The “Step-by-Step” Approach in the Management of Young Febrile Infants
The article: Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants.
Gomez B, Mintegi S, Bressan S, et al. Pediatrics. 2016; 138(2).
The idea: Since the establishment of the classic Rochester, Philadelphia and Boston criteria, the management of infants 90 days and younger with fever has evolved. The “Step-by-Step” approach is an algorithm developed by a group of European pediatric emergency physicians with the goal of indentifying a low risk group of infants who can be safely managed as outpatients without lumbar puncture or empiric antibiotics. The approach had been retrospectively tested before with promising results. The objective of this study was to prospectively validate these results in a larger multicenter population.
The study: A multicenter prospective study involving 11 European pediatric emergency departments. Infants less than or equal to 90 days old presenting with fever without source were included. A urine dipstick, urine culture (catheterized specimen), WBC, CRP, procalcitonin (PCT) and blood culture were collected on each patient. The step-by-step approach is an algorithm whereby the provider sequentially evaluates the infant’s 1) general appearance (sick v not sick), 2) age (</=21 days), 3) leukocyturia, 4) PCT level (>/=0.5), and 5) CRP (>20) or ANC (>10,000), using this information to identify high risk patients who require further workup/treatment. The accuracy of the step-by-step approach, the Rochester criteria, and the Lab-score in indentifying patients at low risk of invasive bacterial infection (IBI) was compared.
The results: Out of 2,185 infants enrolled, 87 (4%) were diagnosed with invasive bacterial infection. The step-by-step approach had a higher sensitivity and negative predictive value compared to the Rochester criteria and Lab-score for ruling out invasive bacterial infection. The prevalence of potentially missed IBI was higher (P<0.05) using the Lab-score or Rochesteria criteria than the step-by-step approach. Interestingly, the initial part of the algorithm prior to evaluating blood work (general appearance, age and presence of leukocyturia) identified 80% of the IBI (including 22 of 26 with sepsis and 9 of 10 with bacterial meningitis).
The takeaway: The step-by-step approach appears to be an accurate method (in this study more acute than the Rochester criteria or Lab-score) of identifying low risk febrile infants that can be safely management as an outpatient without lumbar puncture or empiric antibiotics. The caveat to this may be in the 22-28 day old patient group; 4 of the 7 patients inaccurately placed in the low risk category and ultimately found to have an IBI were in this age group. This suggests that providers should continue to be conservative in their management of this age group and possibly extend the high risk age range to 28 days.