Pantell RH, Newman TB, Bernzweig J, Bergman DA, Takayama JI, Segal M, Finch SA, Wasserman RC. Management and Outcomes of Care of Fever in Early Infancy. JAMA. 2004;291(10):1203-1212. doi:10.1001/jama.291.10.1203
Author Affiliations: Division of General Pediatrics, Department of Pediatrics (Drs Pantell, Newman, Bernzweig, and Takayama), and Department of Epidemiology and Biostatistics (Drs Newman and Segal), School of Medicine, University of California, San Francisco; Department of Pediatrics, Lucile Salter Packard Children's Hospital at Stanford Medical Center, Stanford, Calif (Dr Bergman); Pediatric Research in Office Settings (PROS), Department of Practice and Research, Center for Child Health Research, American Academy of Pediatrics, Elk Grove Village, Ill (Ms Finch and Dr Wasserman); and Department of Pediatrics, Vermont College of Medicine, Burlington (Dr Wasserman).
Context Fever in infants challenges clinicians in distinguishing between serious
conditions, such as bacteremia or bacterial meningitis, and minor illnesses.
To date, the practice patterns of office-based pediatricians in treating febrile
infants and the clinical outcomes resulting from their care have not been
Objectives To characterize the management and clinical outcomes of fever in infants,
develop a clinical prediction model for the identification of bacteremia/bacterial
meningitis, and compare the accuracy of various strategies.
Design Prospective cohort study.
Setting Offices of 573 practitioners from the Pediatric Research in Office Settings
(PROS) network of the American Academy of Pediatrics in 44 states, the District
of Columbia, and Puerto Rico.
Patients Consecutive sample of 3066 infants aged 3 months or younger with temperatures
of at least 38°C seen by PROS practitioners from February 28, 1995, through
April 25, 1998.
Main Outcome Measures Management strategies, illness frequency, and rates and accuracy of
treating bacteremia/bacterial meningitis.
Results The PROS clinicians hospitalized 36% of the infants, performed laboratory
testing in 75%, and initially treated 57% with antibiotics. The majority (64%)
were treated exclusively outside of the hospital. Bacteremia was detected
in 1.8% of infants (2.4% of those tested) and bacterial meningitis in 0.5%.
Well-appearing infants aged 25 days or older with fever of less than 38.6°C
had a rate of 0.4% for bacteremia/bacterial meningitis. Frequency of other
illnesses included urinary tract infection, 5.4%; otitis media, 12.2%; upper
respiratory tract infection, 25.6%; bronchiolitis, 7.8%; and gastroenteritis,
7.2%. Practitioners followed current guidelines in 42% of episodes. However,
in the initial visit, they treated 61 of the 63 cases of bacteremia/bacterial
meningitis with antibiotics. Neither current guidelines nor the model developed
in this study performed with greater accuracy than observed practitioner management.
Conclusions Pediatric clinicians in the United States use individualized clinical
judgment in treating febrile infants. In this study, relying on current clinical
guidelines would not have improved care but would have resulted in more hospitalizations
and laboratory testing.
Febrile infants often lack suggestive clinical symptoms or findings,
making it difficult to distinguish between a minor febrile illness and one
that is life-threatening. To avoid the consequences of failing to detect serious
bacterial illness (SBI), such as bacteremia and bacterial meningitis, a variety
of clinical strategies have been developed to identify infants at high and
low risk, including policies that require extensive laboratory testing, hospitalization,
and treatment with intravenous antibiotics.1- 10 Although
these strategies guarantee treatment of all infants with SBI, the costs are
high, including considerable iatrogenic morbidity for some infants.10
Many strategies were developed from infants cared for in inner-city
emergency departments. Performance of such strategies in the general population
has not been evaluated. Studies surveying responses to case scenarios suggest
that a large proportion of office-based physicians do not routinely follow
these guidelines.11 Little is known about the
actual management of cases of febrile infants in office practice.
The purposes of this study were to (1) characterize the management,
spectrum of diseases, and clinical outcomes of febrile infants aged 3 months
or younger in pediatric practices in the United States; (2) develop a clinical
prediction model for the identification of infants with bacteremia/bacterial
meningitis; and (3) compare the accuracy of practitioners' management with
This study was conducted by the Pediatric Research in Office Settings
(PROS) practice-based research network of the American Academy of Pediatrics
(AAP). A total of 573 members of the PROS network (91% of whom were physicians)
from 219 practices submitted data on eligible infants. Data were received
from 44 states, the District of Columbia, and Puerto Rico. Participant and
nonparticipant characteristics are shown in Table 1. Practitioners who declined to participate or who did not
respond to recruitment efforts varied little from participating practitioners.
