Lampiran ORIGINAL STUDIES

Is 15 Days an Appropriate Cut-off Age for Considering Serious Bacterial Infection in the Management of Febrile Infants
Silvia Garcia, MD,* Santiago Mintegi, PhD,* Borja Gomez, MD,* Jorge Barron, MD, Mari Pinedo, MD,* Nerea Barcena, MD,* Elena Martinez, MD,* and Javier Benito, PhD*
Introduction: Febrile infants 3 months of age have a greater ris for seri! o"s ba#terial infe#tion $S%I&' The ris is inversel( #orrelate) *ith age' +ost proto#ols re#ommen) a)mitting to hospital all febrile infants ,- )a(s of age' .o*ever/ as the prevalen#e of S%I is not homogeno"s in this age gro"p/ some a"thors have #onsi)ere) )e#reasing this #"t!off age/ allo*ing amb"la! tor( management of sele#te) patients meeting lo*!ris #riteria' Objective: To )etermine *hether 01 )a(s is a s"itable #"t!off age for )iffer! ent approa#hes to the management of infants *ith fever' Patients and Methods: 2ross!se#tional )es#riptive st")( of infants 3 months of age *ith fever *itho"t a so"r#e seen bet*een September 0/ ,333 an) A"g"st 33/ ,303 in the pe)iatri# emergen#( )epartment of a tertiar( tea#hing hospital' All infants 3 months of age *ith fever *itho"t a so"r#e $3-2& *ere in#l")e)' The follo*ing )ata *ere #olle#te)4 age/ se5/ temperat"re/ )iagnosis/ management in pe)iatri# emergen#( )epart! ment/ an) o"t#ome' Results: Data *ere #olle#te) for 0161 infants7 of *hom/ 300 $08'69/ 819 #onfi)en#e intervals :2I;4 06'6<,0'6& *ere fo"n) to have an S%I' The rate of S%I in the patients *ho *ere 01 to ,0 )a(s of age *as 33'39 $819 2I4 ,3'69<=,'89&/ similar to that among infants *ho *ere 6 to 0= )a(s of age $30'89/ 819 2I4 ,0'09<=,'69& an) higher than among those ol)er than ,0 )a(s of age $0-'39/ 819 2I4 0>'3<,3'39&' Conclusions: Febrile infants 01 to ,0 )a(s of age ha) a rate of S%I similar to (o"nger infants an) higher than ol)er age infants' It is not appropriate to establish the approa#h to management of infants *ith fever base) on a #"t!off age of , *ee s' Key Words: fever/ neonate/ (o"ng infants/ serio"s ba#terial infe#tion $Pediatr In ect Di! J ,30,7304 =11<=1-&

of age *ith fever *itho"t a so"r#e $FIS& having an S%I' = This/ together *ith there being fe*er signs asso#iate) *ith this t(pe of infe#tion/ in parti#"lar at earl( stages/ means that *e m"st ta e a more #a"tio"s an) interventionist approa#h in these patients than in ol)er #hil)ren'1<03 In re#ent (ears/ ho*ever/ the rates of S%I in infants 3 months of age has )e#rease)/ )"e to improvements in )ete#ting abnormalities in the i)ne( an) "rinar( tra#t "sing pre! natal "ltraso"n) an) "se of intrapart"m antibioti# proph(la5is for gro"p % strepto#o##al infe#tion' 00!03 F"rther/ the )evelopment of ne* )iagnosti# is #a"sing the management of febrile infants to be revie*e)/ moving to*ar) less interventionist approa#hes' 3/0=<0- Sev! eral )ifferent proto#ols re#ommen) a)mission of all infants ,)a(s of age *ith fever/=/08/,3 *hile #onsi)ering amb"lator( manage! ment for sele#te) patients ol)er than 0 month of age meeting lo*! ris #riteria'3/,0<,3 Some a"thors have s"ggeste) lo*ering the #"t! off age for amb"lator( management of sele#te) lo*!ris patients/ altho"gh the( point o"t that there sho"l) be follo*!"p for these in)ivi)"als manage) as o"tpatients',= The obGe#tive of this st")( *as to i)entif( *hether 01 )a(s of age is a s"itable #"t!off point for higher ris of S%I'

This *as a #ross!se#tional )es#riptive st")( of infants 3 months of age *ith FIS $see )efinition later& seen in the ?ED of a tertiar( tea#hing hospital/ )"ring 6 #onse#"tive (ears $Septem! ber ,333<A"g"st ,303&' This ?ED manages an average of >3/333 #hil)ren 0= (ears of age ann"all('

