Practice Variations in the Treatment of Febrile Infants Among Pediatric Emergency Physicians

ARTICLE

Practice Variations in the Treatment of Febrile Infants Among Pediatric Emergency Physicians

Ran D. Goldman, MD, MHRM, FRCPC^a,b,c, Dennis Scolnik, MD^d, Laurel Chauvin-Kimoff, MD^e, Ken J. Farion, MD, FRCPC^f, Samina Ali, MD^g, Tim Lynch, MD^h, Serge Gouin, MDⁱ, Martin H. Osmond, MD, CM, FRCPC^f, David W. Johnson, MD^j,k, Terry P. Klassen, MD, MSc^g for the Fever in Infants Group Research, Pediatric Emergency Research of Canada

PEDIATRICS Vol. 124 No. 2 August 2009, pp. 439-445

 

 

^a Division of Pediatric Emergency Medicine, Department of Pediatrics, British Columbia Children’s Hospital, Vancouver, Canada
^b Department of Pediatrics, University of British Columbia, Vancouver, Canada
^c Child and Family Research Institute, Vancouver, Canada
^d Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
^e Division of Pediatric Emergency Medicine, Department of Pediatrics, McGill University and Montreal Children’s Hospital, Montreal, Quebec, Canada
^f Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Ottawa and Children’s Hospital of Eastern Ontario, Ottawa, Canada
^g Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alberta and Stollery Children’s Hospital, Edmonton, Canada
^h Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Western Ontario and Children’s Hospital of Western Ontario, London, Canada
ⁱ Division of Emergency Medicine, Department of Pediatrics, St Justine University Hospital Center, University of Montreal, Montreal, Quebec, Canada; Departments of
^j Pediatrics
^k Pharmacology and Therapeutics, University of Calgary, Calgary, Canada

 

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ABSTRACT

OBJECTIVES: The objectives of this study were to characterize variations in treatment decisions for young febrile infants in pediatric emergency departments across Canada and to document the extent of practice variations among pediatric emergency department practitioners.

METHODS: This was a prospective, concurrent, cohort study of consecutive infants up to 90 days of age who presented to 6 pediatric emergency departments in Canada with fever (rectal temperature of 38.0°C). We recorded information in the emergency department and contacted the families by telephone to confirm the final disposition.

RESULTS: A total of 257 infants were recruited over 2 to 4 months. Patients were similar across centers in terms of gestational age and weight, chronologic age at arrival, weight, and gender. Temperatures measured at home and during triage and durations of fever also were similar among centers. In one center, significantly more children arrived with cough; in another center, fewer parents reported sick contacts at home. Rates of blood and urine testing were not significantly different across sites, but rates of lumbar puncture, respiratory virus testing, and chest radiography were different. A total of 55% of infants received antibiotics, and significant practice variations in the numbers and types of antibiotics used were documented.

CONCLUSIONS: Practices in the evaluation of young infants with fever in tertiary pediatric emergency departments varied substantially. Blood and urine tests were ordered in the majority of centers, but rates of cerebrospinal fluid testing and antibiotic treatment differed across centers.