In addition, compared with AAP members who listed patient care as their primary
activity in a 1995 periodic survey, PROS practitioners were similar in age
and sex, but fewer (7.3% vs 12%; P<.001) practiced
in urban inner-city areas. Infants who were eligible but not enrolled also
closely resembled enrolled infants with respect to temperature and on average
were slightly older (4 days); hospitalization rates were similar.
Infants were eligible for the study if they were aged 3 months or younger,
had been discharged from the hospital as a newborn, had a temperature of 38°C
or greater either at home or in the clinician's office, and had no other major
comorbidities (eg, congenital anomalies, extreme prematurity, conditions associated
with organ system failure). For analysis, we used the maximum rectal temperature
taken in the office or reported by the parent in the past 24 hours, after
adding 0.5°C for axillary temperatures. Data were collected for 3131 consecutive
infants, 3066 of whom met eligibility requirements. The study was approved
by the Committee on Human Research of the University of California, San Francisco.
We used a prospective cohort study design to follow the episode of care
for infants seen by PROS practitioners from February 28, 1995, through April
25, 1998. Demographic and clinical data were recorded by office staff and
clinicians on standard forms. Practitioners recorded clinical signs and symptoms
and an overall assessment of clinical appearance before ordering laboratory
tests. They also answered questions about clinical appearance similar to those
of the Yale Observation Scale,12,13 with
the addition of an item on respiratory distress. For clinical appearance,
practitioners indicated whether the infant appeared well/minimally ill, moderately
ill, or very ill. Initial management, changes in treatment strategies, and
subsequent medical contacts were decided by individual clinicians and documented
until resolution of illness, when they recorded final diagnosis. A variety
of techniques were used to maximize patient enrollment and minimize selection
bias and ensure data quality.
Laboratory testing was performed at the discretion of the clinician
according to their usual and customary practice. Testing was performed at
the usual laboratories of the practice sites; all clincians were supplied
with and asked to use urine dipsticks (Ames-Multistix, Miles Inc, Elkhart,
A study manual was developed containing definitions of all clinical
conditions and variables. While other studies have addressed SBI (ie, bacteremia,
bacterial meningitis, urinary tract infection, and bacterial gastroenteritis)
as the main outcome variable, this report focuses on occult infections that
have generated the most uncertainty in developing clinical strategies; ie,
bacteremia with pathogenic organisms and bacterial meningitis. We have reported
elsewhere on urinary tract infections14 and
also report herein the frequency of other, less common serious bacterial illnesses,
such as cellulitis and osteomylelitis. A pediatric infectious disease specialist
reviewed all cases of bacteremia and excluded those not considered to be caused
by pathologic bacteria. Similarly, all cases of meningitis were reviewed to
ascertain the accuracy of the diagnosis and whether the meningitis was likely
bacterial, partially treated bacterial, or viral in origin.
STATA software, version 6 (CRC Inc, College Station, Tex) was used for
statistical analyses. For multivariate analyses of bacteremia/bacterial meningitis
that included laboratory data as predictors, we included only patients for
whom a blood culture was obtained. For these models, the white blood cell
(WBC) count was considered to be abnormal if it was less than 5000/µL
or at least 15 000/µL and the urinalysis was considered abnormal
if the dipstick test was positive for leukocyte esterase or nitrite or if
more than 5 WBCs per high-powered field were reported on microscopic examination.
We used a backward stepwise logistic regression model, with a P value of .02 to predict ordering of WBC counts and blood cultures
and a P value of .10 to predict bacteremia/bacterial
meningitis. Standard errors for all logistic models were adjusted for clustering
by practitioner and models tested for goodness of fit by the method of Hosmer
and Lemeshow. Tree-structured analyses were conducted using S-PLUS, version
3.4 (MathSoft, Seattle, Wash).15,16
To compare the accuracy of various clinical prediction models, we analyzed
several alternative scenarios. For model 1, we used patient appearance alone
as a predictor of bacteremia/bacterial meningitis. Two additional models were
created by adding WBC count and WBC count with urinalysis, respectively. For
the fourth model, we relied on current guidelines. Current guidelines6,17 and protocols5,7,18,19 differ
slightly in specific lower limits of age to be considered "low risk" (28-30
days), definition of abnormal WBC count (>15 000/µL to >20 000/µL),
urinalysis performance, whether stool WBC count should be performed in infants
with diarrhea, whether a lumbar puncture is required in all infants regardless
of appearance and screening test results, and whether screening should be
done in all febrile infants or only in those without a source of infection.
