Posted by Andy Jagoda, MD in: Feature Update , trackback
Due to an immature immune system and pathogens often specific to the age group, the young infant (generally aged < 60-90 days, depending on the specific study or review) is at high risk for serious bacterial infections (SBIs); in particular, urinary tract infection (UTI), bacteremia, and bacterial meningitis. Consequently, the febrile young infant with a rectal temperature ≥ 38°C (100.4°F) is commonly encountered in the emergency department (ED). The incidence of SBI in febrile infants aged < 90 days is 8% to 12.5%, and it is nearly 20% in neonates (aged ≤ 28 days). The incidence of potentially life-threatening bacteremia and/or bacterial meningitis (ie, invasive bacterial infection [IBI]) is approximately 2%.
Due to their lack of social responsiveness (eg, social smile) and verbal cues, even well-appearing febrile young infants may harbor an SBI, in contrast to well-appearing febrile older infants and children who are at lower risk for IBI. Multiple studies have demonstrated that both observation scales and clinician suspicion for SBI are poorly predictive of bacterial infection in febrile infants. Additionally, bacterial meningitis is the most common diagnosis involved in pediatric medical malpractice claims in the emergency department (ED).
Over 2 decades ago, several risk stratification criteria were created to identify febrile young infants at low risk for SBI, and the criteria have been utilized to potentially avoid hospitalization of certain low-risk patients. More recently, newer risk stratification algorithms that incorporate biomarkers such as procalcitonin (PCT) and C-reactive protein (CRP) have been developed and validated in febrile infants.
Among well-appearing febrile infants, neonates have the highest prevalence of SBI and IBI and the least reliable clinical examination. These infants should undergo a full sepsis evaluation, including CSF testing. While the Rochester criteria and the recently published PECARN prediction rule do not include routine CSF testing in this age group (see table below), infants classified as low-risk by any criteria may still have bacterial meningitis, so CSF testing is generally recommended for all infants aged ≤ 28 days. Consideration should be given to testing for HSV in the neonate aged ≤ 21 days, even in the absence of vesicles or maternal history of HSV infection.
This table will help you predict the risk stratification criteria for management of febrile young infants. Download now.
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