Guideline adherence in febrile children below 3 months visiting European Emergency Departments: an observational multicenter study

doi:10.1007/s00431-022-04606-5

Observational Study

. 2022 Dec;181(12):4199-4209.

doi: 10.1007/s00431-022-04606-5. Epub 2022 Sep 30.

Guideline adherence in febrile children below 3 months visiting European Emergency Departments: an observational multicenter study

Chantal D Tan¹, Eline E P L van der Walle¹, Clementien L Vermont², Ulrich von Both^{3

4}, Enitan D Carrol^{5

6}, Irini Eleftheriou⁷, Marieke Emonts^{8

9

10}, Michiel van der Flier^{11

12

13}, Ronald de Groot¹¹, Jethro Herberg¹⁴, Benno Kohlmaier¹⁵, Michael Levin¹⁴, Emma Lim^{8

16}, Ian K Maconochie¹⁷, Federico Martinon-Torres¹⁸, Ruud G Nijman¹⁴, Marko Pokorn¹⁹, Irene Rivero-Calle¹⁸, Maria Tsolia⁷, Shunmay Yeung²⁰, Werner Zenz¹⁵, Dace Zavadska²¹, Henriëtte A Moll²²; PERFORM consortium (Personalised Risk assessment in febrile children to optimize Real-life Management across the European Union)

