Management and outcomes of care of fever in early infancy

Article Outline

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Pantell RH, Newman TB, Bernzweig J, Bergman DA, Takayama JI, Segal M, et al. JAMA 2004;291:1203-12

Context Fever in infants challenges clinicians to distinguish between serious conditions, such as bacteremia or bacterial meningitis, and minor illnesses. 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.

Objectives To characterize the management and clinical outcomes of fever in infants, develop a clinical prediction model for the identification of bacteremia/bacterial meningitis, and compare the accuracy of various strategies.

Design Prospective cohort study.

Setting Offices of 573 practitioners from the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics in 44 states, the District of Columbia, and Puerto Rico.

Participants Consecutive sample of 3066 infants aged 3 months or younger with temperatures of at least 38°C seen by PROS practitioners from February 28, 1995, through April 25, 1998.

Main outcome measures Management strategies, illness frequency, and rates and accuracy of treating bacteremia/bacterial meningitis.

Results The PROS clinicians hospitalized 36% of the infants, performed laboratory testing in 75% (74% with complete blood cell count or blood culture; 54% with urine testing; 33% with lumbar punctures), and initially treated 57% with antibiotics. The majority (64%) were treated exclusively outside of the hospital. Bacteremia was detected in 1.8% of infants (2.4% of those tested) and bacterial meningitis in 0.5%. Well-appearing infants aged 25 days or older with fever of <38.6°C had a rate of 0.4% for bacteremia/bacterial meningitis. Frequency of other illnesses included urinary tract infection, 5.4%; otitis media, 12.2%; upper respiratory tract infection, 25.6%; bronchiolitis, 7.8%; and gastroenteritis, 7.2%. Practitioners followed current guidelines in 42% of episodes. However, in the initial visit, they treated 61 of the 63 cases of bacteremia/bacterial meningitis with antibiotics. Neither current guidelines nor the model developed in this study performed with greater accuracy than observed practitioner management.

Conclusions Pediatric clinicians in the United States use individualized clinical judgment in treating febrile infants. In this study, relying on current clinical guidelines would not have improved care but would have resulted in more hospitalizations and laboratory testing.

Comment These authors tried hard to develop a clinical prediction tool that would identify infants with serious bacterial illness, but nothing proved more effective than the clinical judgment of the PROS practitioners.

A concern that was an initial stumbling block to this study being funded was that testing would not be done on every infant—so how would we know that all serious bacterial illnesses were identified? The authors responded that outcome is a more important endpoint than the number of abnormal tests. Therefore, some infants in this study may well have had unrecognized bacteremia or urinary tract infections—some self-resolving, some treated successfully—but it seems quite unlikely that the most serious condition, bacterial meningitis, was missed, even though only a third of infants underwent lumbar puncture.

How should this study be applied? Were the practitioners really good or just lucky? Are practitioners vindicated for not applying published protocols? Should residents and emergency department (ED) physicians stop using protocols? The answers may rest on two observations: (1) In only 4% of cases did the practitioners have only 1 contact with the families during the course of the febrile illness. That is quite different from the situation in EDs; (2) Outcomes such as bacterial meningitis not suspected clinically are rare in practice but are more likely discovered in EDs, simply because of the frequency with which young febrile infants are seen.

It is clear that the rate of serious bacterial infections is much higher in the first month of life than thereafter, therefore infants aged 0 to 3 months should not be considered a homogeneous group. Infants older than 1 month who do not appear clinically ill and have only a low-grade fever are very unlikely to have bacteremia or bacterial meningitis. Moreover, the fear of missing bacteremia and bacterial meningitis should not direct attention away from the possibility of urinary tract infection, a much more likely condition, particularly in girls and uncircumcised boys.

Despite the best research efforts, no set of guidelines or clinical prediction tools identify all infants who need treatment, short of hospitalizing and treating all febrile infants, an approach that is not without its own risks as well as costs. Studies like this one demonstrate the benefit of collaborative research in office settings and the limits of extrapolating findings from studies in academic medical centers and EDs to office practices.