A new protocol avoids spinal taps and antibiotics in the quest for evaluating febrile infants.
There are many challenges when it comes to diagnostics in pediatrics, especially in infants.
Figuring out why that 2-month-old with a fever is crying often includes spinal taps, which are painful and risky, alongside rapid antibiotic treatment to avoid meningitis.
Bacterial meningitis can be deadly, especially in infants; the US Centers for Disease Control and Prevention (CDC) reports that between 2003 and 2007, there were 4100 cases of bacterial meningitis reported in pediatric patients in the United States, as well as 500 deaths.
Given these rates and the risk of life-threatening infections, it’s not unusual that pediatricians would want to perform a spinal tap or administer antibiotics until further diagnostics can be performed.
Fortunately, a new protocol has been developed that could not only make a diagnosis of bacterial infections in infants easier but would remove the need for spinal taps and unnecessary antibiotic treatments.
Investigators from the Pediatric Emergency Care Applied Research Network (PECARN) created a new protocol from a study of more than 1800 infants seen across 26 emergency departments in the United States.
Although previous studies have found that 8% to 13% of infants up to 2 months of age who presented at the emergency room with a fever had a serious bacterial infection (SBI), the PECARN study sought to evaluate the other diagnostic mechanisms. For infants with SBIs, the most common are urinary tract infections, bacteremia (bloodstream infection), and bacterial meningitis. To confirm meningitis, spinal taps are needed, but they carry the risk of complications.
This new protocol, though, evaluated levels of bacteria in the urine, as well as procalcitonin (produced in response to bacterial infections) in serum, and neutrophils. By analyzing these markers, researchers were able to rule out serious bacterial infections. In fact, they were able to accurately rule out all but 3 of the 170 serious bacterial infections detected, including meningitis.
Of the 1821 infants studied, the rate of SBIs was 9.3%, including “26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis,” the investigators found. Moreover, of all the patients with bacterial meningitis, none were missed. Investigators evaluated these infants from March 2011 to May 2013 and found that the sensitivity of the new protocol was 97.7% and specificity was 60%. The team also found that the performance of this protocol was the same when the outcome was restricted to bacteremia and/or bacterial meningitis. One infant with bacteremia and 2 with urinary tract infections were misclassified.
Although there is still a considerable need for larger studies, especially in infants over 2 months of age, these results are promising. Less invasive testing is wholly beneficial to the patient and reduces the risk of complications related to spinal taps. Moreover, if these more rapid tests can be used to cut down on time to treatment or reduce hospitalizations, then the cost-saving measures for both patients and hospitals are considerable. From an antimicrobial stewardship perspective, avoiding prophylactic antibiotic treatments in infants with potentially SBIs is always beneficial. These unnecessary antibiotics are given during the period of unknown and this new protocol seeks to bring clarity to both the medical providers, but also the families.