Collaborators, Affiliations

Collaborators

PERFORM consortium (Personalised Risk assessment in febrile children to optimize Real-life Management across the European Union):
Michael Levin, Aubrey Cunnington, Tisham De, Jethro Herberg, Myrsini Kaforou, Victoria Wright, Lucas Baumard, Evangelos Bellos, Giselle D'Souza, Rachel Galassini, Dominic Habgood-Coote, Shea Hamilton, Clive Hoggart, Sara Hourmat, Heather Jackson, Ian Maconochie, Stephanie Menikou, Naomi Lin, Samuel Nichols, Ruud Nijman, Ivonne Pena Paz, Priyen Shah, Ching-Fen Shen, Ortensia Vito, Clare Wilson, Amina Abdulla, Ladan Ali, Sarah Darnell, Rikke Jorgensen, Sobia Mustafa, Salina Persand, Molly Stevens, Eunjung Kim, Benjamin Pierce, Katy Fidler, Julia Dudley, Vivien Richmond, Emma Tavliavini, Ching-Chuan Liu, Shih-Min Wang, Federico Martinón-Torres, Antonio Salas, Fernando Álvez González, Cristina Balo Farto, Ruth Barral-Arca, María Barreiro Castro, Xabier Bello, Mirian Ben García, Sandra Carnota, Miriam Cebey-López, María José Curras-Tuala, Carlos Durán Suárez, Luisa García Vicente, Alberto Gómez-Carballa, Jose Gómez Rial, Pilar Leboráns Iglesias, Federico Martinón-Torres, Nazareth Martinón-Torres, José María Martinón Sánchez, Belén Mosquera Pérez, Jacobo Pardo-Seco, Lidia Piñeiro Rodríguez, Sara Pischedda, Sara Rey Vázquez, Irene Rivero Calle, Carmen Rodríguez-Tenreiro, Lorenzo Redondo-Collazo, Miguel Sadiki Ora, Antonio Salas, Sonia Serén Fernández, Cristina Serén Trasorras, Marisol Vilas Iglesias, Dace Zavadska, Anda Balode, Arta Bārzdiņa, Dārta Deksne, Dace Gardovska, Dagne Grāvele, Ilze Grope, Anija Meiere, Ieva Nokalna, Jana Pavāre, Zanda Pučuka, Katrīna Selecka, Aleksandra Sidorova, Dace Svile, Urzula Nora Urbāne, Effua Usuf, Kalifa Bojang, Syed M A Zaman, Fatou Secka, Suzanne Anderson, Anna Roca, Isatou Sarr, Momodou Saidykhan, Saffiatou Darboe, Samba Ceesay, Umberto D'alessandro, Henriëtte A Moll, Dorine M Borensztajn, Nienke N Hagedoorn, Chantal Tan, Clementien L Vermont, Joany Zachariasse, W Dik, Philipp Agyeman, Luregn J Schlapbach, Christoph Aebi, Verena Wyss, Mariama Usman, Philipp Agyeman, Luregn J Schlapbach, Eric Giannoni, Martin Stocker, Klara M Posfay-Barbe, Ulrich Heininger, Sara Bernhard-Stirnemann, Anita Niederer-Loher, Christian Kahlert, Giancarlo Natalucci, Christa Relly, Thomas Riedel, Christoph Aebi, Christoph Berger, Enitan D Carrol, Stéphane Paulus, Elizabeth Cocklin, Rebecca Jennings, Joanne Johnston, Simon Leigh, Karen Newall, Sam Romaine, Maria Tsolia, Irini Eleftheriou, Maria Tambouratzi, Antonis Marmarinos, Marietta Xagorari, Kelly Syggelou, Colin Fink, Marie Voice, Leo Calvo-Bado, Werner Zenz, Benno Kohlmaier, Nina A Schweintzger, Manfred G Sagmeister, Daniela S Kohlfürst, Christoph Zurl, Alexander Binder, Susanne Hösele, Manuel Leitner, Lena Pölz, Glorija Rajic, Sebastian Bauchinger, Hinrich Baumgart, Martin Benesch, Astrid Ceolotto, Ernst Eber, Siegfried Gallistl, Gunther Gores, Harald Haidl, Almuthe Hauer, Christa Hude, Markus Keldorfer, Larissa Krenn, Heidemarie Pilch, Andreas Pfleger, Klaus Pfurtscheller, Gudrun Nordberg, Tobias Niedrist, Siegfried Rödl, Andrea Skrabl-Baumgartner, Matthias Sperl, Laura Stampfer, Volker Strenger, Holger Till, Andreas Trobisch, Sabine Löffler, Shunmay Yeung, Juan Emmanuel Dewez, Martin Hibberd, David Bath, Alec Miners, Ruud Nijman, Catherine Wedderburn, Anne Meierford, Baptiste Leurent, Ronald de Groot, Michiel van der Flier, Marien I de Jonge, Koen van Aerde, Wynand Alkema, Bryan van den Broek, Jolein Gloerich, Alain J van Gool, Stefanie Henriet, Martijn Huijnen, Ria Philipsen, Esther Willems, G P J M Gerrits, M van Leur, J Heidema, L de Haan, C J Miedema, C Neeleman, C C Obihara, G A Tramper-Stranders, Andrew J Pollard, Rama Kandasamy, Stéphane Paulus, Michael J Carter, Daniel O'Connor, Sagida Bibi, Dominic F Kelly, Meeru Gurung, Stephen Thorson, Imran Ansari, David R Murdoch, Shrijana Shrestha, Zoe Oliver, Marieke Emonts, Emma Lim, Lucille Valentine, Karen Allen, Kathryn Bell, Adora Chan, Stephen Crulley, Kirsty Devin, Daniel Fabian, Sharon King, Paul McAlinden, Sam McDonald, Anne McDonnell, Ailsa Pickering, Evelyn Thomson, Amanda Wood, Diane Wallia, Phil Woodsford, Frances Baxter, Ashley Bell, Mathew Rhodes, Rachel Agbeko, Christine Mackerness, Bryan Baas, Lieke Kloosterhuis, Wilma Oosthoek, Tasnim Arif, Joshua Bennet, Kalvin Collings, Ilona van der Giessen, Alex Martin, Aqeela Rashid, Emily Rowlands, Gabriella de Vries, Fabian van der Velden, Lucille Valentine, Mike Martin, Ravi Mistry, Ulrich von Both, Laura Kolberg, Manuela Zwerenz, Judith Buschbeck, Christoph Bidlingmaier, Vera Binder, Katharina Danhauser, Nikolaus Haas, Matthias Griese, Tobias Feuchtinger, Julia Keil, Matthias Kappler, Eberhard Lurz, Georg Muench, Karl Reiter, Carola Schoen, François Mallet, Karen Brengel-Pesce, Alexandre Pachot, Marine Mommert, Marko Pokorn, Mojca Kolnik, Katarina Vincek, Tina Plankar Srovin, Natalija Bahovec, Petra Prunk, Veronika Osterman, Tanja Avramoska, Taco Kuijpers, Ilse Jongerius, J M van den Berg, D Schonenberg, A M Barendregt, D Pajkrt, M van der Kuip, A M van Furth, Evelien Sprenkeler, Judith Zandstra, G van Mierlo, J Geissler

