Fever Without an Apparent Source in Young Infants: A Multicenter Retrospective Evaluation of Adherence to the Dutch Guidelines.
Journal
The Pediatric infectious disease journal
ISSN: 1532-0987
Titre abrégé: Pediatr Infect Dis J
Pays: United States
ID NLM: 8701858
Informations de publication
Date de publication:
12 2020
12 2020
Historique:
pubmed:
29
8
2020
medline:
27
7
2021
entrez:
29
8
2020
Statut:
ppublish
Résumé
The Dutch fever without an apparent source (FWS) guidelines were published to timely recognize and treat serious infections. We determined the adherence to the Dutch FWS guidelines and the percentage of serious infections in infants younger than 3 months of age. Second, we identified which clinical criteria, diagnostic tests, and management were associated with nonadherence to the guidelines. A retrospective cohort study was performed in 2 Dutch teaching hospitals. We assessed the charts of all infants with FWS who presented at the emergency departments from September 30, 2017, to October 1, 2019. Diagnostic and therapeutic decisions were compared with the recommendations, as published in the Dutch guidelines. Infants were categorized into the nonadherence group in case 1 or more recommendations were not adhered to. Data on 231 infants were studied; 51.5% of the cases adhered to the Dutch guidelines and 16.0% suffered from a serious infection. The percentage of infants with a serious infection was higher in the adherence compared with the nonadherence group. We observed no relevant differences in clinical outcomes. Univariate regression analysis showed that an abnormal white blood cell count was associated with nonadherence (OR 0.4, P = 0.049). Not obtaining a urine and blood culture and not starting intravenous antibiotic treatment were the most frequent reasons for nonadherence to the guidelines. Our study indicates that there was nonadherence in a large proportion of FWS cases. The guidelines may need to be adjusted to increase adherence.
Sections du résumé
BACKGROUND
The Dutch fever without an apparent source (FWS) guidelines were published to timely recognize and treat serious infections. We determined the adherence to the Dutch FWS guidelines and the percentage of serious infections in infants younger than 3 months of age. Second, we identified which clinical criteria, diagnostic tests, and management were associated with nonadherence to the guidelines.
METHODS
A retrospective cohort study was performed in 2 Dutch teaching hospitals. We assessed the charts of all infants with FWS who presented at the emergency departments from September 30, 2017, to October 1, 2019. Diagnostic and therapeutic decisions were compared with the recommendations, as published in the Dutch guidelines. Infants were categorized into the nonadherence group in case 1 or more recommendations were not adhered to.
RESULTS
Data on 231 infants were studied; 51.5% of the cases adhered to the Dutch guidelines and 16.0% suffered from a serious infection. The percentage of infants with a serious infection was higher in the adherence compared with the nonadherence group. We observed no relevant differences in clinical outcomes. Univariate regression analysis showed that an abnormal white blood cell count was associated with nonadherence (OR 0.4, P = 0.049). Not obtaining a urine and blood culture and not starting intravenous antibiotic treatment were the most frequent reasons for nonadherence to the guidelines.
CONCLUSIONS
Our study indicates that there was nonadherence in a large proportion of FWS cases. The guidelines may need to be adjusted to increase adherence.
Identifiants
pubmed: 32858646
doi: 10.1097/INF.0000000000002878
pii: 00006454-202012000-00010
doi:
Substances chimiques
Anti-Bacterial Agents
0
Types de publication
Journal Article
Multicenter Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
1075-1080Références
Arora R, Mahajan P. Evaluation of child with fever without source: review of literature and update. Pediatr Clin North Am. 2013;60:1049–1062.
DePorre AG, Aronson PL, McCulloh RJ. Facing the ongoing challenge of the febrile young infant. Crit Care. 2017;21:68.
Greenhow TL, Hung YY, Pantell RH. Management and outcomes of previously healthy, full-term, febrile infants ages 7 to 90 days. Pediatrics. 2016;138:e20160270.