PATIENTS AND METHODS

Study Design
Data *ere #olle#te) from o"r registr( of infants less than 3 months *ith FIS' Ie in#l")e all the infants of this age *ith FIS' Ever( (ear/ bet*een ,63 an) ,-3 episo)es are entere) into this )atabase' The follo*ing variables *ere #olle#te)4 age/ se5/ temperat"re/ )iagnosis/ #omplementar( tests/ an) patient o"t#ome $follo*!"p b( the primar( #are ?e)iatri#ian ! ?2?!/ revisits to the ?ED/ antibioti# treatment/ an) final )iagnosis&'

ever is one of the most #ommon reasons for #hil)ren to be bro"ght to a pe)iatri# emergen#( )epartment $?ED&/ espe#iall( in the #ase of (o"ng infants' 0/, Normall(/ fever is #a"se) b( self! limiting viral infe#tions/ b"t some infants *ith fever *ho appear *ell an) *ith no relevant fin)ings on ph(si#al e5amination have a ba#terial infe#tion that #o"l) potentiall( be serio"s' 3 The rate of serio"s ba#terial infe#tion $S%I& among those 3 months of age is higher than that reporte) in other age gro"ps/ its in#i)en#e being inversel( #orrelate) *ith age/ *ith "p to ,39 of those 0 month
A##epte) for p"bli#ation De#ember 08/ ,300' From the @?e)iatri# Emergen#( Department/ 2r"#es Universit( .ospital/ %il! bao/ %asA"e 2o"ntr(/ Spain7 BDepartment of ?ae)iatri#s/ Universit( of the %asA"e 2o"ntr(/ %asA"e 2o"ntr(/ Spain7 an) C+i#robiolog( Servi#e/ 2r"#es Universit( .ospital .ospital/ %ilbao/ %asA"e 2o"ntr(/ Spain' The a"thors have no f"n)ing or #onfli#ts of interest to )is#lose' A))ress for #orrespon)en#e4 Santiago +integi/ ?hD/ ?e)iatri# Emergen#( Department/ 2r"#es Universit( .ospital/ ?laDa )e 2r"#es sEn/ %ilbao/ %asA"e 2o"ntr(/ Spain' E!mail4 santiago'mintegiFosa i)etDa'net' S"pplemental )igital #ontent is available for this arti#le' Dire#t URL #itations appear in the printe) te5t an) are provi)e) in the .T+L an) ?DF versions of this arti#le on the Go"rnalHs Ieb site $***'pi)G'#om&' 2op(right J ,30, b( Lippin#ott Iilliams K Iil ins ISSN4 3-80!3>>-E0,E3031!3=11 DOI4 03'0386EINF'3b303e30-,=6b8f,

Management in the PED

The management algorithm for infants 3 months of age *ith FIS "se) in o"r ?ED/ re#ommen)s to obtain an "rine )ip! sti# test/ #omplete bloo) #o"nt/ 2!rea#tive protein $2R?& an) pro#al#itonin $?2T& tests $the latter being a))e) to o"r proto#ol in November ,336&/ an) bloo) an) "rine #"lt"res for all #ases' Ie re#ommen) to perform a #erebrospinal fl"i) $2SF& e5amination in those 01 )a(s of age/ in ol)er than 01 )a(s of age *ho )o not *ell!appear *ell/ an) in those *ith abnormal res"lt in bloo) tests $same #"toffs as lo*!ris #riteria/ see later&' D"ring the infl"enDa season/ *e also #arr( o"t a rapi) )iagnosti# test for infl"enDa' For infants ol)er than 01 )a(s of age *ho appear *ell an) meet lo*!ris #riteria $previo"sl( health(/ *ell appearan#e/ "rine )ipsti# res"lt negative for le" o#(t"ria an) nitrit"ria/ le"! o#(te levels bet*een 1333 an) 01/333 per mm 3/ 03/333 ne"! trophilsEmm3/ ?2T 3'1 ngEmL :sin#e November ,336;/ 2R? ,3 mgEL *ith no pleo#(tosis in l"mbar p"n#t"re if performe)/
.../pid0/com 1

