Febrile Infant Hospitalizations: When Is the Right Time to Discharge?

Abstract

Early in their training, pediatricians come to grips with a scary fact about young febrile infants <3 months of age: they can be sick without looking sick.1–3 Until the early 1990s, both well- and ill-appearing young febrile infants were managed conservatively, with the same cookbook strategy: hospitalization for 48 to 72 hours on empirical parenteral antibiotics as urine, blood, and spinal fluid cultures marinated.4,5 Pediatric house staff became proficient at spinal taps but also learned that most infants had cultures that tested negative. This “rule out sepsis” recipe clearly subjected many infants to the risks and costs of unnecessary hospitalization and treatment.6 At least 2 questions ensued: which infants could be spared hospitalization? And, if an infant was hospitalized, when could she or he be safely discharged? With regard to the first question, in 2012, the US Agency for Healthcare Research and Quality published a comprehensive review of the myriad of approaches to this conundrum,7 and most are familiar with the current state of affairs.8 First, pediatric trainees still learn the algorithms developed decades ago in Boston,9 Milwaukee,10 Philadelphia,11 and Rochester,12 which teased out a subpopulation of “low-risk” febrile infants who might safely be spared tests, antibiotics, and/or hospitalization. In other studies, authors supported intramuscular ceftriaxone and close follow-up as an alternative to hospitalization for selected infants 28 to 90 days of age.13 Second, despite changes in bacteriology, such as the virtual disappearance of Listeria and Haemophilus influenzae , and the impressive reduction in group B streptococcal and pneumococcal infections,14,15 the overall ball park rates of serious bacterial infection in young febrile infants remain stubbornly unchanged: 5% to 10% have a …