Affiliations

¹ Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, P.O. Box 2060, 3000 CB, Rotterdam, the Netherlands.
² Department of Paediatric Infectious Diseases and Immunology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.
³ Division of Paediatric Infectious Diseases, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.
⁴ German Centre for Infection Research, DZIF, Partner Site Munich, Munich, Germany.
⁵ Institute of Infection, Veterinary and Ecological Sciences Liverpool, University of Liverpool, Liverpool, UK.
⁶ Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
⁷ Second Department of Paediatrics, National and Kapodistrian University of Athens, P. and A. Kyriakou Children's Hospital, Athens, Greece.
⁸ Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
⁹ Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
¹⁰ NIHR Newcastle Biomedical Research Centre Based at Newcastle Upon Tyne Hospitals NHS Trust and Newcastle University, Westgate Rd, Newcastle upon Tyne, NE4 5PL, UK.
¹¹ Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, RadboudUMC, Nijmegen, the Netherlands.
¹² Paediatric Infectious Diseases and Immunology, Amalia Children's Hospital, RadboudUMC, Nijmegen, the Netherlands.
¹³ Paediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands.
¹⁴ Section of Paediatric Infectious Diseases, Imperial College, London, UK.
¹⁵ Department of General Paediatrics, Medical University of Graz, Graz, Austria.
¹⁶ Department of Medicine, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.
¹⁷ Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, London, UK.
¹⁸ Vaccines, Infections and Paediatrics Research Group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela. Genetics, Santiago de Compostela, Spain.
¹⁹ Department of Infectious Diseases and Faculty of Medicine, University Medical Centre Ljubljana, University of Ljubljana, Ljubljana, Slovenia.
²⁰ London School of Hygiene and Tropical Medicine, Faculty of Tropical and Infectious Disease, London, UK.
²¹ Rīgas Stradiņa universitāte, Department of Paediatrics, Children Clinical University Hospital, Riga, Latvia.
²² Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, P.O. Box 2060, 3000 CB, Rotterdam, the Netherlands. h.a.moll@erasmusmc.nl.

PMID: 36178539
PMCID: PMC9649464
DOI: 10.1007/s00431-022-04606-5

Observational Study

Guideline adherence in febrile children below 3 months visiting European Emergency Departments: an observational multicenter study

Chantal D Tan et al. Eur J Pediatr. 2022 Dec.

. 2022 Dec;181(12):4199-4209.

doi: 10.1007/s00431-022-04606-5. Epub 2022 Sep 30.

