No Benefit in 48-Hour Hospitalization of Infants for Fever Without Source

Clinical question: What is the appropriate length of hospitalization necessary for infants <30 days admitted for fever without source?

Background: Infants ≤30 days old are routinely hospitalized for fever without source (FWS). From 1988-2006, 2.5 million infants younger than three months old were admitted for sepsis, according to National Hospital Discharge Survey data. Term infants <7 days of age accounted for 33% of these hospitalizations. Current national guidelines recommend observation in the hospital for 48-72 hours after cultures of blood, urine, and cerebrospinal fluid (CSF) are initiated. Whether this length of hospitalization is appropriate for well-appearing infants in this age group is not clear, based on current data.

Study design: Single-center, retrospective, cohort study.

Setting: 574-bed tertiary medical center with a 30-bed general pediatric inpatient unit.

Synopsis: Researchers identified infants ≤30 days old who had blood and/or CSF cultures performed from 1999 to 2010. After excluding infants with cultures from the NICU and PICU, infants hospitalized with FWS were identified by chart review. A pediatric infectious disease specialist reviewed positive cultures from blood and CSF to exclude skin contaminants. Time to notification was defined as the time between sample collection and medical staff notification. Blood cultures were monitored continuously for growth at this institution, with staff being notified of positive results immediately during the day but not until 8 a.m. if this occurred overnight. Microbiology laboratory staff reviewed CSF cultures once daily. Of the 408 confirmed FWS hospitalizations, 26 resulted in positive cultures of blood and/or CSF. Time to notification of >24 hours occurred in six of these hospitalizations. Overall, of the 388 FWS hospitalizations with no positive blood or CSF cultures at 24 hours, six went on to develop positive cultures after 24 hours, a rate of 1.5%. All six had at least one high-risk characteristic (WBC <5,000 or >15,000 per µL, a band count >1,500 per per µL, or abnormal urinalysis). However, five patients with no high-risk characteristics and a normal urinalysis on admission were diagnosed with a UTI after 24 hours.

Bottom line: Infants ≤30 days old with no high-risk characteristics for sepsis may not need a full 48 hours of hospitalization for FWS, although this approach could lead rarely to a diagnosis of UTI after discharge.

Citation: Fielding-Singh V, Hong DK, Harris SJ, et al. Ruling out bacteremia and bacterial meningitis in infants less than one month of age: is 48 hours of hospitalization necessary? Hosp Pediatrics. 2013;3(4):355-361.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the appropriate length of hospitalization necessary for infants <30 days admitted for fever without source?

Background: Infants ≤30 days old are routinely hospitalized for fever without source (FWS). From 1988-2006, 2.5 million infants younger than three months old were admitted for sepsis, according to National Hospital Discharge Survey data. Term infants <7 days of age accounted for 33% of these hospitalizations. Current national guidelines recommend observation in the hospital for 48-72 hours after cultures of blood, urine, and cerebrospinal fluid (CSF) are initiated. Whether this length of hospitalization is appropriate for well-appearing infants in this age group is not clear, based on current data.

Study design: Single-center, retrospective, cohort study.

Setting: 574-bed tertiary medical center with a 30-bed general pediatric inpatient unit.

Synopsis: Researchers identified infants ≤30 days old who had blood and/or CSF cultures performed from 1999 to 2010. After excluding infants with cultures from the NICU and PICU, infants hospitalized with FWS were identified by chart review. A pediatric infectious disease specialist reviewed positive cultures from blood and CSF to exclude skin contaminants. Time to notification was defined as the time between sample collection and medical staff notification. Blood cultures were monitored continuously for growth at this institution, with staff being notified of positive results immediately during the day but not until 8 a.m. if this occurred overnight. Microbiology laboratory staff reviewed CSF cultures once daily. Of the 408 confirmed FWS hospitalizations, 26 resulted in positive cultures of blood and/or CSF. Time to notification of >24 hours occurred in six of these hospitalizations. Overall, of the 388 FWS hospitalizations with no positive blood or CSF cultures at 24 hours, six went on to develop positive cultures after 24 hours, a rate of 1.5%. All six had at least one high-risk characteristic (WBC <5,000 or >15,000 per µL, a band count >1,500 per per µL, or abnormal urinalysis). However, five patients with no high-risk characteristics and a normal urinalysis on admission were diagnosed with a UTI after 24 hours.

Bottom line: Infants ≤30 days old with no high-risk characteristics for sepsis may not need a full 48 hours of hospitalization for FWS, although this approach could lead rarely to a diagnosis of UTI after discharge.

Citation: Fielding-Singh V, Hong DK, Harris SJ, et al. Ruling out bacteremia and bacterial meningitis in infants less than one month of age: is 48 hours of hospitalization necessary? Hosp Pediatrics. 2013;3(4):355-361.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the appropriate length of hospitalization necessary for infants <30 days admitted for fever without source?

Background: Infants ≤30 days old are routinely hospitalized for fever without source (FWS). From 1988-2006, 2.5 million infants younger than three months old were admitted for sepsis, according to National Hospital Discharge Survey data. Term infants <7 days of age accounted for 33% of these hospitalizations. Current national guidelines recommend observation in the hospital for 48-72 hours after cultures of blood, urine, and cerebrospinal fluid (CSF) are initiated. Whether this length of hospitalization is appropriate for well-appearing infants in this age group is not clear, based on current data.

Study design: Single-center, retrospective, cohort study.

Setting: 574-bed tertiary medical center with a 30-bed general pediatric inpatient unit.

Synopsis: Researchers identified infants ≤30 days old who had blood and/or CSF cultures performed from 1999 to 2010. After excluding infants with cultures from the NICU and PICU, infants hospitalized with FWS were identified by chart review. A pediatric infectious disease specialist reviewed positive cultures from blood and CSF to exclude skin contaminants. Time to notification was defined as the time between sample collection and medical staff notification. Blood cultures were monitored continuously for growth at this institution, with staff being notified of positive results immediately during the day but not until 8 a.m. if this occurred overnight. Microbiology laboratory staff reviewed CSF cultures once daily. Of the 408 confirmed FWS hospitalizations, 26 resulted in positive cultures of blood and/or CSF. Time to notification of >24 hours occurred in six of these hospitalizations. Overall, of the 388 FWS hospitalizations with no positive blood or CSF cultures at 24 hours, six went on to develop positive cultures after 24 hours, a rate of 1.5%. All six had at least one high-risk characteristic (WBC <5,000 or >15,000 per µL, a band count >1,500 per per µL, or abnormal urinalysis). However, five patients with no high-risk characteristics and a normal urinalysis on admission were diagnosed with a UTI after 24 hours.

Bottom line: Infants ≤30 days old with no high-risk characteristics for sepsis may not need a full 48 hours of hospitalization for FWS, although this approach could lead rarely to a diagnosis of UTI after discharge.

Citation: Fielding-Singh V, Hong DK, Harris SJ, et al. Ruling out bacteremia and bacterial meningitis in infants less than one month of age: is 48 hours of hospitalization necessary? Hosp Pediatrics. 2013;3(4):355-361.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.