We blended these guidelines so that infants aged 30 days or younger and ill-appearing
infants required a WBC count, blood culture, urinalysis, urine culture, cerebrospinal
fluid analysis and culture, hospitalization, and antibiotics; well-appearing
infants aged 31 days or older required a WBC count and urinalysis as the basis
for proceeding with further management. For the fifth model, we used the decision
tree derived from applying tree-structured analysis to our sample. We compared
the sensitivity and specificity of the 5 clinical prediction models described
herein with the actual management and outcomes of the PROS practitioners.
Sensitivity was calculated as the number of infants with bacteremia/bacterial
meningitis who would have been treated in each strategy or, for study infants,
were actually treated with antibiotics at the initial visit divided by the
number with bacteremia/bacterial meningitis (n = 63). The concept of specificity,
defined as the percentage of patients without the condition (bacteremia/bacterial
meningitis) who were not treated, does not strictly apply, since other diseases
require antibiotics. However, to reflect the trade-off between sensitivity
and specificity, we calculated a specificity in which the denominator used
represents all infants without bacteremia/bacterial meningitis and other conditions
requiring antibiotics (ie, otitis media, urinary tract infection, pneumonia),
while the numerator represents children not treated at the initial encounter
with an antibiotic. "Specificity" in this context does not infer unnecessary
treatment but is used as an indicator of the relative frequency of antibiotic
use in different strategies.
Of the 3066 infants, 1975 (64%) were managed exclusively outside of
the hospital. Only 125 episodes of care were managed with a single office
visit without other medical contacts (eg, telephone). A single visit was recorded
for 909 infants, while 761 infants had 2 visits and 305 had 3 or more visits
to the hospital. In addition, 1014 episodes were accompanied by a single follow-up
telephone call, 325 received more than 1 telephone encounter. Of infants managed
outside of the hospital, 68 were seen in emergency departments following the
initial office visit.
Testing and management strategies did not vary by practitioner age,
sex, or region but varied with certain infant demographic and clinical variables.
Compared with older infants, those younger than 1 month were significantly
more likely to have a WBC count or blood culture (83.0 vs 71.4%; P<.001), have a lumbar puncture (54.8 vs 25.6%; P<.001), begin antibiotic treatment at the time of the initial examination
(68.2% vs 53.7%; P<.001), and be hospitalized
(60.1% vs 27.3%; P<001). Adjusted odds ratios
for independent predictors of blood testing (WBC count and/or blood culture)
are documented in Table 2. Prediction
was fair, with the area under the receiver operating characteristic curve
(AUROC) = 0.735. Coding temperature and age as continuous variables improved
the fit slightly with AUROC = 0.746. Patients seen outside of typical office
hours were significantly more likely to receive laboratory testing and to
be treated with antibiotics and admitted to the hospital. Infants receiving
Medicaid had more testing and hospitalizations.
Nearly one quarter of infants had no blood, urine, or cerebrospinal
fluid tested during their evaluation (n = 726), and slightly more than half
had their urine tested (n = 1666). Actual management strategies varied considerably
from suggested approaches to febrile infants. Table 3 compares PROS practitioners' management with recommended
Table 4 lists the primary
final diagnoses at the end of the illness episodes. Most febrile episodes
were due to benign illnesses, while bacteremia was present in 2.4% of infants
with blood cultures and bacterial meningitis in 0.5% of the entire sample
of infants. Other causes of "serious" bacterial illness were documented but
many (eg, cellulitis) were not occult.
