Alaska Tribal Health Webinar Series
Dr. Emily Hogeland
Pediatric Hospitalist
Alaska Native Medical Center
September 3, 2021
Brief overview of epidemiology
Walk-through of ANMC guideline for febrile infants:
◦ 0-28 days
◦ 29-60 days
◦ 61-90 days
Comparisons to new AAP guideline
Clinical management of febrile infants ≤ 3 months of age
has been the topic of research and debate for many years
in the pediatric community
Wide variety in clinical management persists despite
attempts to standardize work-up with various guidelines
In 2017, shortage of cefotaxime encouraged us to revise
ANMC guidelines (previously updated 2006)
◦ Major revision in Feb 2021
Principal sources: Seattle Children’s and YKHC guidelines
(among several other institutions), literature review,
departmental consensus with input from Antimicrobial
Stewardship Program, ER, and peds ID
Infants between 0-3 months of age are particularly
vulnerable to serious bacterial infections (SBI - i.e.
meningitis, sepsis, and UTI) and may present with vague or
non-specific symptoms, making it difficult to differentiate
between viral and bacterial etiologies
◦ UTI: ~10%
◦ Bacteremia: ~2-4% (declines with age)
◦ Meningitis: 0.5-1.3% (0-28 days), 0.25% (29-60 days)
E. Coli and GBS most common pathogens for
bacteremia/meningitis; E. Coli most common cause of UTI
Listeria now quite rare
Strong sense that rates of sepsis/meningitis are higher
in the AK Native population, but limited data available
Overall higher rates of Hib and pneumococcal disease
Rates of invasive GBS have not been shown to be
higher about AK Native children (Dr. Singleton,
personal communication)
Invasive Hib Disease, Children Aged <5 Years, Alaska, 1980 -
2020
700
Native
600 Non-Native
500
Cases/100,000
400 PRP-OMP PRP-OMP/HbOC
300 DTwP-HbOC
PRP-OMP
200
100
0
Year
Singleton, et al. J Pediatr 2000; 137:313-20 and CDC, unpublished
Invasive Pneumococcal Disease,
Alaska Children, 1986-2020
Overall IPD Rates, Children < 5 Years of Age,
Alaska, 1986-2016 AK Native
400 PCV7 Non-Native
350
Rate per 100,000 per year
300
PCV13
250
200
150
100
50
0
Divided in to 3 age groups:
◦ 0-28 days (presenting after initial hospital discharge)
◦ 29-60 days
◦ 61-90 days
anthcstaff.org: anmc.org/clinical-guidelines
Main differences between
ANMC vs AAP:
◦ Separate 22-28 day
category
◦ Role for home observation
(only when interpretable
CSF obtained and
reassuring)
◦ “May perform LP” if
inflammatory markers
normal vs. universal LP
◦ Option to use ceftriaxone
for empiric treatment
All febrile babies in this age group should get a full
septic work-up with blood, urine, and CSF studies
Admission on antibiotics for initial ~36 hours while
cultures pending
Minimize delays in definitive work-up (i.e. skip clinic
visit if fever identified ahead of time -> straight to
nearest ED or other facility that can perform necessary
studies)
Main differences
between ANMC vs AAP:
◦ More detailed
discussion of
inflammatory markers,
including fever > 38.5C
(101.3F)
◦ “May perform LP” if
elevated inflammatory
markers
◦ Role for outpatient
treatment for UTI
Possible future
modifications to “low risk”
criteria:
◦ Substitute WBC criteria for
ANC (1000-4000?) and
delete band count criteria
◦ Add option for CRP < 2
mg/dL (20mg/L) if
procalcitonin not available
with rapid turnaround
◦ Consideration for fever
>38.5C (101.3F)?
Initial decision: term, well-appearing, and previously
healthy?
“No” to any: full work-up with blood, urine, and CSF
studies; start antibiotics for initial ~36h of pending
cultures
“Yes” to all low-risk criteria: risk-stratification using lab
values and other factors
“Low risk” babies with UTI generally do not need LP
Close follow-up important for any baby not
hospitalized
To include this age group or not?
Very informal chart review of 61-90 day old febrile infants with any blood,
urine, or CSF cultures at ANMC ED or inpatient peds (misses babies with
work-ups done elsewhere or no work-up done) over 12-month period
Of 18 infants, there were two cases of invasive bacterial infections (both
had both sepsis + meningitis) in this age group (11%):
◦ One baby who had multiple episodes of fever previously (before reaching 60 days)
without complete work-up
◦ An ex-26 weeker who had a prolonged NICU stay
One UTI (6%)
56% were admitted, 47% got started on antibiotics
89% got blood cultures drawn, 83% got urine cultures, 33% underwent an
LP (at least attempted)
33% were described as post-immunization fevers; none of these infants
had a bacterial infection identified
Initial decision: > 35 weeks, well-appearing, and
previously healthy?
