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Chapter 8

PECARN Pie: Infant Fever Pt 1

Nate Kupperman, MD, MPH and Solomon Behar, MD

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The young febrile infant is at risk for serious infections. Older risk stratification strategies have involved extensive, invasive work-ups. New research from the PECARN group has allowed for a simpler evaluation of the full term, well appearing febrile young infant using only blood and urine testing. Sol sits down with fellow EM physician, and founding chair of the PECARN network, Dr. Nate Kuppermann to discuss the latest trends in evaluating this high risk population.

  • The epidemiology of bacteremia and bacterial meningitis in newborns has changed substantially since the introduction of screening of pregnant women for GBS and use of peripartum penicillin treatment. 

  • About 500,000 febrile infants younger than two months go to the emergency departments every year for the evaluation of fever and many more go to primary care clinics.

  • Approximately 8-10% of febrile infants ≤60 days of age presenting to emergency departments have serious bacterial infections including urinary tract infections (UTIs), bacteremia, and bacterial meningitis. 

  • Many algorithms for the evaluation of febrile infants combine subjective clinical findings and laboratory markers using pre-existing numerical cutoffs. In 2016, Gomez et al published the “Step-by-Step” approach in the management of young febrile infants. This approach evaluates sequentially the general appearance of the infant, the age, and result of the urinalysis and, lastly, the results of blood biomarkers, including procalcitonin, CRP, and absolute neutrophil count (ANC). 

  • A recent study from PECARN has derived an algorithm that includes only three objective factors to risk stratify febrile, well appearing infants that are 0 to 60 days old: procalcitonin, ANC and urine. 

  • In order of importance, in terms of identifying serious bacterial infection, was the urinalysis (positive or negative), then  an absolute neutrophil count at a cutoff of 4.09, and the third was procalcitonin at 1.71. Using those three cutoffs, the sensitivity of the prediction tool was over 97% and specificity was around 60%. 

    • A UTI was defined using the following criteria: for the suprapubic tap, a colony count of a thousand. For catheterized urine specimens, the colony count of at least 10,000 with a positive urinalysis or a colony count greater than 50,000 with a negative urinalysis.

      • A urinalysis is considered positive if any of the following are present: ≥ 5 WBC/hpf, nitrates,  leukocyte esterase or bacteriuria. 

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