Zarkesh M, Sedaghat F, Heidarzadeh A, et al. Diagnostic value of IL-6, CRP, WBC, and absolute neutrophil count to predict serious bacterial infection in febrile infants. Acta Med Iran. 2015;53:408–411.
Woelker JU, Sinha M, Christopher NC, et al. Serum procalcitonin concentration in the evaluation of febrile infants 2 to 60 days of age. Pediatr Emerg Care. 2012;28:410–415.
Nosrati A, Ben Tov A, Reif S. Diagnostic markers of serious bacterial infections in febrile infants younger than 90 days old. Pediatr Int. 2014;56:47–52.
Bachur RG, Harper MB. Predictive model for serious bacterial infections among infants younger than 3 months of age. Pediatrics. 2001;108:311–316.
Baraff LJ. Editorial: Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med. 2003;42:546–549.
Ishimine P. Fever without source in children 0 to 36 months of age. Pediatr Clin North Am. 2006;53:167–194.
Bowker R, Richardson M, Riordan A, et al. Fever in under 5s: assessment and initial management. London National Institute for Health and Car Excellence (UK) web site. November 7, 2019. Available from: https://www.nice.org.uk/guidance/ng143. Accessed January 10, 2020.
Nijman RG, Vergouwe Y, Thompson M, et al. Clinical prediction model to aid emergency doctors managing febrile children at risk of serious bacterial infections: diagnostic study. BMJ. 2013;346:f1706.
Bleeker SE, Derksen-Lubsen G, Grobbee DE, et al. Validating and updating a prediction rule for serious bacterial infection in patients with fever without source. Acta Paediatr. 2007;96:100–104.
Roukema J, Steyerberg EW, van der Lei J, et al. Randomized trial of a clinical decision support system: impact on the management of children with fever without apparent source. J Am Med Inform Assoc. 2008;15:107–113.
Pantell RH, Newman TB, Bernzweig J, et al. Management and outcomes of care of fever in early infancy. JAMA. 2004;291:1203–1212.
Gomez B, Mintegi S, Bressan S, et al. Validation of the “step-by-step” approach in the management of young febrile infants. Pediatrics. 2016;138:e20154381.
Kuppermann N, Dayan PS, Levine DA, et al.; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections. JAMA Pediatr. 2019;173:342–351.
De S, Williams GJ, Hayen A, et al. Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study. BMJ. 2013;346:1–9.
Jain S, Cheng J, Alpern ER, et al. Management of febrile neonates in US pediatric emergency departments. Pediatrics. 2014;133:187–195.
Belfer RA, Gittelman MA, Muñiz AE. Management of febrile infants and children by pediatric emergency medicine and emergency medicine: comparison with practice guidelines. Pediatr Emerg Care. 2001;17:83–87.
Ferguson CC, Roosevelt G, Bajaj L. Practice patterns of pediatric emergency medicine physicians caring for young febrile infants. Clin Pediatr (Phila). 2010;49:350–354.
Young C. The management of Febrile infants by primary-care pediatricians in Utah: comparison with published practice guidelines. Pediatrics. 1995;95:623–627.
Rules P, Make T. Annals of internal medicine academia and clinic translating clinical research into clinical practice : impact of using prediction rules to make decisions. Ann Intern Med. 2006;144:201–210.
Maguire JL, Kulik DM, Laupacis A, et al. Clinical prediction rules for children: a systematic review. Pediatrics. 2011;128:e666–e677.
Niele N, van Houten MA, Boersma B, et al. Multi-centre study found that strict adherence to guidelines led to computed tomography scans being overused in children with minor head injuries. Acta Paediatr. 2019;108:1695–1703.
Oostenbrink R. Richtlijn: Koorts in de tweede lijn bij kinderen van 0-16 jaar, Kindergeneeskunde NVK. NVK web site. December, 2013. Available from: https://www.nvk.nl/Portals/0/richtlijnen/koorts/koortsrichtlijn.pdf. Accessed January 10, 2020.