The Pediatric Infectious Disease Journal ! "#$%M&'1()%MB&*5(MA+,-1,

455

Garcia et al

The Pediatric Infectious Disease Journal ! "#$%M&'1()%MB&*5(MA+ ,-1,

an) *ith normal fin)ings on #lini#al e5amination after several ho"rs/ ,= ho"rs/ in the observation "nit&/ *e re#ommen) )is! #harge *itho"t antibioti# treatment an) eval"ation in the follo*ing ,= ho"rs b( the ?2?' %( #ontrast/ *e re#ommen) hospital a)mis! sion for those 01 )a(s of age/ those *ith abnormal laborator( res"lts an) *hen there is *orsening in #lini#al stat"s' Ever( month/ a pe)iatri#ian of the ?ED revie*s the ele#! troni# registr( #on#erning all the #ases seen in the )epartment to ens"re that )ata have been #orre#tl( entere) for all the infants *ith fever'

infants *ith fever an) *hose parents reporte) onl( mil) nasal #on! gestion *ere in#l")e) in the st")('

Data Collection
The ele#troni# me)i#al re#or)s of the ?ED *ere revie*e) an) the follo*ing )ata *ere #olle#te) for ea#h patient4 )emographi# var! iables $age an) se5&/ me)i#al histor(/ the time that elapse) bet*een the fever being )ete#te) an) the #hil) being seen in the hospital/ bo)( temperat"re meas"re) at home an) in the ?ED/ the general appearan#e of the infant on arrival/ signs an) #lini#al fin)ings in the ph(si#al e5amination/ res"lts of an( tests performe)/ treatment re#eive)/ )iagnosis/ site of #are/ an) #lini#al progression' In the #ases in *hi#h the #hil) *as a)mitte)/ the patientsH #harts at )is#harge *ere #he# e)' On the other han)/ *hen the #hil) *as not a)mitte) to hospital/ a follo*!"p telephone #all *as ma)e to the patientHs home b( a pe)iatri#ian resi)ent/ after re#eiving s"it! able training/ to assess the #lini#al progression of the #hil)' F"rther/ the hospital )atabase *as revie*e) to )etermine *hether there ha) been an( a))itional visits to the emergen#( )epartment/ after the initial #ons"ltation'

Definitions
FIS4 A5illar( or re#tal temperat"re at home/ or re#tal temperat"re in the ?ED/ of 3-2/ *itho"t #atarrhal or respira! tor( s(mptomsEsigns $s"#h as ta#h(pnea& or a )iarrheal pro#ess/ in patients *ith normal ph(si#al e5amination/ a##or)ing to the )iag! nosti# #o)es iss"es b( the Spanish So#iet( of ?e)iatri# Emergen! #ies',1 Infants *ere e5#l")e) if fever *as assesse) b( parents at home *itho"t "sing a thermometer/ altho"gh the )egree of sensi! tivit( in terms of s"bGe#tive fever assessments #arrie) o"t b( par! ents ranges bet*een 6=9 an) -=9/ *ith a spe#ifi#it( of 6>9 to 8>9',>/,6 Iell!appearing4 Define) b( a normal pe)iatri# assessment after being eval"ate) b( a ?e)iatri# emergen#( ph(si#ian )"ring the first ho"r after atten)ing the ?ED' Appearan#e $mental stat"s&/ *or of breathing an) #ir#"lation to the s in ha) to be normal for infants to be #lassifie) as *ell!appearing/ an) )ata ha) to be refle#te) on the patientHs #harts' S%I4 Isolation of a ba#terial pathogen in the 2SF/ bloo)/ or "rine or posterior )iagnosis of a fo#al infe#tion is #onsi)ere) to be severe in this age gro"p of patients' ?ositive bloo) #"lt"re4 %loo) #"lt"re in *hi#h a tr"e patho! geni# ba#teria has been isolate) $Stre"tococc#! "ne#moniae/ Nei!$ !eria meningitidi!/ Enterococc#! sp'/ E!cherichia coli/ %le&!iella "ne#moniae/ Sta"h'lococc#! a#re#!/ gro"p A an) % Stre"tococc#!/ (i!teria monoc'togene!/ or Salmonella sp'& The gro*th of Sta"h'$ lococc#! e"idermidi!/ ?ropioniba#teri"m a#nes/ an) )iphtheroi)s in bloo) #"lt"res of previo"sl( health( imm"no#ompetent #hil)ren $*ith no histor( of heart problems/ or of pla#ement of #atheters/ ventri#"loperitoneal sh"nt/ or other prostheses& *ere #lassifie) as #ontaminate) samples' O##"lt ba#teremia4 ?ositive bloo) #"lt"re in *ell!appearing infants )iagnose) *ith FIS' %a#terial meningitis4 $a& ?ositive 2SF #"lt"re or 2SF gram/ $b& 2SF pleo#(tosis *ith a positive bloo) #"lt"re' Urinar( tra#t infe#tion4 Gro*th of more than 13/333 #olon(! forming "nits per mL of a ba#terial spe#ies from a single "rine sample #olle#te) b( #atheteriDation of the bla))er' A))itionall(/ the gro*th of 03/333 to 13/333 #olon(!forming "nits per mm 3 *as #onsi)ere) to in)i#ate a "rinar( tra#t infe#tion *hen there *as also le" o#(t"ria an)Eor nitrit"ria' ?revio"sl( health( infant4 To be #lassifie) as s"#h/ the patient m"st have been born at term $ 36 *ee s of gestation&/ no #hroni# or "n)erl(ing )isease/ not treate) for "ne5plaine) h(perbilir"bine! mia/ not hospitaliDe) longer than the mother/ not re#eiving #"rrent or prior antimi#robial therap( an) no previo"s hospitaliDation'