The 54 cases of bacteremia represent cases reviewed by an infectious
disease consultant and diagnosed as having pathogenic organisms; 18 other
cases originally classified as bacteremic by clinicians were recoded to either
the next listed diagnostic category or to an unidentified source. Of 16 infants
originally classified as having bacterial meningitis by clinicians, the external
reviewer confirmed 14 cases, including some cases in which the culture was
sterile because of prior antibiotics but the cerebrospinal fluid and clinical
findings were consistent with bacterial meningitis. Five of the infants with
bacterial meningitis also had bacteremia. The bacterial organisms in infants
with bacteremia/bacterial meningitis are identified in Table 5. Much of the bacteremia/bacterial meningitis occurred in
the first month after birth, when 4.1% of febrile infants had bacteremia/bacterial
meningitis compared with 1.9% in the second month and 0.7% in the third month
We also examined the frequency of bacteremia/bacterial meningitis and
other bacterial illnesses by temperature. Because fever of at least 38.0°C
at home was an eligibility criteria, some infants included were afebrile at
the time of office visit. The frequency of bacteremia/bacterial meningitis
found in infants who were afebrile in the office as well as those who had
higher temperatures is documented in Table
We used logistic regression analyses to identify the best clinical predictors
of bacteremia. The analysis in Table 8 is
for the entire sample of 3066 infants. In this analysis, we exclude laboratory
results to identify which clinical features are potentially useful in initially
identifying infants at high risk. We allowed for entry of variables with P<.10 because of the small number of cases of bacteremia.
Age and very ill appearance emerged as the strongest predictors (AUROC = 0.820).
To evaluate the predictive value of laboratory testing, we first performed
a logistic regression on the 1746 infants who had both WBC counts and blood
cultures but excluded WBC results. Without WBC count, the AUROC was 0.767.
By adding abnormal WBC count (as a dichotomous variable with abnormal counts
considered to be <5000/µL or ≥15 000/µL), the AUROC
increased to 0.803. The resulting model is summarized in Table 9. By adding abnormal urinalysis, the AUROC increased to 0.806,
but the coefficient for an abnormal urinalysis was not statistically significant.
Finally, we used recursive partitioning analysis with tree-structured
analysis to develop a classification tree to identify low- and high-risk groups.
The classification procedure initially dichotomizes on the single variable
that best separates low- and high-risk groups using internal split sampling
into tenths. It then continues to select the best variable for separating
the remaining patients into low- and high-risk groups. In the model (Figure 1), infants who are moderately or
severely ill appearing have a bacteremia/bacterial meningitis rate of 4.4%,
while those who appeared well/minimally ill have a 1.2% occurrence. Of this
latter group, 3.4% of those younger than 25 days had bacteremia/bacterial
meningitis while 0.8% of those aged 25 days or older had bacteremia/bacterial
meningitis. Finally, for infants who appeared well/minimally ill, were at
least 25 days old, and had a temperature of 38.6°C or higher, bacteremia/bacterial
meningitis was found in 1.2%, while those with these characteristics but temperature
of less than 38.6°C had a 0.4% chance of bacteremia/bacterial meningitis,
or a negative predictive value of 99.6%.
We compared the sensitivity of different approaches to identify infants
with bacteremia/bacterial meningitis. The results are displayed in Table 10 for infants with WBC counts and
blood cultures. Only 58.1% with bacteremia/bacterial meningitis appeared clinically
ill; the "specificity" as defined for this analysis was 68.1% (model 1). Adding
abnormal WBC count as a predictor increases sensitivity to 83.9% but decreases
"specificity" to 54.0% (model 2). The addition of a urinalysis increases the
sensitivity to 87.1%, with a small decrement in specificity. Current guidelines
(model 4) call for treating all infants with high-risk criteria while giving
options for treating low-risk infants. Using this approach, 3 of 62 with bacteremia/bacterial
meningitis would have been classified as low risk (1 infant with bacteremia/bacterial
meningitis did not have clinical appearance recorded initially and is excluded
from this analysis). Therefore, we estimate that 59 of 62 with bacteremia/bacterial
meningitis would have received appropriate antibiotics.
For model 5, tree-structured analysis (Figure 1), the sensitivity closely resembles current guidelines
but the model is less specific. The PROS practitioners (model 6) initially
treated 61 of the 63 infants with bacteremia/bacterial meningitis on the initial
visit; all but 1 received parenteral antibiotics; 36% initially received ceftriaxone,
34% ampicillin plus cephalosporin, 22% ampicillin plus gentamycin, and 8%
other antibiotic combinations. The sensitivity of PROS practitioners in treating
bacteremia/bacterial meningitis was 96.8%. The 2 infants not treated initially
included a 26-day-old infant who appeared well, had an initial WBC count of
13 000/µL, and had a blood culture positive for group B streptococci
on the following day; the infant was treated and had an uneventful recovery.
The other child was a 4-week-old infant who appeared well and had a WBC count
of 15 300/µL with 8% bands. The infant was sent home without antibiotics,
became progressively more irritable the next day, and was diagnosed as having
pneumococcal meningitis; reports over the following year indicated that the
infant achieved normal developmental milestones.
