New CPS statement on managing febrile infants disrupts usual management strategy

A position statement on how to manage well-appearing febrile infants turns previous practice recommendations on their heads.Instead of focusing on approaches that assume all patients may be at high-risk for invasive bacterial infections (IBI), it introduces strategies to figure out which infants are at lower risk and could have less invasive management, according to the statement’s lead author Dr. Brett Burstein, an assistant professor in the Department of Pediatrics at McGill University.“It’s the first of any international guideline that allows for any well-appearing infant in the first 60 days of life that meets low risk criteria to not need to be managed so aggressively and conservatively,” he said.The eight-page statement, published in Paediatrics & Child Health, is intended to help physicians in a variety of settings across Canada. It focuses on infants aged up to 90 days who present with a rectal temperature of at least 38.0°C but who otherwise appear well.Generally, when infants with fever are taken to the doctor, they are referred to the local emergency department where they routinely undergo invasive procedures such as cerebrospinal fluid (CSF) testing, prolonged hospitalization, and received broad-spectrum antibiotics to prevent rare cases of bacterial meningitis.But a lot of infants undergo a painful invasive procedure that isn’t really needed, Dr. Burstein told the Medical Post. They are done just-in-case, or in order not to miss the rare case, rather than because it is actually necessary for all.Within the first three months of life nearly 2% of all healthy, term newborns are brought to medical attention because of fever. Most have self-limited viral illness, but between 10% and 13% have a serious bacterial infection (SBI) which could include urinary tract infections (UTIs), bacteremia, and bacterial meningitis, the statement said. And doctors have to balance the risks of infection against the harms from over-investigation and over-treatment. “The prevalence of invasive bacterial infections (IBIs), specifically bacteremia and bacterial meningitis, is greatest in the first month post-birth and decreases with age,” the statement said.Canadian doctors have been lacking a current guideline, with much of the practice based on knowledge that’s over 30 years old. There was a guideline published by the CPS in 1996, which was reaffirmed by the CPS in 2002, he said. But there have been a number of advances since then.For one, previous recommendations were published before the widespread use of pneumococcal conjugate and Haemophilus influenzae type B vaccines and intrapartum group B streptococcus prophylaxis.Importantly, this new statement includes newer validated approaches and tests that doctors can use to better identify which infants are actually at low-risk of IBIs. These approaches include use of the Pediatric Emergency Care Applied Research Network (PECARN) prediction rule developed by U.S. researchers and published in 2019; the Step-by-Step method developed in Europe in 2016; and the Aronson rule which was published in 2019.For predicting invasive bacterial infections, these approaches use newer biomarkers such as procalcitonin (PCT) and C-reactive protein. Studies have shown that they outperform absolute neutrophil counts and white blood cell count, the statement said.The downside is that few doctors in Canada have access to labs that can do the PCT testing either at all or in the turnaround time required for decision-making. Even the Montreal Children's Hospital where Dr. Burstein works in the pediatric emergency department started having this test available only in 2020. PCT has a long history of use for febrile young infants across Europe.“If you don't have access to PCT testing, our guideline has provided an alternative strategy,” he said. The Aronson rule does not require PCT, and it’s still pretty good – it just uses markers of infection that tend to rise more slowly. It is still better than any risk-stratification criteria used historically. But whichever strategy is used should be alongside other clinical criteria.“Ultimately our recommendation is that it is reasonable to maintain a conservative approach if you are not using a procalcitonin strategy,” he said. The details are spelled out in the statement, and there are some differences depending on the age of infant and other clinical factors.The CPS statement stands out “because there's no international guideline that goes as far as we do in saying these rules are well performing. And if an infant meets low-risk criteria then it’s not necessary to perform invasive testing as we used to do,” he said. Once they are adopted, it should spare many infants from unnecessary lumbar punctures, spinal tap procedures hospitalizations.“Even the American guidelines from 2021 are still recommending that every infant 21-days-old and under have lumbar punctures and be admitted to hospital for intravenous antibiotics until it’s proven there is no invasive bacterial infection," he said.The U.S. guidelines look at the overall risk of 2.5% for IBI rather than the risk for different stratified groups. “Our guideline says yes the disease prevalence is 2.5%, but using our modern risk stratification strategies we now know that it can be as low as 0.01% or lower for the low-risk infants,” he said. Low-risk infants 28-days-old and under, without lumbar punctures should still be admitted to hospital without antibiotics, and observed to see how they evolve. Taking into account the age of the infant, and where they fall on the spectrum of risk for IBIs after test results, treatment decisions including whether they should undergo lumbar punctures should then be a joint decision with parents, Dr. Burstein said. High-risk infants should be treated empirically with antibiotics and other indicated treatments and tests.

New CPS statement on managing febrile infants disrupts usual management strategy

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