Statistical Analysis
The statisti#al anal(sis *as #arrie) o"t "sing S?SS soft*are $version 08/ 2hi#ago/ IL&' Data are e5presse) as means/ #onfi)en#e intervals $2Is&/ an) stan)ar) )eviations for A"antitative variables an) as n"mbers an) per#entages for #ategori#al variables' 2on! tin"o"s variables *ere #ompare) "sing the St")ent t test/ *hereas #ategori#al variables *ere anal(De) "sing the 2, or the Fisher e5a#t tests' The level of signifi#an#e *as set at P 3'31' This st")( *as approve) b( the Resear#h 2ommittee of the ?ED' Given that the )ata *ere ta en from a )atabase/ on *hi#h entries are anon(mo"s/ an) no interventions *ere performe) on or *ithhel) from an( patients7 it *as not #onsi)ere) ne#essar( to obtain informe) #onsent'

ES!"TS
D"ring the st")( perio)/ 0161 infants 3 months of age *ith FIS *ere in#l")e)' Table/ S"pplemental Digital 2ontent 0/ http4EElin s'l**'#omEINFE%-3 lists the general #hara#teristi#s of these patients' Of the total/ 336 patients *ere ,- )a(s of age' Table/ S"pplemental Digital 2ontent ,/ http4EElin s'l**'#omEINFE%-= reports the "se of these tests b( age gro"p' Of the total/ 300 $08'69/ 819 2I4 06'6<,0'6& infants *ere fo"n) to have an S%I' The )iagnoses of these patients are sho*n in Table/ S"pplemental Digital 2ontent 0/ http4EElin s'l**'#omEINFE%-3' The rate of S%I in 01! to ,0!)a(!ol) patients *as 33'39 $819 2I4 ,3'69<=,'89&/ similar to that among those 6! to 0=!)a(!ol) patients $30'89/ 2I 819 ,0'0<=,'69&/ an) higher than that in infants ol)er than ,0 )a(s of age $0-'39/ 2I 819 0>'3<,3'39&' %( age/ Table/ S"pplemental Digital 2ontent ,/ http4EElin s'l**'#omEINFE%-=/ an) Fig'/ S"pplemental Digital 2ontent 3/ http4EElin s'l**'#omEINFE%-1 sho* the overall rate of S%I/ *hereas Table 0 lists the t(pes of S%I )iag! nose)' ?atients *ith #ell"litis an) AO+ ha) a normal ph(si#al e5amina! tion *hen the( arrive) to the ED' In total/ >>'19 of the patients 3 months of age *ere man! age) as o"tpatients after several ho"rs of observation $01 6 ho"rs/ al*a(s ,= ho"rs& an) *itho"t re#eiving antibioti# treatment' This rate *as lo*er in (o"nger patients/ L,69 in infants 01 to ,0 )a(s of age7 ho*ever/ as man( as 139 of infants ,0 to ,- )a(s of age manage) as o"tpatients' D"ring the st")( perio)/ 8-- infants *ere initiall( )iagnose) *ith FIS an) 188 met lo*!ris #riteria' Of these/ ==8 $6='89& *ere manage) as o"tpatients *itho"t 2SF e5amination or antibioti# ther! ap(' Of these/ *e registere) 3= $6'19& "ns#he)"le) visits be#a"se of ) *+,* (i""incott -illiam! . -il/in!

