A survey of the management of febrile infants in pediatric emergency departments

Emergency department and inpatient clinical decision tools for the management of febrile young infants among tertiary paediatric centres across Canada

Objectives

With no nationally-endorsed guidelines and the emergence of newer diagnostic tools, there exists significant variation in the management of febrile infants <90 days. We sought to evaluate the prevalence and content of clinical decision tools (CDTs) for the emergency department (ED) and inpatient management of febrile young infants across Canada.

Methods

We undertook a cross-sectional analysis of febrile young infant CDTs from ED and inpatient units at all 16 Canadian tertiary paediatric hospitals. Additional data were collected using an electronic survey of ED and inpatient representatives, characterizing their clinical settings and diagnostic test availability. Content of all existent CDTs was independently reviewed using list items determined a priori. The primary outcome was the proportion of EDs and inpatient units with CDTs.

Results

Information regarding CDTs was gathered from all 16 EDs and 16 inpatient units. CDTs were infrequently available (9/32, 28%), and were more common in the ED than inpatient setting (8/16 versus 1/16, P=0.02). Review of existing CDTs revealed inter-centre differences for inclusion ages, treatment regimens, lumbar puncture recommendations, diagnostic testing and normal laboratory values. Despite availability reported at nearly all centres, C-reactive protein and respiratory virus testing were recommended in 3/9 and 5/9 CDTs, respectively. Procalcitonin testing was available at only 2/16 (13%) centres, and not incorporated into any CDTs.

Conclusions

CDTs for the management of febrile young infants are infrequently available among Canadian tertiary paediatric centres, and rarely incorporate newer diagnostic tests. Heterogeneity among existent CDTs highlights the need for evidence-based unified ED and inpatient national guidelines.

Validation of Procedural Codes to Identify Infants Evaluated for Serious Bacterial Infection

OBJECTIVE

To validate a novel coding method using Current Procedural Terminology, Fourth Edition (CPT-4) codes for identifying infants who underwent a full evaluation for serious bacterial infection (SBI).

METHODS

We performed a multicenter, retrospective examination to determine the accuracy of a combination of CPT-4 codes for blood, cerebrospinal fluid (CSF), and urine cultures to identify previously healthy infants ≤90 days old admitted to a general care floor and fully evaluated for SBI. Full SBI evaluation was defined as blood, CSF, and urine cultures performed during the emergency department encounter or corresponding hospitalization. Cases were defined as infants who had codes for blood, CSF, and urine cultures (87040, 87070, and either 87086 or 87088), and these were compared with all other encounters. We validated these findings by comparing medical record documentation of blood, CSF, and urine cultures to the corresponding CPT-4 codes, with calculation of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

We identified 8548 qualifying encounters, and 347 (4%) had a combination of CPT-4 codes 87040, 87070, and either 87086 or 87088. This combination had a sensitivity of 100% (95% confidence interval, 98.9-100) and specificity of 98.2% (95% confidence interval, 97.3-98.8) for identifying infants who underwent full SBI evaluation for an unknown source.

CONCLUSIONS

CPT-4 codes provide an accurate means to identify infants who underwent complete SBI evaluation.

Axillary, Oral and Rectal Routes of Temperature Measurement During Treatment of Acute Kawasaki Disease

BACKGROUND

Important therapeutic decisions are made based on the presence or absence of fever in patients with Kawasaki disease (KD), yet no standard method or threshold exists for temperature measurement during the diagnosis and treatment of these patients. We sought to compare surface and internal (rectal or oral) routes of temperature measurement for the detection of fever as a marker of treatment resistance.

METHODS

From a randomized, placebo-controlled trial of infliximab as an adjunct to primary intravenous immunoglobulin treatment for acute KD, we collected concurrent (within 5 minutes) axillary and internal temperature measurements and performed receiver-operating characteristic and Bland-Altman analyses. We also determined the ability of surface temperatures to detect treatment resistance defined by internal temperature measurements.

RESULTS

Among 452 oral-axillary and 439 rectal-axillary pairs from 159 patients, mean axillary temperatures were 0.25 and 0.43 °C lower than oral and rectal temperatures and had high receiver-operating characteristic areas under curves. However, axillary temperatures ≥ 38.0 °C had limited sensitivity to detect fever defined by internal temperatures. Axillary thresholds of 37.5 and 37.2 °C provided maximal sensitivity and specificity to detect oral and rectal temperatures ≥ 38.0 °C, respectively.

CONCLUSIONS

Axillary temperatures are an insensitive metric for fevers defining treatment resistance. Clinical trials should adopt temperature measurement by the oral or rectal routes for adjudication of treatment resistance in KD.

Comparison of pediatric and general emergency medicine practice patterns in infants with fever

OBJECTIVES

To evaluate and compare the management approaches of pediatric and general emergency medicine physicians in infants presenting to the emergency department (ED) with complaint of fever.

METHODS

Infants 90 days of age or younger with a chief complaint of fever were included for review. Vital signs, laboratory workup, disposition, and final diagnosis were collected. Compliance with guidelines was assessed and compared between EDs.

RESULTS

Compliance with admission guidelines was not significantly different in any of the 3 age groups evaluated between the pediatric and general ED (PED and GED). Compliance with guideline recommendations for laboratory workup was not significantly different between the 2 EDs, nor was overall compliance with guideline recommendations.

CONCLUSIONS

No significant variations in the management of febrile infants or compliance with published guidelines between PED and GED physicians were observed. Young infants can be safely treated for fever in the PED or GED.

Fever survey highlights significant variations in how infants aged ≤60 days are evaluated and underline the need for guidelines

AIM

To assess the common practices for evaluating and treating febrile infants aged ≤60 days in a nationwide survey.

METHODS

Questionnaires were administrated to inpatient paediatric departments in all 25 hospitals in Israel.

RESULTS

Of the 25 centres surveyed (100% response rate), only 36% had written protocols concerning the approach to young febrile infants. The existence of a written protocol was significantly associated with the level of medical centre (tertiary versus primary and secondary, p = 0.041) and with the number of local paediatric infectious disease specialists (p = 0.034). In 13 (52%) hospitals, a normal white blood cell count was defined as 5000-15 000 cells/mL and 20 (80%) centres use C-reactive protein. Hospitalisation was mandatory in most (96%) centres for all neonates aged ≤28 days. Low-risk infants aged 29-60 days were hospitalised in 68.4% of the primary and secondary hospitals, compared with 33.3% tertiary centres. Ampicillin and gentamicin was the routine empiric antibiotic treatment for febrile infant in 92% of centres.

CONCLUSION

Significant differences exist among centres in the evaluation of febrile infants aged ≤60 days exist. These differences reflect the lack of, and highlight the need for, national or international guidelines for the evaluation of fever in this age group.