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Are We Missing the Target on Febrile Infants 60 Days to 6 Months?

September 20, 2022

Written by Ketan Patel

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The lack of evidence-based guidelines in the management of the febrile infants 2 to 6 months old results in variable practices amongst providers.

Why does this matter?
Fever is an extremely common presentation in the pediatric emergency department (ED). Below 60 days, evidence-based guidelines allow providers to risk stratify the febrile patient and hone the workup to maximize identification of invasive bacterial infection (IBI = bacteremia or meningitis) as the cause of fever. Above 60 days, viral pathogens are more commonplace, and intrinsic immunologic factors, as well as widespread Hib and pneumococcal vaccination in these children, means a lower prevalence of IBI. However, due to a lack of clear guidelines, overutilization of low-utility testing, without truly targeting those infants with IBI, seems to be commonplace in the management of this cohort of patients.

Off target approach
This article reviewed ~21,000 visits over 9 years in children 2 to 6 months old presenting to EDs in their cohort with fevers (≥38.0°C). Their data conformed with recent studies that showed febrile infants above 3 months have a less than 1% rate of IBI (in comparison to those under 60 days, which ranged between 2-4%). In addition, they found utilization of testing including blood cultures and lumbar punctures was highly variable across sites, with no uniform approach or guideline in place to target higher risk children with fevers in this age group. In addition to this, the significant false positive blood and CSF culture rates (estimated at 5%), result in further unnecessary testing and healthcare utilization.

In conclusion, the authors recommend further work in establishing guidelines in care and management in this subset of patients. The end goal is to, “implement evidence-based care, reduce practice variability, and avoid unnecessary diagnostic procedures with their associated harms.”

Prevalence and Management of Invasive Bacterial Infections in Febrile Infants Ages 2 to 6 Months. Ann Emerg Med. 2022 Aug 5:S0196-0644(22)00441-3. doi: 10.1016/j.annemergmed.2022.06.014. Epub ahead of print.

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