Plötz F, Bekhof J. Zorgevaluatieonderzoek en de AV. NTVG. 2018;162:D2915.
Rudinsky SL, Carstairs KL, Reardon JM, et al. Serious bacterial infections in febrile infants in the post-pneumococcal conjugate vaccine era. Acad Emerg Med. 2009;16:585–590.
Garcia S, Mintegi S, Gomez B, et al. Is 15 days an appropriate cut-off age for considering serious bacterial infection in the management of febrile infants?. Pediatr Infect Dis J. 2012;31:455–458.
Van den Bruel A, Haj-Hassan T, Thompson M, et al.; European Research Network on Recognising Serious Infection investigators. Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review. Lancet. 2010;375:834–845.
Poletto E, Zanetto L, Velasco R, et al. Bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infection: a systematic review. Eur J Pediatr. 2019;178:1577–1587.
Wallace SS, Brown DN, Cruz AT. Prevalence of concomitant acute bacterial meningitis in neonates with febrile urinary tract infection: a retrospective cross-sectional study. J Pediatr. 2017;184:199–203.
Cruz AT, Mahajan P, Bonsu BK, et al.; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network. Accuracy of complete blood cell counts to identify febrile infants 60 days or younger with invasive bacterial infections. JAMA Pediatr. 2017;171:e172927.
Hamiel U, Bahat H, Kozer E, et al. Diagnostic markers of acute infections in infants aged 1 week to 3 months: a retrospective cohort study. BMJ Open. 2018;8:e018092.
Roberts KB, Downs SM, Finnell SME, et al. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128:595–610.
Banerjee J, Jadresic L, Body S, et al. Urinary tract infection in under 16s: diagnosis and management. London National Institute for Health and Car Excellence (UK) web site. October 31, 2018. Available from: https://www.nice.org.uk/guidance/cg54/chapter/Recommendations. Accessed January 10, 2020.
Tsai JD, Lin CC, Yang SS. Diagnosis of pediatric urinary tract infections. Urol Sci. 2016;27:131–134.
Utsch B, Klaus G. Urinalysis in children and adolescents. Dtsch Arztebl Int. 2014;111:617–625; quiz 626.
Esposito S, Rinaldi VE, Argentiero A, et al. Approach to neonates and young infants with fever without a source who are at risk for severe bacterial infection. Mediators Inflamm. 2018;2018:4869329.
L’Huillier AG, Mardegan C, Cordey S, et al. Enterovirus, parechovirus, adenovirus and herpes virus type 6 viraemia in fever without source. Arch Dis Child. 2019;1:1–7.
Cabrerizo M, Trallero G, Pena MJ, et al.; study group of “Enterovirus and parechovirus infections in children under 3 years-old, Spain” PI12-00904. Comparison of epidemiology and clinical characteristics of infections by human parechovirus vs. those by enterovirus during the first month of life. Eur J Pediatr. 2015;174:1511–1516.
Aronson PL, Lyons TW, Cruz AT, et al.; Pediatric Emergency Medicine Clinical Research Network (PEM CRC) Herpes Simplex Virus (HSV) Study Group. Impact of enteroviral polymerase chain reaction testing on length of stay for infants 60 days old or younger. J Pediatr. 2017;189:169–174.e2.
Niele N, Willemars L, van Houten M, et al. National survey on managing minor childhood traumatic head injuries in the Netherlands shows low guideline adherence and large interhospital variations. Acta Paediatr. 2018;107:168–169.
Barth JH, Misra S, Aakre KM, et al. Why are clinical practice guidelines not followed? The European Federation of Clinical Chemistry and Laboratory Medicine and European Union of Medical Specialists joint working group on Guidelines. Clin Chem Lab Med. 2016;54:1133–1139.