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Some Febrile Young Infants May Be Safely Followed in the Outpatient Setting

Question

  • Can some infants aged 1-3 months presenting with fever be accurately classified as "low-risk" based on clinical information, thus avoiding laboratory evaluation for sepsis?

Clinical Bottom Lines
1. All febrile infants less than one month of age AND any febrile infants up to three months old who appear ill on exam should undergo a full "rule-out sepsis" work up (including lumbar puncture), be admitted to the hospital, and receive parenteral antibiotics.
2. Febrile infants seen in clinic who have no comorbidities or focal illness and are between the ages of 1 and 3 months who appear well or minimally ill, AND whose highest temperature in the last 24 hours was less than 38.6 degrees C (0.5 degrees C added for axillary readings) may be closely followed as outpatients without laboratory evaluation.


Summary of Key Evidence
  1. The decision-tree model described above was computer derived, based on data from 3066 febrile infants less than 3 months old who were prospectively studied in pediatric clinics. Applied retrospectively to the patients studied, it showed 93.6% sensitivity and 27.3% specificity for identifying bacteremia and bacterial meningitis.1
  2. The negative predictive value of the model was 99.6%, while the positive predictive value was only 2.9%.
  3. The clinicians who participated in this study followed individualized approaches to evaluate the infants (a standard approach was applied only 42% of the time), yet they had a superior sensitivity and specificity when compared to the standard approach and when compared to the computer model. (Clinician sensitivity 97.1%, specificity 35.5%; Standard approach sensitivity 95.2%, specificity 35.2%).
  4. The prevalence of bacteremia and bacterial meningitis was similar to that found in studies of inner-city ED populations (bactermia 1.8% [2.4% of those initially tested] and bacterial meningitis 0.5%)

Additional Comments

  • Good follow-up was essential; only 4% of the patients had a single contact with the healthcare system.
  • This study differs from several other major studies in the literature in the following respects: it was conducted in the clinic setting; the physicians evaluating the infants were attending-level pediatricians, not residents; and infants who only had fevers at home prior to the clinic visit were also included.
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Citation

  1. Pantel RH, Newman TB, Bernzweig J, et al. Management and Outcomes of Care of Fever in Early Infancy. JAMA 2004; 291:1203-12.
CAT Author: Vija Merrill, MD

CAT Appraisers: Jon Fliegel, MD

Date appraised: March 17, 2004

Last updated April 26, 2004
Department of Pediatrics and Communicable Diseases
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