Successful Outpatient Management of Febrile Infants Without a Lumbar Puncture or Antibiotics

Febrile infants aged ≤90 days presenting to U.S. emergency departments (EDs) typically receive a full evaluation for serious bacterial infection (SBI), the most common of which is urinary tract infection (UTI). The workup includes blood culture, urine culture, cerebrospinal fluid (CSF) culture, lumbar puncture, urinalysis, and complete blood count (CBC). Based on the results of the CSF profile, urinalysis, and CBC, infants are categorized as low or high risk, and low-risk infants between ages 4 and 12 weeks are managed without antibiotics as outpatients.

Researchers in Spain prospectively assessed outcomes of outpatient management without use of lumbar puncture or antibiotics in 586 febrile infants presenting to a pediatric ED who were deemed low risk for SBI. Low-risk criteria were (1) well appearance, (2) age ≥21 days, (3) no leucocytes on urine dipstick, (4) absolute neutrophil count ≤10,000, (5) C-reactive protein ≤20 mg/L, (6) procalcitonin <0.5 ng/mL, and (7) no clinical deterioration during ED observation (the length of which was <6 hours in 30%, between 6 and 24 hours in 68%, and unrecorded in 2%).

Two infants were found to have a definite SBI (Staphylococcus aureus bacteremia in one and bacterial gastroenteritis with Salmonella group C in another), and another 29 infants (5%) had a possible SBI. No infant had bacterial meningitis. Nine percent of infants had a return ED visit, but none had SBIs, and all recovered well.