Infants with fevers receive as good care when physicians rely on judgment than clinical guidelines

March 09, 2004

Pediatricians and other pediatric clinicians who use individualized clinical judgment in treating infants with fevers can effectively diagnose serious illnesses and provide appropriate follow-up care, even when not following all the current clinical guidelines on how to manage such cases, according to a study in the March 10 issue of The Journal of the American Medical Association (JAMA).

According to background information in the article, infants with fevers (febrile infants) often lack the symptoms necessary for physicians to distinguish between a minor illness and one that is life-threatening. "To avoid the consequences of failing to detect serious bacterial illness (SBI), such as bacteremia (bacteria in the blood) 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." The authors add that previous studies indicate that a large proportion of office-based physicians do not routinely follow these guidelines.

In this study, Robert H. Pantell, M.D., from the University of California, San Francisco and colleagues evaluated data from 3,066 infants aged 3 months or younger with temperatures of at least 38 degrees Celsius (100.4 degrees Fahrenheit) who were seen by physicians from February 28, 1995 through April 25, 1998. The 573 practitioners in the study were part of the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics in 44 states, the District of Columbia, and Puerto Rico.

"The PROS clinicians hospitalized 36 percent of the infants, performed laboratory testing in 75 percent, and initially treated 57 percent with antibiotics," the authors report. "The majority (64 percent) were treated exclusively outside of the hospital. [Bacteria in the blood] was detected in 1.8 percent of infants (2.4 percent of those tested) and bacterial meningitis in 0.5 percent." The authors found that the physicians followed current guidelines in 42 percent of episodes. Had clinicians followed guidelines, all of the infants under one month of age would have been hospitalized, whereas clinicians in this study kept 40 percent of these infants out of the hospital and cared for them during regular office visits.

"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 authors write. "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 (unfavorable outcomes). 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."

(JAMA. 2004;291:1203-1212. Available post-embargo at JAMA.com.)

Editor's Note: This study was supported by a grant from the Agency for Healthcare Research and Quality, with additional support from the Health Resources and Services Administration Maternal and Child Health Bureau.

EDITORIAL: YOUNG, FEBRILE INFANTS - A 30-YEAR ODYSSEY ENDS WHERE IT STARTED

In an accompanying editorial, Kenneth B. Roberts, M.D., from Moses Cone Health System, Greensboro, N.C., writes: "In this issue of The Journal, Pantell et al share the long-awaited results of a collaborative study conducted in pediatric practices using the American Academy of Pediatrics Pediatric Research in Office Settings (PROS) network. ... The practitioners ordered fewer tests for their febrile infant patients than guidelines recommended, yet the 'miss' rate of infants with bacteremia or bacterial meningitis was very low."

"... despite best research efforts over the past 30 years, there is no risk-free alternative, no easy way to identify 100 percent of infants who need treatment or 100 percent of those who do not. Studies like that by Pantell et al demonstrate the benefit of collaborative research in office settings and the limits of extrapolating findings from studies in academic medical centers and EDs (emergency departments) to office practices."

(JAMA. 2004;291:1261-1262. Available post-embargo at JAMA.com.)
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