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Return Rates Low When Feverish Infants Have Incomplete Bacterial Testing

SAN FRANCISCO — How emergency departments respond to infants presenting with fever without a known source varies considerably, although missed infections are relatively rare, according to a new study.

The research, which sought to describe the current clinical practice regarding culture acquisition on febrile young infants and to review the outcomes of infants with and without cultures obtained, was published recently in the journal Pediatrics.

“The diagnostic strategy advocated for febrile infants includes urine, blood, and cerebrospinal fluid (CSF) cultures, but depending on age many do not have all three cultures or any cultures obtained,” according to the report. “Over 25% of febrile infants less than 3 months do not have any cultures collected, yet have low return rates to EDs and outpatient clinics.”

A study team led by researchers from Kaiser Permanente Northern California analyzed the healthcare system’s electronic medical record to identify all febrile, full-term, previously healthy infants born between July 1, 2010, and June 30, 2013, presenting for care between 7 and 90 days of age.

During the three-year study, 96,156 full-term infants were born at Kaiser Permanente Northern California, and 1,380 infants presented for care with a fever, for an incidence rate of 14.4 per 1,000 full-term births. Results indicate that 59% of infants 7 to 28 days old had a full evaluation, compared with 25% of infants 29 to 60 days old and 5% of infants 61 to 90 days old.

The study notes that older infants with lower febrile temperatures presenting to an office setting were less likely to have a culture.

In the 30 days after fevers, 1% of infants returned with a urinary tract infection, although none returned with bacteremia or meningitis.

The researchers point out that recent research has documented “incomplete culturing and low rates of return for subsequent infections when infants are sent home with incomplete bacterial testing,” with one study in a multicenter ED setting of febrile neonates describing low return rates for missed infections at 0.3%.

“As a closed system, we were able to describe return rates for both the ED and office setting,” they add. “We confirmed that within 1 month of initial evaluation, return rates were very low with 1% returning in the following month with a febrile UTI with no cases of missed bacteremia or meningitis.”