Exclusion Criteria
?atients in *hom it *as possible to i)entif( the #a"se of the fever/ from their me)i#al histor( or ph(si#al e5amination on a)mission to the ?ED/ *ere not in#l")e) in st")(/ nor *ere those *ith )iarrhea or respirator( signs/ s"#h as ta#h(pnea/ )iffi#"lt( breathing/ *heeDing/ stri)or/ nasal flaring/ #hest retra#tion/ rhon! #hi/ rales/ an) areas of )e#rease) breath so"n)s' On the other han)/

456

1 .../pid0/com

The Pediatric Infectious Disease Journal ! "olume '1( )umber 5( May ,-1,

Bacterial Infection in Febrile Infants

TABLE 1. Type of Serious Bacterial Infection by Age Group

Serious Bacterial Infection Age 7 d (25) 814 d (72) 1521 d (93) 2228 d (117) 2960 d (641) 6190 d (627) UTI 4 (16%) 19 (26.3%) 26 (28%) 25 (21.3%) 100 (15.6%) 100 (15.9%) Bacteremia 1 (1.4%) with associated UTI 2 (2.1%) with associated UTI 13 (2%) 6 with associated UTI 7 (1.1%) 2 with associated UTI Sepsis 1 (1.4%) 2 (2.1%) 1 (0.1%) 2 (0.3%) Meningitis 2 (2.7%) 1 (1.1%) 1 (0.9%) 1 (0.1%) Others 2 (0.3%) 1 (0.1%) Total 16% 31.9% 33.3% 22.2% 18.2% 17.5%

UTI indicates urinary tract infection.

persisten#e of fever or ne* s(mptoms an) 0> s#he)"le) visits $arrival of a positive #"lt"re/ mainl( positive "rine #"lt"re *itho"t le" o#(t"! ria or nitrit"ria&' No patient manage) as an o"tpatient ret"rne) to the ?ED )"e to a #lini#al )eterioration or referre) a #lini#al )eterioration at home/ *hen the( *ere #onta#te) b( phone' 2omplete follo*!"p of the patients *as ma)e in 8,9

A##or)ing to o"r res"lts/ the prevalen#e of S%I is not homogeno"s among febrile infants 3 months of age' Spe#ifi#all(/ the prevalen#e is higher among those 3 *ee s of age' F"rther/ 01! to ,0!)a(!ol) febrile infants have a rate of S%I that is similar to (o"nger infants b"t higher than that among ol)er gro"ps' For this reason/ *e )o not believe that it is appropriate to a)opt )ifferent approa#hes to the management of febrile infants "sing 01 )a(s of life as the #"t!off point' If *e a##ept that febrile infants 3 months of age )o not #onstit"te an homogeneo"s gro"p/ a##or)ing to o"r )ata an) regar)ing the S%I rate/ the most a)eA"ate age #"t!off point for a )ifferent approa#h sho"l) be ,0 )a(s' Altho"gh the 2Is for the S%I in neonates 3 *ee s of age sho* overlap *hen #ompare) *ith neonates = *ee s of age/ it seems reasonable to establish the age #"t!off for higher ris of S%I at 3 *ee s an) not at , or = *ee s of age' Tra)itionall(/ febrile infants have been #lassifie) into vario"s age gro"ps for )ifferent management strategies4 neonates $3<,- )a(s&7 (o"ng infants $"s"all( #orrespon)ing to 0<3 months of age/ altho"gh some a"thors onl( in#l")e those 0<, months of age&7 an) ol)er infants $3<3> months&'The management of febrile infants still is #ontroversial for those 3 months of age an)/ even more so/ for those less than 0 month of age' 3/03/0=<0> This latter gro"p has been #onsi)ere) to be at high ris be#a"se of relativel( high prevalen#e of S%I/ to the )iffi#"lt( of ma ing a #lini#al assess! ment/ an) be#a"se of their *ea imm"ne response' 1<03 The fe*er #lini#al signs of infe#tion in this age gro"p ma es it more )iffi! #"lt to "se #lassi# assessment s#ales to #lassif( them into gro"ps at higher an) lo*er ris of having an S%I' ,-/,8 Ma)ish et al,= report rates of S%I of "p to 39 among patients 0 to ,- )a(s of age *ho meet lo*!ris #riteria a##or)ing to the %oston an) ?hila)elphia proto#ols an) *ho *ere manage) as o"tpatients' In a))ition/ s"#h infants ten) to arrive at the emergen#( "nit earl(Nin o"r hospi! tal more than 139 of #hil)ren 3 months are bro"ght in *ithin > ho"rs of onset of the fever' In a re#ent st")(/ S#h*atD et al= report fig"res of S%I in #hil)ren ,- )a(s of age of 08'=9/ stratif(ing the prevalen#e of S%I b( age $in *ee s&' The( observe) that the prevalen#e of S%I in neonates O01 )a(s of age *as signifi#antl( lo*er than those in (o"nger infants' .o*ever/ the( )i) not establishe) )ifferent man! agement strategies as a f"n#tion of age in *ee s' Ie fo"n) that the rate of S%I in 01! to ,0!)a(!ol) patients $33'39& *as similar to that in 6! to 0=!)a(!ol) infants $30'89& an) higher than in those ,0 )a(s of age or ol)er $0-'09&' Therefore/ o"r st")( sho*s that ) *+,* (i""incott -illiam! . -il/in!

