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Wilcox H, Umana E, Fauteux-Lamarre E, Velasco R, Waterfield T. Conundrums in the Management of Febrile Infants under Three Months of Age and Future Research. Antibiotics (Basel) 2024; 13:88. [PMID: 38247647 PMCID: PMC10812496 DOI: 10.3390/antibiotics13010088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/23/2024] Open
Abstract
Febrile infants under three months of age pose a diagnostic challenge to clinicians. Unlike in older children, the rates of invasive bacterial infections (IBIs), such as bacteraemia or meningitis, are high. This greater risk of IBI combined with the practical challenges of assessing young infants results in a cautious approach with many febrile infants receiving parenteral antibiotics "just in case". However, there is a range of validated tailored care guidelines that support targeted investigation and management of febrile infants, with a cohort identified as lower risk suitable for fewer invasive procedures and observation without parenteral antibiotics. This manuscript outlines five common conundrums related to the safe application of tailored-care guidelines for the assessment and management of febrile infants under three months of age. It also explores future research which aims to further refine the management of febrile infants.
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Affiliation(s)
- Helena Wilcox
- St. Georges University Hospital NHS Foundation Trust, London SW17 0QT, UK;
| | - Etimbuk Umana
- Wellcome Wolfson Institute of Experimental Medicine, Queen’s University Belfast, Belfast BT9 7BL, UK;
| | | | - Roberto Velasco
- Pediatric Emergency Unit, Hospital Universitari Parc Tauli, Institut d’Investigació i Innovació I3PT, 08208 Sabadell, Spain;
| | - Thomas Waterfield
- Wellcome Wolfson Institute of Experimental Medicine, Queen’s University Belfast, Belfast BT9 7BL, UK;
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Rees CA, Lim J, Westbrook AL, El Helou R, Schmid A, Rubin-Smith J, Shreeve K, Rotman C, Govindapillai S, Dorney K, Niescierenko M. Systematic review and meta-analysis of the diagnostic value of four biomarkers in detecting neonatal sepsis in low- and middle-income countries. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2022-001627. [PMID: 36649385 PMCID: PMC9835957 DOI: 10.1136/bmjpo-2022-001627] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/29/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Biomarkers may enhance diagnostic capability for common paediatric infections, especially in low- and middle-income countries (LMICs) where standard diagnostic modalities are frequently unavailable, but disease burden is high. A comprehensive understanding of the diagnostic capability of commonly available biomarkers for neonatal sepsis in LMICs is lacking. Our objective was to systematically review evidence on biomarkers to understand their diagnostic performance for neonatal sepsis in LMICs. METHODS We conducted a systematic review and meta-analysis of studies published in English, Spanish, French, German, Dutch, and Arabic reporting the diagnostic performance of C reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC) and procalcitonin (PCT) for neonatal sepsis. We calculated pooled test characteristics and the area under the curve (AUC) for each biomarker compared with the reference standards blood culture or clinical sepsis defined by each article. RESULTS Of 6570 studies related to biomarkers in children, 134 met inclusion criteria and included 23 179 neonates. There were 80 (59.7%) studies conducted in LMICs. CRP of ≥60 mg/L (AUC 0.87, 95% CI 0.76 to 0.91) among 1339 neonates and PCT of ≥0.5 ng/mL (AUC 0.87, 95% CI 0.70 to 0.92) among 617 neonates demonstrated the greatest discriminatory value for the diagnosis of neonatal sepsis using blood culture as the reference standard in LMICs. CONCLUSIONS PCT and CRP had good discriminatory value for neonatal sepsis in LMICs. ESR and WBC demonstrated poor discrimination for neonatal sepsis in LMICs. Future studies may incorporate biomarkers into clinical evaluation in LMICs to diagnose neonatal sepsis more accurately. PROSPERO REGISTRATION NUMBER CRD42020188680.
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Affiliation(s)
- Chris A Rees
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA .,Division of Pediatric Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jamie Lim
- Department of Pediatrics, Boston Medical Center and Boston Children's Hospital, Boston, Massachusetts, USA
| | - Adrianna L Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rachelle El Helou
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexis Schmid
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Global Health Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Julia Rubin-Smith
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Global Health Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kyra Shreeve
- Global Health Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Chloe Rotman
- Medical Library, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sindu Govindapillai
- Department of Pediatrics, Qikiqtani General Hospital, Iqaluit, Nunavut, Canada
| | - Kate Dorney
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Global Health Program, Boston Children's Hospital, Boston, Massachusetts, USA
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