Among children without bacteremia/bacterial meningitis, otitis media,
urinary tract infection, or pneumonia, clinicians treated 64.5%, for a "specificity"
of 35.5%. Practitioners also hospitalized 309 fewer infants younger than 1
month of age and conducted fewer diagnostic tests (Table 3) than they would have had they followed current guidelines.
Fever in young infants has generated substantial interest, research,
and controversy over the past 30 years. A number of factors in the 1970s contributed
to concerns about the appropriate treatment of febrile infants, including
emerging awareness of late-onset group B β-hemolytic streptococcal sepsis
and occult bacteremia due to Streptococcus pneumoniae.20- 22 In response, many
academic centers encouraged extensive diagnostic testing, hospitalization,
and antibiotic treatment of all infants younger than 60 or 90 days. This approach
had considerable costs and morbidities10 and
was followed by efforts to identify methods to distinguish infants at high
and low risk of serious bacterial illness. Different strategies were developed
and tested in emergency departments in urban centers (Boston, Mass,18 Philadelphia, Pa,7 Rochester,
NY,4,5 and Pittsburgh, Pa19), and guidelines were also promulgated.5,17 Subsequent
experience revealed good sensitivity and negative predictive value but less
so in infants younger than 1 month.23- 26 The
generalizability of these strategies to office practice has not been studied,
and there are indications that these guidelines do not seem to have been widely
adopted11,27 and were imperfectly
applied in institutions where they were generated.6,28
This is the first nationwide study of febrile infants treated in community-based
pediatric practices in the United States. We have developed a portrait of
how febrile infants are cared for and the types of illnesses seen in office
practice. It is clear that the PROS practitioners in our sample do not follow
existing guidelines for treating febrile infants, even for those younger than
1 month. While use of less-invasive testing such as WBC count and urinalysis
occurs in the majority of cases, more invasive testing, such as lumbar punctures
and hospitalizations, occurrs less frequently, especially in older infants,
than called for by published strategies or documented in series from emergency
Our results suggest that clinical characteristics of febrile infants
have a strong association with both diagnostic evaluation and management strategies.
Younger infants, those appearing more ill, and those with higher fever were
significantly more likely to receive laboratory evaluations, receive antibiotics,
or be hospitalized. A few patient characteristics unrelated to clinical appearance
predicted management. Medicaid-insured infants were more likely to receive
laboratory tests and be hospitalized after adjusting for other factors, likely
due to perceived barriers in obtaining adequate follow-up care. Because testing
was less selective in infants with Medicaid, they had a lower rate of bacteremia.
The majority of febrile infants in this study had benign and self-limited
illnesses; our sample size permits reasonable estimates of the risk of bacteremia/bacterial
meningitis as well as other serious illnesses, including urinary tract infection.
The frequency of urinary tract infections was 5.4% in the total sample of
3066 infants and 9.7% in the 1666 infants who had urine testing at the initial
visit. The detection of bacterial meningitis in 0.5% of patients is less than
that in an analysis of 14 studies from 1972 to 1991, in which 0.8% of 1703
infants had bacterial meningitis.29 Most of
these studies were conducted in urban emergency departments. More recent studies
found 2 cases of bacterial meningitis in a series of 394 (0.5%),19 17
of 5279 (0.3%),25 and 5 of 422 (1.2%).6 We detected bacteremia in 1.8% of our population of
3066 infants (2.4% of those who had blood cultures performed) compared with.7%19 and 1.2%25 in other
contemporary series. An earlier meta-analysis documented a bacteremia/bacterial
meningitis rate in febrile infants younger than 1 month of 3.7% and 1.6% in
infants aged 1 to 3 months.30 The sample size
and geographic diversity of this study helps provide accurate estimates of
the risk of various illnesses. These estimates may be helpful in discussions
with parents about management strategies commensurate with the estimated level
of risk. Along with parents' individual preferences,31 these
could enhance collaborative decision making.
We documented a wide array of organisms responsible for bacteremia/bacterial
meningitis. Given the low frequency of pneumococcal disease, introduction
of the pneumococcal vaccine subsequent to this study will not appreciably
change the epidemiology reported. Of interest was the frequency of Escherichia coli infections, which was greater than group B β-hemolytic
streptococcal infections. The greater use of intrapartum antibiotics may have
decreased the risk of group B β-hemolytic Streptococcus and increased the risk of E coli.