DISC!SSION

"sing , *ee s of age as the #"t!off point to a)opt )ifferent man! agement strategies for febrile infants is not appropriate' Notabl(/ the rate of S%I in infants 6 )a(s of age in o"r st")( *as 0>9/ lo*er than in the other age gro"ps' This pattern of a lo*er rate of S%I in the first *ee of life has also been )es#ribe) in other series' = In o"r #ase/ it #o"l) be attrib"te) to the fa#t that o"r registr( )i) not in#l")e an( infants 3 )a(s of age' This is be#a"se/ in line *ith o"r hospitalHs proto#ols/ ne*borns are ro"tinel( )is#harge) bet*een =- an) 6, ho"rs after birth/ an) if )"ring their hospital sta( the( have a fever/ the( are a)mitte) to the neonatal "nit )ire#tl( from the maternit( *ar)' In re#ent (ears/ several st")ies have aime) to i)entif( lo*! ris infants "sing the mo)ifie) versions of the #lassi# Ro#hester an) ?hila)elphia #riteria' These s#ales ta e into a##o"nt not onl( #lini#al fin)ings b"t also res"lts for 2R?/ the presen#e of le" o! #(tosis or immat"re #ells/ an) more re#entl( ?2T val"es/ among others'3/0=/0>/,=/33 There is/ ho*ever/ no #onsens"s *ith regar)s to the "sef"lness of these #riteria to i)entif( #hil)ren at lo* ris of a S%I' %a er et al,8 #lassifie) neonates in lo*! an) high!ris gro"ps of having an S%I a##or)ing to the ?hila)elphia #riteria' Of those #lasse) in the high!ris gro"p 0-'>9 *ere fo"n) to have an S%I/ b"t "p to ='>9 of those #lassifie) in the lo*!ris gro"p also )evelope) this t(pe of infe#tion' 2hi" et al30 st")ie) ,13 febrile patients ,- )a(s of age an)/ "sing their o*n #riteria for lo* ris / #on#l")e) that hospital observation *itho"t anti! bioti# therap( *as a safe option for the management of these patients' +ore re#entl(/ +aron et al3, in)i#ate) that meeting lo*!ris #riteria ma( be a "sef"l tool for i)entif(ing neonates at high ris of an S%I/ so that lo*!ris infants #an be manage) as o"tpatients *itho"t antibioti# therap( after some ho"rs less than observation in hospital' In o"r ?ED/ *e are moving to*ar) a less aggressive management *ith regar) to #omplemen! tar( tests/ hospitaliDation/ an) antibioti# therap( for infants 0 month of age/ spe#ifi#all( for the s"bgro"p bet*een ,0 )a(s an) 0 month of age' A more #onservative management of lo*! ris patients is relevant in terms of sparing health #are #osts/ emerging antibioti# resistan#e an) potential #ompli#ations asso! #iate) *ith hospitaliDation' This st")( has several limitations' A prospe#tive st")( *o"l) have allo*e) greater rigor in the #olle#tion of )ata #on#ern! ing these patients' .o*ever/ )ata *ere e5tra#te) from a prospe#tive registr( *ith goo) A"alit( )ata' F"rther/ the telephone follo*!"ps/ #arrie) o"t b( traine) ph(si#ians/ help to minimiDe this limitation' Se#on)/ it *as not a m"lti#enter st")(/ so the res"lts are )iffi#"lt to e5trapolate to other pop"lations' Thir)/ in o"r hospital/ )is#harge of ne*borns o##"rs in the first =- to 6, ho"rs after birth/ so that febrile infants of , to 3 )a(s of age are a)mitte) to the neonatal "nit )ire#tl(' Finall(/ not all the tests *ere performe) on all patients' .o*ever/ a #lose follo*!"p *as ma)e as it is e5pose) in the Res"lts se#tion an) no patient *ith #omplete or in#omplete testing *ent on to be#ome si# er an) *o"n) "p having S%Is'
.../pid0/com 1