Reference

1. Nelson DS, Walsh K, Fleisher GR. Spectrum and frequency of pediatric illness presenting to a general community hospital emergency department. Pediatrics. 1992;90 (1):5 –10[Abstract/Free Full Text]
2. Krauss BS, Harakal T, Fleisher GR. The spectrum and frequency of illness presenting to a pediatric emergency department. Pediatr Emerg Care. 1991;7 (2):67 –71[Medline]
3. Dershewitz RA, Wigder HN, Wigder CM, Nadelman DH. A comparative study of the prevalence, outcome, and prediction of bacteremia in children. J Pediatr. 1983;103 (3):352 –358[CrossRef][Web of Science][Medline]
4. Baraff LJ, Oslund SA, Schriger DL, Stephen ML. Probability of bacterial infections in febrile infants less than three months of age: a meta-analysis. Pediatr Infect Dis J. 1992;11 (4):257 –264[Web of Science][Medline]
5. Byington CL, Rittichier KK, Bassett KE, et al. Serious bacterial infections in febrile infants younger than 90 days of age: the importance of ampicillin-resistant pathogens. Pediatrics. 2003;111 (5):964 –968[Abstract/Free Full Text]
6. Baskin MN. The prevalence of serious bacterial infections by age in febrile infants during the first 3 months of life. Pediatr Ann. 1993;22 (8):462 –466[Web of Science][Medline]
7. Bonadio WA, Hegenbarth M, Zachariason M. Correlating reported fever in young infants with subsequent temperature patterns and rate of serious bacterial infections. Pediatr Infect Dis J. 1990;9 (3):158 –160[Web of Science][Medline]
8. Kadish HA, Loveridge B, Tobey J, Bolte RG, Corneli HM. Applying outpatient protocols in febrile infants 1–28 days of age: can the threshold be lowered? Clin Pediatr (Phila). 2000;39 (2):81 –88[Abstract/Free Full Text]
9. McCarthy PL, Sharpe MR, Spiesel SZ, et al. Observation scales to identify serious illness in febrile children. Pediatrics. 1982;70 (5):802 –809[Abstract/Free Full Text]
10. Dagan R, Sofer S, Phillip M, Shachak E. Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections. J Pediatr. 1988;112 (3):355 –360[CrossRef][Web of Science][Medline]
11. Baskin MN, O’Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr. 1992;120 (1):22 –27[CrossRef][Web of Science][Medline]
12. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med. 1993;329 (20):1437 –1441[Abstract/Free Full Text]
13. Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med. 2000;36 (6):602 –614[CrossRef][Web of Science][Medline]
14. Berkowitz CD, Orr DP, Uchiyama N, et al. Variability in the management of the febrile infant under 2 months of age. J Emerg Med. 1985;3 (5):345 –351[CrossRef][Medline]
15. Jones RG, Bass JW. Febrile children with no focus of infection: a survey of their management by primary care physicians. Pediatr Infect Dis J. 1993;12 (3):179 –183[Web of Science][Medline]
16. Wittler RR, Cain KK, Bass JW. A survey about management of febrile children without source by primary care physicians. Pediatr Infect Dis J. 1998;17 (4):271 –277[CrossRef][Web of Science][Medline]
17. Baraff LJ. Management of the febrile child: a survey of pediatric and emergency medicine residency directors. Pediatr Infect Dis J. 1991;10 (11):795 –800[Web of Science][Medline]
18. Schweich PJ, Smith KM, Dowd MD, Walkley EI. Pediatric emergency medicine practice patterns: a comparison of pediatric and general emergency physicians. Pediatr Emerg Care. 1998;14 (2):89 –94[Web of Science][Medline]
19. Young PC. The management of febrile infants by primary-care pediatricians in Utah: comparison with published practice guidelines. Pediatrics. 1995;95 (5):623 –627[Abstract/Free Full Text]
20. Isaacman DJ, Kaminer K, Veligeti H, Jones M, Davis P, Mason JD. Comparative practice patterns of emergency medicine physicians and pediatric emergency medicine physicians managing fever in young children. Pediatrics. 2001;108 (2):354 –358[Abstract/Free Full Text]
21. Leduc DG, Pless IB. Pediatricians and general practitioners: a comparison of the management of children with febrile illness. Pediatrics. 1982;70 (4):511 –515[Abstract/Free Full Text]
22. Kramer MS, Shapiro ED. Management of the young febrile child: a commentary on recent practice guidelines. Pediatrics. 1997;100 (1):128 –134[Free Full Text]
23. Schriger DL. Management of the young febrile child: clinical guidelines in the setting of incomplete evidence. Pediatrics. 1997;100 (1):136[Free Full Text]
24. Baraff LJ. Commentary: lack of impact of guidelines on management of febrile children. Pediatr Infect Dis J. 1998;17 (4):277 –279[CrossRef][Web of Science]
25. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Ann Emerg Med. 1993;22 (7):1198 –1210[CrossRef][Web of Science][Medline]
26. Baraff LJ. Capillary refill: is it a useful clinical sign? Pediatrics. 1993;92 (5):723 –724[Abstract/Free Full Text]
27. Zerr DM, Del Beccaro MA, Cummings P. Predictors of physician compliance with a published guideline on management of febrile infants. Pediatr Infect Dis J. 1999;18 (3):232 –238[CrossRef][Web of Science][Medline]
28. Bergman DA, Mayer ML, Pantell RH, Finch SA, Wasserman RC. Does clinical presentation explain practice variability in the treatment of febrile infants? Pediatrics. 2006;117 (3):787 –795[Abstract/Free Full Text]
29. Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics. 2004;113 (6):1728 –1734[Abstract/Free Full Text]

 

 

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