Background In many academic centers it is standard practiceto hospitalize all febrile infants younger than two months ofage, whereas in community settings such infants are often caredfor as outpatients.
Methods We conducted a controlled study of 747 consecutive infants29 through 56 days of age who had temperatures of at least 38.2°C. After a complete history taking, physical examination,and sepsis workup, the 460 infants with laboratory or clinicalfindings suggestive of serious bacterial illness were hospitalizedand treated with antibiotics. The screening criteria for seriousbacterial illness included a white-cell count of at least 15,000per cubic millimeter, a spun urine specimen that had 10 or morewhite cells per high-power field or that was positive on bright-fieldmicroscopy, cerebrospinal fluid with a white-cell count of 8or more per cubic millimeter or a positive Gram's stain, ora chest film showing an infiltrate. The 287 infants who hadunremarkable examinations and normal laboratory results wereassigned to either inpatient observation without antibiotics(n = 148) or outpatient care without antibiotics but with reexaminationsafter 24 and 48 hours (n = 139).
Results Serious bacterial illness was diagnosed in 65 infants(8.7 percent). Of these 65 infants, 64 were identified by ourscreening criteria for inpatient care and antibiotic treatment(sensitivity = 98 percent; 95 percent confidence interval, 92to 100). Of the 287 infants assigned to observation and no antibiotics,286 (99.7 percent) did not have serious bacterial illness. Onlytwo infants assigned to outpatient observation were subsequentlyadmitted to the hospital; neither was found to have a seriousillness. Outpatient care without antibiotics of the febrileinfants at low risk for serious illness resulted in a savingsof about $3,100 per patient.
Conclusions With the use of strict screening criteria, a substantialnumber of febrile one-to-two-month-old infants can be caredfor safely as outpatients and without antibiotics.
Source Information
From the Division of General Pediatrics, Section of Emergency Medicine (M.D.B., L.M.B., J.R.A.), and the Division of Allergy, Immunology, and Infectious Diseases (L.M.B.), Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia. Presented in part at a meeting of the Ambulatory Pediatric Association, New Orleans, May 6, 1993.
Address reprint requests to Dr. Baker at the Section of Emergency Medicine, Children's Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA 19104.
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