457

Garcia et al

The Pediatric Infectious Disease Journal ! "#$%M&'1()%MB&*5(MA+ ,-1,

E#E ENCES
0' Nelson DS/ Ialsh M/ Fleisher GR' Spe#tr"m an) freA"en#( of pe)iatri# illness presenting to a general #omm"nit( hospital emergen#( )epartment' Pediatric!0 088,783$0 pt 0&41<03' ,' +assin ++/ +ontesanti P/ Gerar) ?/ et al' Spe#tr"m an) freA"en#( of illness presenting to a pe)iatri# emergen#( )epartment' 1cta 2lin Belg0 ,33>7>040>0<0>1' 3' Ishimine ?' Fever *itho"t so"r#e in #hil)ren 3 to 3> months of age' Pediatr 2lin North 1m0 ,33>71340>6<08=' =' S#h*artD S/ Raveh D/ To er O/ et al' A *ee b( *ee anal(sis of the lo* ris #riteria for serio"s ba#terial infe#tion in febrile neonates' 1rch Di! 2hild0 ,33878=4,-6<,8,' 1' %a er +D/ %ell L+' Unpre)i#tabilit( of serio"s ba#terial illness in febrile infants from birth to 0 month of age' 1rch Pediatr 1dole!c Med0 08887013413-<100' >' %a#h"r RG/ .arper +%' ?re)i#tive mo)el for serio"s ba#terial infe#tions among infants (o"nger than 3 months of age' Pediatric!0 ,330703-4300<30>' 6' %ema / 2h% +/ .arper +%' I)entif(ing febrile (o"ng infants *ith ba#! teremia4 is the peripheral *hite bloo) #ell #o"nt an a##"rate s#reenQ 1nn Emerg Med0 ,3337=,4,0><,,1' -' GomeD %/ +integi S/ %enito P/ et al' %loo) #"lt"re an) ba#teremia pre)i#tors in infants less than three months of age *ith fever *itho"t so"r#e' Pediatr In ect Di! J0 ,3037,84=3<=6' 8' %ressan S/ An)reola %/ 2attelan F/ et al' ?re)i#ting severe ba#terial infe#tions in *ell!appearing febrile neonates' Pediatr In ect Di! J0 ,3037,84,,6<,3,' 03' %a er +D/ %ell L+' Unpre)i#tabilit( of serio"s ba#terial illness in febrile infants from birth to 0 month of age' 1rch Pediatr 1dole!c Med0 08887013413-<100' 00' 2enters for Disease 2ontrol an) ?revention $2D2&' Earl(! onset an) late! onset neonatal gro"p % strepto#o##al )iseaseNUnite) States/ 088><,33=' Mor& Mortal -/l' 3e"' ,33171=40,31<0,3-' 0,' ?hares 2R/ L(nfiel) R/ Farle( ++' Epi)emiolog( of invasive gro"p % strep! to#o##al )isease in the Unite) States/ 0888<,331' J1M10 ,33-7,884,311< ,3>1' 03' Eberl( +/ RaGni R' The effe#t of "niversal maternal s#reening on the in#i! )en#e of neonatal earl(! onset Gro"p % Strepto#o##al )isease' 2lin Pediatr0 ,3387=-43>8<361' 0=' Mo"rtis A?/ S"llivan DT/ Sathian U' ?ra#ti#e g"i)elines for the management of febrile infants less than 83 )a(s of age at the amb"lator( net*or of a large pe)iatri# health #are s(stem in the Unite) States4 s"mmar( of ne* evi)en#e' 2lin Pediatr0 ,33=7=3400<0>' 01' +integi S/ Gar#Ra!Gar#Ra PP/ %enito P et al' Rapi) infl"enDa test in (o"ng febrile infants for the i)entifi#ation of lo*!ris patients' Pediatr In ect Di! J0 ,3387,-403,><03,-' 0>' +ania#i S/ Da"ber A/ Ieiss S/ et al' ?ro#al#itonin in (o"ng febrile infants for the )ete#tion of serio"s ba#terial infe#tions' Pediatric!0 ,33-70,,4630<603'