“No” to any: full work-up with blood, urine, and CSF
studies; start antibiotics for initial ~36h of pending
cultures
“Yes” to all low-risk criteria: do just do urine studies +
other targeted testing
Infants presenting with a focal source of infection (i.e.
acute otitis media, pneumonia, omphalitis, cellulitis,
osteomyelitis) may require targeted antibiotic therapy
instead of, or in addition to, the standard antibiotics
outlined in these guidelines
◦ AAP recommends that acute otitis media does NOT count as an
exclusion the guideline
We do not recommend routine use of respiratory viral PCR
panels, as bacterial infections may be overlooked if a fever
is entirely ascribed to the presence of a virus, which may or
may not be clinically significant
◦ Very limited data on role of COVID; would generally not use COVID +
swab as exemption to guideline
Consults: ANMC Operator 907 563 2662
Transfers: ANMC Transfer Center 907 729 2337
TigerText: ANMC On-Call Pediatrics
◦ If likely transfer, please call transfer center instead
Children’s Hospital Colorado. Fever in Infants Less than 60 Days. 2018 February. Available from: https://www.childrenscolorado.org/
globalassets/healthcare-professionals/clinical-pathways/fever-in-infants-less-than-60-days.pdf
Gomez B, et al. Diagnostic Value of Procalcitonin in Well-Appearing Young Febrile Infants. Pediatrics 2012; 130 (5): 815-22.
Hughes, H et al. The Harriet Lane Handbook – 21st Edition. Philadelphia, PA: Elsevier, 2018. Dosing information for ampicillin, acyclovir,
cefepime, ceftriaxone, gentamicin, and vancomycin.
Hui C, et al. Diagnosis and Management of Febrile Infants (0–3 months). Evidence Report/Technology Assessment No. 205 (Prepared by the
University of Ottawa Evidence-based Practice Center under Contract No. HHSA 290-2007-10059-I.) AHRQ Publication No. 12-E004-EF.
Rockville, MD: Agency for Healthcare Research and Quality. March 2012. http://www.ahrq.gov/clinic/epcix.htm.
Milcent K, et al. Use of Procalcitonin Assays to Predict Serious Bacterial Infection in Young Febrile Infants. JAMA Pediatr 2016; 170 (1): 62-9.
Nugent J, et al. Risk of Meningitis in Infants Aged 29-90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis. J Pediatr 2019
Sept; 212: 102-110.
Pantell R, et al. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old . Pediatrics. 2021;148(2):e2021052228
Scarfone R, et al. Lumbar Puncture for All Febrile Infants 29-56 Days Old: A Retrospective Cohort Reassessment Study. J Pediatr 2017 Aug; 187:
200-205.
Scarfone R, et al. Children’s Hospital of Philadelphia – Emergency Department Clinical Pathway for Evaluation/Treatment of Febrile Infants Less
than 56 Days Old. 2019 August. Available from: https://www.chop.edu/clinical-pathway/febrile-infant-emergent-evaluation-clinical-
pathway
Seattle Children’s Hospital, et al. Neonatal Fever Pathway. 2019 January. Available from: http://www.seattlechildrens.org/pdf/ neonatal-fever-
pathway.pdf
Smitherman, H & Macias, C. Febrile infant (younger than 90 days of age): Outpatient evaluation. UpToDate. Waltham, MA: UpToDate Inc.
Accessed 9 November 2020.
Smitherman, H & Macias, C. Febrile infant (younger than 90 days of age): Management. UpToDate. Waltham, MA: UpToDate Inc. Accessed 9
November 2020.
Thomson J, et al. Concomitant Bacterial Meningitis in Infants with Urinary Tract Infection. The Pediatric Infectious Disease Journal 2017 Sept; 36
(9): 908-910.
Wang M, et al. Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis. Pediatrics 2019 Sept; 144 (3): 20183979.
YKHC Clinical Guidelines. Fever ≥100.4F (38C) in Infants 0-90 days. 2019 May. Available from: https://yk-health.org/images/f/f7/
Fever_less_than_90_days.pdf
Young B, et al. The Prevalence of Bacterial Meningitis in Febrile Infants 29-60 Days With Positive Urinalysis. Hospital Pediatrics 2018 Aug; 8 (8):
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