SGEM#474: Help! Which Clinical Decision Aid should I use to Risk Stratify Febrile Infants?

Reference: Umana E, et al. Performance of clinical decision aids for the care of young febrile infants: A multicenter prospective cohort study. eClinicalMedicine Lancet December 2024 Date: March 6, 2025 Dr. Demetris Athanasiou Guest Skeptic: Dr. Demetris Athanasiou is a paediatric registrar based in London and enrolled in the PEM MSc program through Queen Mary University in London. Case: A 6-week-old boy is brought by his parents to your emergency department (ED) for fever. His older sister has been sick with upper respiratory symptoms for the past week but seems to be recovering. Today, while his father was feeding him a bottle, he noticed that the baby was feeling warm and took his temperature, which was 38.2°C (100.7 °F). The boy has otherwise been feeding and acting normally. You examine the baby with an astute medical trainee. As you discuss the next steps in management, she asks you, “I know there’s a bunch of guidelines or decision tools to help risk stratify which babies are low risk for bacterial infections, but I can never keep them straight. Is there one you prefer?” Background: Back in the day, we were performing lumbar punctures (LP) on febrile infants up to 3 months of age because there was concern for bacterial infections. We used to lump urinary tract infections, bacteremia, and meningitis under one umbrella term, “serious bacterial infection” or SBI. Recently, we’ve been told to stop using that term and be more specific about what we are referring to. Bacteremia and meningitis have been termed invasive bacterial infections (IBI) and, fortunately, are rare, occurring in 1-4%. There have been several guidelines and clinical decision tools, such as those developed by the National Institute for Health and Care Excellence (NICE), the American Academy of Pediatrics (AAP), and others that offer strategies to identify low-risk infants who might avoid invasive procedures like a lumbar puncture. These clinical decision tools have been developed to stratify febrile infants into high- and low-risk categories to balance the risk of under-treatment and over-treatment. Several of these tools have been reviewed on the SGEM. SGEM #341: AAP Guidelines SGEM #296: PECARN SGEM #171: Step By Step The hot new test is procalcitonin. Unfortunately, it’s expensive, and not all EDs have access to it or can receive the results promptly to help with decision making. Some are still using other inflammatory markers like C-reactive protein (CRP). With ongoing research and evolving guidelines, the clinical utility of these decision tools continues to be refined. Understanding their strengths, limitations, and applicability in various healthcare systems remains a crucial aspect of evidence-based emergency medicine. Clinical Question: How well do various clinical decision aids perform in identifying febrile infants at low risk for invasive bacterial infection? Reference: Umana E, et al. Performance of clinical decision aids for the care of young febrile infants: A multicenter prospective cohort study. eClinicalMedicine Lancet December 2024 Population: Infants from birth to 90 days of age from across 35 paediatric EDs and paediatric assessment units across the UK and Ireland with fever ≥38°C Excluded: Guardians who declined or withdrew consent Intervention: Application of clinical decision aids (CDA) [American Academy of Pediatrics (AAP), British Society Antimicrobial Chemotherapy (BSAC), National Institute for Health and Care Excellence (NICE) NG143, Aronson] Comparison: Against each other and “treat all” approach Outcome: Primary Outcome: Diagnostic accuracy of CDAs Secondary Outcomes: Etiology of IBI, clinical predictors of IBI, and mean cost per patient Trial: Prospective multicenter cohort study Guest Author : Dr. Etimbuk Umana (Timbs) is a consultant in emergency medicine and lead author of the FIDO study.