Investigation of afebrile neonates with a history of fever

Time to first dose of antibiotics in febrile neonates

AIM

To assess whether febrile neonates from the community received their first dose of intravenous antibiotics within 1 h from time of arrival, as per the regional paediatric sepsis pathway, at a tertiary combined adult/child emergency department in New Zealand.

METHOD

Retrospective data were collected from January 2018 to December 2019 with 28 patients included.

RESULTS

Mean time to first antibiotic dose for all neonates and those with serious bacterial infection was 3 h 20 min and 2 h 53 min respectively. No case used the paediatric sepsis pathway. A pathogen was identified in 19/28 (67%) neonates and 16/28 (57%) had clinical signs of shock.

CONCLUSION

This study adds to Australasian data on community neonatal sepsis. Antibiotic administration was delayed for neonates with serious bacterial infection, clinical signs of shock and raised lactate. The reasons for delay are examined, with a number of potential areas for improvement identified.

Fever Characteristics and Risk of Serious Bacterial Infection in Febrile Infants

BACKGROUND

Fever is a common complaint in the pediatric emergency department (ED), but the vast majority of children evaluated with fever do not have a serious bacterial infection (SBI). However, in the neonate, a missed SBI can have devastating consequences.

OBJECTIVES

To determine the association between various fever characteristics and the risk of SBI in febrile infants.

METHODS

This is a secondary analysis of the Pediatric Emergency Care Applied Research Network study on febrile infants. Infants with a fever were prospectively enrolled at 26 enrolling EDs between 2008 and 2013. We analyzed association of height of fever, location of where temperature was taken (enrolling ED vs. non-health care location), and duration of fever with SBI.

RESULTS

We included 4821 patients who had at least a blood culture completed. Height of fever was significantly associated with risk of SBI, with an odds ratio of 1.5 (95% confidence interval 1.2-1.8). Duration of fever was not associated with risk of SBI, and a fever taken in the enrolling ED vs. at a non-health care facility was minimally associated with risk of SBI (odds ratio 1.3, 95% confidence interval 1.0-1.5).

CONCLUSION

In all analyses, height of fever was associated with all three major types of SBI in febrile infants. Duration and location of fever were less reliably associated with risk of SBI, but there was a small association of risk of SBI and a fever taken at the enrolling ED vs. at a non-health care location.

Risk of Serious Bacterial Infection in Infants Aged ≤60 Days Presenting to Emergency Departments with a History of Fever Only

OBJECTIVE

To compare the risk of serious bacterial infection between infants aged ≤60 days who are febrile in the emergency department (ED) and those who have only a history of fever and are afebrile on arrival to the ED.

STUDY DESIGN

In this secondary analysis of a multicenter prospective study using data collected between December 2008 and May 2013, we compared the rate of serious bacterial infection (urinary tract infection [UTI], bacteremia, and/or bacterial meningitis) between infants who have a history of fever but are afebrile on arrival to the ED and those with fever documented in the ED (rectal temperature ≥38.0 °C) using relative risk (RR) with 95% CI. Stratified analyses were performed for age (≤28 and 29-60 days) and serious bacterial infection type. Infants born prematurely and those with a clinical focal infection or serious illness were excluded.

RESULTS

A total of 3825 infants (mean age, 35.2 days; 56.9% male) were included. Of the 1233 (32.2%) who were afebrile in the ED, 108 (8.8%) had a serious bacterial infection (UTI, n = 94 [7.6%]; bacteremia, n = 19 [1.5%]; bacterial meningitis, n = 8 [0.6%]). Of the 2592 infants (67.8%) who were febrile in the ED, 331 (12.8%) had a serious bacterial infection (UTI, n = 285 [11.0%]; bacteremia, n = 61 [2.4%]; bacterial meningitis, n = 17 [0.7%]). The RR for serious bacterial infection for afebrile vs febrile infants was 0.68 (95% CI, 0.56-0.84). A lower risk of serious bacterial infection was also seen among afebrile vs febrile infants aged ≤28 days (RR, 0.69; 95% CI, 0.52-0.93) and age 29-60 days (RR, 0.67; 95% CI, 0.50-0.89).

CONCLUSIONS

The prevalence of serious bacterial infection is lower in infants aged ≤60 days with a history of fever compared with those who are febrile on arrival to the ED. The small risk reduction in this group is unlikely to alter decision making.

Rotavirus infection as a frequent cause of neonatal fever

BACKGROUND

Fever rather than diarrhea or vomiting was the most common symptom of neonatal rotavirus (RV) infection in our previous study. We investigated whether RV infection is a major cause of neonatal fever and compared the clinical characteristics of bacterial infection, viral infection and unknown causes of neonatal fever.

METHOD

We reviewed the electronic medical records of 48 newborns aged ≤28 days who were admitted to the Special Care Nursery of Hanyang University Guri Hospital for fever (≥38°C) from 2005 to 2009. All the newborns underwent complete blood count, urinalysis, C-reactive protein, cultures of blood, urine, and cerebrospinal fluid as well as stool RV enzyme-linked immunosorbent assay. Respiratory virus polymerase chain reaction for cough or rhinorrhea, and stool culture for diarrhea were also done.

RESULTS

All the babies were term, with mean age 13 ± 8 days and peak body temperature 38.5 ± 0.5°C. The causes of neonatal fever were viral (44%), bacterial (10%) and unknown (46%). The viral infections included RV (n = 12), enterovirus (n = 6), respiratory syncytial virus (n = 2), and rhinovirus (n = 1). All the rotavirus genotypes were G4P[6]. Only three of 12 RV-infected febrile newborns had diarrhea. The bacterial infections included three cases of urinary tract infection (Escherichia coli, n = 2; Klebsiella pneumoniae, n = 1), and two cases of sepsis complicated with meningitis (all Streptococcus agalactiae).

CONCLUSIONS

RV infection is the most common single cause of neonatal fever. It may be necessary to include stool RV tests for febrile newborns.

Consensus Guidelines on Evaluation and Management of the Febrile Child Presenting to the Emergency Department in India

JUSTIFICATION

India, home to almost 1.5 billion people, is in need of a country-specific, evidence-based, consensus approach for the emergency department (ED) evaluation and management of the febrile child.

PROCESS

We held two consensus meetings, performed an exhaustive literature review, and held ongoing web-based discussions to arrive at a formal consensus on the proposed evaluation and management algorithm. The first meeting was held in Delhi in October 2015, under the auspices of Pediatric Emergency Medicine (PEM) Section of Academic College of Emergency Experts in India (ACEE-INDIA); and the second meeting was conducted at Pune during Emergency Medical Pediatrics and Recent Trends (EMPART 2016) in March 2016. The second meeting was followed with futher e-mail-based discussions to arrive at a formal consensus on the proposed algorithm.

OBJECTIVE

To develop an algorithmic approach for the evaluation and management of the febrile child that can be easily applied in the context of emergency care and modified based on local epidemiology and practice standards.

RECOMMENDATIONS

We created an algorithm that can assist the clinician in the evaluation and management of the febrile child presenting to the ED, contextualized to health care in India. This guideline includes the following key components: triage and the timely assessment; evaluation; and patient disposition from the ED. We urge the development and creation of a robust data repository of minimal standard data elements. This would provide a systematic measurement of the care processes and patient outcomes, and a better understanding of various etiologies of febrile illnesses in India; both of which can be used to further modify the proposed approach and algorithm.