This study also provides data on how well current guidelines would perform
in infants seen in clinicians' offices. We found that the current guidelines
are very sensitive in detecting bacteremia/bacterial meningitis. Practitioners
relying on their clinical judgments were at least as sensitive in treating
bacteremia and bacterial meningitis, missing only 2 cases of bacteremia/bacterial
meningitis while sparing many infants unnecessary hospitalization and tests.
(At least 1 protocol calls for lumbar puncture in all children, while only
a third of patients in this study had lumbar punctures.) Using recursive partitioning
analysis, we were able to approximate the performance of current guidelines
without the need for laboratory tests. While this model did not perform quite
as well as practitioners in this study, it identified patients at very low
risk of bacteremia/bacterial meningitis. Only 4 in 1056 infants aged 25 days
or older who appeared minimally ill and had temperatures of less than 38.6°C
had bacteremia/bacterial meningitis. Many such infants might be spared unnecessary
laboratory testing. This is of practical importance in situations in which
laboratory testing might not be immediately available.
The variation of the strategies of PROS practitioners from established
guidelines may reflect the changing frequency of serious illnesses accompanying
febrile illness in infants. With bacterial meningitis in 0.5% and no bacterial
meningitis in more than 1000 infants aged 2 to 3 months, it is not surprising
that clinicians used fewer laboratory tests than suggested in published guidelines.
Also noteworthy is that a majority of infants had more than 1 office
visit and frequent telephone contacts. The ability to achieve this level of
follow-up was an important element in this group of primary care patients
and may also explain the low frequency of hospitalization. The cost of 2 to
3 follow-up visits is substantially less than a hospitalization and was safe
in this population. Any new guidelines for the management of fever in infants
should consider a strategy of watchful waiting with repeat observations for
infants who, in the judgment of the clinician, can be safely observed at home
and have continuing access to care.
The following limitations of our study should be noted. While not all
febrile infants were enrolled during the study period, infants eligible but
not enrolled were slightly older, suggesting that the true frequency of SBI,
including bacteremia/bacterial meningitis, may be less than that reported.
The distribution of illness found in the sample of infants is likely representative
of infants seen in community-based practice but is not broadly generalizable
to infants seen in emergency department settings. Our methods differed from
most studies by including children with normal temperatures in the office
but febrile at home. However, we documented 6 cases of bacteremia/bacterial
meningitis in this group, suggesting that these infants should not be ignored.
Finally, this study included few African American, Hispanic, or inner-city
infants. The PROS network has subsequently made efforts to recruit practices
to reflect the current demographic portrait of the United States.
While this report focuses on the success of clinicians in addressing
2 of the most serious underlying causes of fever in infancy, we are not suggesting
that the quality of care could not be further improved. As reported in detail
elsewhere,14 urinary tract infections in tested
infants were documented in 19% of uncircumcised boys, 13% of girls, and 17%
of infants with prolonged illness. Yet only slightly more than 50% of infants
had a urine test, including uncircumcised boys, among whom 41% did not have
urine evaluations. This discrepancy represents a potential opportunity to
improve practice. However, obtaining urine tests in all infants may not be
necessary; the selective approach by PROS practitioners did not result in
detected adverse outcomes.
In summary, we have documented strategies for managing fever in infants
by community practitioners and the frequency of illnesses diagnosed. The large
sample size has allowed us to precisely assess the frequency and factors associated
with high risk of bacteremia/bacterial meningitis in infants (age ≤30 days,
higher temperatures, ill appearance, abnormal cry, and abnormal WBC count);
and we have identified a group with a risk of bacteremia/bacterial meningitis
of 0.4% (well appearing, aged 25 days or older, and temperature <38.6°C).
Despite lack of adherence to guidelines, PROS clinicians detected as many
cases of bacteremia/bacterial meningitis while performing fewer tests and
hospitalizing fewer infants than would have occurred if strictly adhering
to practice parameters. The findings suggest that if close follow-up care
is attainable, the management of selected cases by experienced clinicians
using clinical judgment may be more appropriate than strict adherence to published
recommendations, with the potential benefit of reducing considerable costs
and iatrogenic morbidity. While guidelines have an important role in ensuring
the quality of care for many clinical issues, their performance in complex
clinical situations, such as the management of febrile illnesses, should be
analyzed to evaluate whether the guidelines actually optimize care.