06' Ola#ireg"i I/ .ernTn)eD U/ +"UoD PA/ et al' +ar ers that pre)i#t serio"s ba#terial infe#tion in infant "n)er 3 months of age presenting *ith fever of "n no*n origin' 1rch Di! 2hild0 ,33878=4130<131' 0-' Dagan R/ ?o*ell MR/ .all 2%/ et al' I)entifi#ation of infants "nli el( to have serio"s ba#terial infe#tion altho"gh hospitaliDe) for s"spe#te) sepsis' J Pediatr0 08-170364-11<->3' 08' %araff L' +anagement of fever *itho"t so"r#e in infants an) #hil)ren' 1nn Emerg Med0 ,33373>4>3,<>0=' ,3' Steere +/ Sharieff GV/ Sten l(ft ?.' Fever in #hil)ren less than 3> months of age4 A"estions an) strategies for management in the emergen#( )epart! ment' J Emerg Med0 ,3337,140=8<016' ,0' Dagan R/ Sofer S/ ?hillip +/ et al' Amb"lator( #are of febrile infants (o"nger than , months of age #lassifie) as being at lo* ris for having seri! o"s ba#terial infe#tions' J Pediatr0 08--700,4311<3>3' ,,' %as in +N/ OHRo"r e EP/ Fleisher GR' O"tpatient treatment of febrile infants ,- to -8 )a(s of age *ith intram"s#"lar a)ministration of #eftria5! one' J Pediatr0 088,70,34,,<,6' ,3' %a er +D/ %ell L+/ Avner PR' The effi#a#( of ro"tine o"tpatient man! agement *itho"t antibioti#s of fever in sele#te) infants' Pediatric!0 088870334>,6<>30' ,=' Ma)ish .A/ Loveri)ge %/ Tobe( P/ et al' Appl(ing o"tpatient proto#ols in febrile infants 0<,- )a(s of age4 #an the threshol) be lo*ere)Q 2lin Pediatr 4Phila50 ,3337384-0<--' ,1' %enito P' Gr"po )e trabaGo )e 2o)ifi#a#iWn )iagnWsti#a )e la SEU?' 2o)ifi! #a#iWn )iagnWsti#a en "rgen#ias )e ?e)iatrRa0 1n E!" Pediatr0 ,3337134,>0< ,>,' ,>' .oo er EA/ SmithSI/ +iles T/ et al' S"bGe#tive assessment of fever b( parents4 #omparison *ith meas"rement b( non#onta#t t(mpani# thermom! eter an) #alibrate) re#tal glass mer#"r( thermometer' 1nn Emerg Med0 088>7,-4303<306' ,6' Graneto PI/ Soglin DF' +aternal s#reening of #hil)hoo) fever b( palpation' Pediatr Emerg 2are0 088>70,40-3<0-=' ,-' Pas ie*i#D PA/ +#2arth( 2A/ Ri#har)son A2/ et al' for the Febrile Infant 2ollaborative St")( Gro"p' Febrile infants at lo* ris for serio"s ba#terial infe#tion! an appraisal of the Ro#hester #riteria an) impli#ations for man! agement' Pediatric!0 088=78=4383<38>' ,8' %a er +D/ %ell L+/ Avner PR' O"tpatient management *itho"t antibioti#s of fever in sele#te) infants' N Engl J Med0 088373,840=36<0==0' 33' %a#h"r RG/ .arper +%' ?re)i#tive mo)el for serio"s ba#terial infe#! tions among (o"nger than 3 months of age' Pediatric!0 ,330703-4 300<30>' 30' 2hi" 2/ Lin T/ %"llar) +' I)entifi#ation of febrile neonates "nli el( to have ba#terial infe#tions' Pediatr In ect Di! J0 088670>418<>3' 3,' +arom R/ Sa ran I/ Antonelli P/ et al' V"i# i)entifi#ation of febrile neonates *ith lo* ris for serio"s ba#terial infe#tion4 an observational st")(' 1rch Di! 2hild 6etal Neonatal Ed0 ,33678,4F01<F0-'

45

1 .../pid0/com

) *+,* (i""incott -illiam! . -il/in!