Performance of low-risk criteria in the evaluation of young infants with fever: review of the literature

Abstract

Objective: The goal was to determine the performance of low-risk criteria for serious bacterial illnesses (SBIs) in febrile infants in prospective studies in which empiric antibiotic treatment was withheld, compared with studies (prospective and retrospective) in which empiric antibiotic treatment was administered.

Methods: A search of the English-language literature was undertaken by using a PubMed database and reference lists of relevant studies of fever, low-risk criteria, and SBIs. Studies of infants >90 days of age, infants with specific infections, or infants with additional risk factors for infection were excluded. Publications were categorized as retrospective, prospective with empiric antibiotic treatment for all patients, or prospective with antibiotics withheld. The relative risk of SBI in high-risk versus low-risk patients was determined for pooled data in each category. The rates of SBIs in low-risk patients in each category were compared.

Results: Twenty-one studies met the inclusion criteria. In prospective studies in which patients were cared for without empiric antibiotic treatment, 6 patients assigned to the low-risk category had SBIs; all recovered uneventfully. The rate of SBIs in these low-risk patients was 0.67%. The relative risk of SBIs in high-risk versus low-risk patients in these studies was 30.56 (95% confidence interval: 7.0-68.13). The rate of SBIs in low-risk patients in all studies was 2.23%. The rate of SBIs in low-risk patients in the prospective studies without empiric antibiotic treatment was significantly different from the rate in all other studies (0.67% vs 2.71%; P = .01).

Conclusions: Low-risk criteria perform well in prospective studies in which empiric antibiotic treatment is withheld. These criteria allow approximately 30% of young febrile infants to be observed without antibiotic treatment, thus avoiding unnecessary hospitalization, nosocomial infection, injudicious use of antibiotics, and adverse effects of antibiotics.