomatic herpes infections at delivery. Thus, maternal history and physical examination of the neonate alone may miss the diagnosis; this supports a conservative approach for HSV screening among those likely to be at highest risk. Schnadower et al. reported that among 1,895 infants 29 to 60 days old with fever and pyelonephritis, 5 had concomitant bacterial meningitis. This rate, while low, is higher than that reported for FYI without pyelonephritis leaving individual clinicians to determine the utility of routinely performing an LP among FYI found to have pyuria. For questions such as the ones raised here, instituting a clinical pathway based on supporting evidence in the literature can help standardize care for this population of patients.

PATHWAY GOALS AND MEASUREMENTS

Goals

The goals for this pathway are as follows:

Standardize the care of FYI who do not have clearly identifiable sources of illness

Streamline the ED evaluation of FYI

Obtain all necessary studies to evaluate for possible SBI

Omit unnecessary testing that is not likely to yield a diagnosis

Define appropriate candidates for HSV screening and the appropriate screening tests

Define when it is cost-effective to perform enteroviral testing of cerebrospinal fluid (CSF)

Improve timeliness of key points of care of FYI including times from ED arrival to:

MD evaluation

Urinary catheterization to screen for UTI

Peripheral intravenous (PIV) line placement and serologic tests

LP (if indicated)

Chest radiograph (if indicated)

Antibiotics (if indicated)

Standardize order sets for laboratory studies to assist front-line clinicians, including RNs in initiating timely workups

Reexamine the practice of routinely performing an LP in all febrile infants 29 to 56 days old; for those who meet low-risk criteria, assess utility of LP