Authors

Collaborators

PERFORM consortium (Personalised Risk assessment in febrile children to optimize Real-life Management across the European Union):
Michael Levin, Aubrey Cunnington, Tisham De, Jethro Herberg, Myrsini Kaforou, Victoria Wright, Lucas Baumard, Evangelos Bellos, Giselle D'Souza, Rachel Galassini, Dominic Habgood-Coote, Shea Hamilton, Clive Hoggart, Sara Hourmat, Heather Jackson, Ian Maconochie, Stephanie Menikou, Naomi Lin, Samuel Nichols, Ruud Nijman, Ivonne Pena Paz, Priyen Shah, Ching-Fen Shen, Ortensia Vito, Clare Wilson, Amina Abdulla, Ladan Ali, Sarah Darnell, Rikke Jorgensen, Sobia Mustafa, Salina Persand, Molly Stevens, Eunjung Kim, Benjamin Pierce, Katy Fidler, Julia Dudley, Vivien Richmond, Emma Tavliavini, Ching-Chuan Liu, Shih-Min Wang, Federico Martinón-Torres, Antonio Salas, Fernando Álvez González, Cristina Balo Farto, Ruth Barral-Arca, María Barreiro Castro, Xabier Bello, Mirian Ben García, Sandra Carnota, Miriam Cebey-López, María José Curras-Tuala, Carlos Durán Suárez, Luisa García Vicente, Alberto Gómez-Carballa, Jose Gómez Rial, Pilar Leboráns Iglesias, Federico Martinón-Torres, Nazareth Martinón-Torres, José María Martinón Sánchez, Belén Mosquera Pérez, Jacobo Pardo-Seco, Lidia Piñeiro Rodríguez, Sara Pischedda, Sara Rey Vázquez, Irene Rivero Calle, Carmen Rodríguez-Tenreiro, Lorenzo Redondo-Collazo, Miguel Sadiki Ora, Antonio Salas, Sonia Serén Fernández, Cristina Serén Trasorras, Marisol Vilas Iglesias, Dace Zavadska, Anda Balode, Arta Bārzdiņa, Dārta Deksne, Dace Gardovska, Dagne Grāvele, Ilze Grope, Anija Meiere, Ieva Nokalna, Jana Pavāre, Zanda Pučuka, Katrīna Selecka, Aleksandra Sidorova, Dace Svile, Urzula Nora Urbāne, Effua Usuf, Kalifa Bojang, Syed M A Zaman, Fatou Secka, Suzanne Anderson, Anna Roca, Isatou Sarr, Momodou Saidykhan, Saffiatou Darboe, Samba Ceesay, Umberto D'alessandro, Henriëtte A Moll, Dorine M Borensztajn, Nienke N Hagedoorn, Chantal Tan, Clementien L Vermont, Joany Zachariasse, W Dik, Philipp Agyeman, Luregn J Schlapbach, Christoph Aebi, Verena Wyss, Mariama Usman, Philipp Agyeman, Luregn J Schlapbach, Eric Giannoni, Martin Stocker, Klara M Posfay-Barbe, Ulrich Heininger, Sara Bernhard-Stirnemann, Anita Niederer-Loher, Christian Kahlert, Giancarlo Natalucci, Christa Relly, Thomas Riedel, Christoph Aebi, Christoph Berger, Enitan D Carrol, Stéphane Paulus, Elizabeth Cocklin, Rebecca Jennings, Joanne Johnston, Simon Leigh, Karen Newall, Sam Romaine, Maria Tsolia, Irini Eleftheriou, Maria Tambouratzi, Antonis Marmarinos, Marietta Xagorari, Kelly Syggelou, Colin Fink, Marie Voice, Leo Calvo-Bado, Werner Zenz, Benno Kohlmaier, Nina A Schweintzger, Manfred G Sagmeister, Daniela S Kohlfürst, Christoph Zurl, Alexander Binder, Susanne Hösele, Manuel Leitner, Lena Pölz, Glorija Rajic, Sebastian Bauchinger, Hinrich Baumgart, Martin Benesch, Astrid Ceolotto, Ernst Eber, Siegfried Gallistl, Gunther Gores, Harald Haidl, Almuthe Hauer, Christa Hude, Markus Keldorfer, Larissa Krenn, Heidemarie Pilch, Andreas Pfleger, Klaus Pfurtscheller, Gudrun Nordberg, Tobias Niedrist, Siegfried Rödl, Andrea Skrabl-Baumgartner, Matthias Sperl, Laura Stampfer, Volker Strenger, Holger Till, Andreas Trobisch, Sabine Löffler, Shunmay Yeung, Juan Emmanuel Dewez, Martin Hibberd, David Bath, Alec Miners, Ruud Nijman, Catherine Wedderburn, Anne Meierford, Baptiste Leurent, Ronald de Groot, Michiel van der Flier, Marien I de Jonge, Koen van Aerde, Wynand Alkema, Bryan van den Broek, Jolein Gloerich, Alain J van Gool, Stefanie Henriet, Martijn Huijnen, Ria Philipsen, Esther Willems, G P J M Gerrits, M van Leur, J Heidema, L de Haan, C J Miedema, C Neeleman, C C Obihara, G A Tramper-Stranders, Andrew J Pollard, Rama Kandasamy, Stéphane Paulus, Michael J Carter, Daniel O'Connor, Sagida Bibi, Dominic F Kelly, Meeru Gurung, Stephen Thorson, Imran Ansari, David R Murdoch, Shrijana Shrestha, Zoe Oliver, Marieke Emonts, Emma Lim, Lucille Valentine, Karen Allen, Kathryn Bell, Adora Chan, Stephen Crulley, Kirsty Devin, Daniel Fabian, Sharon King, Paul McAlinden, Sam McDonald, Anne McDonnell, Ailsa Pickering, Evelyn Thomson, Amanda Wood, Diane Wallia, Phil Woodsford, Frances Baxter, Ashley Bell, Mathew Rhodes, Rachel Agbeko, Christine Mackerness, Bryan Baas, Lieke Kloosterhuis, Wilma Oosthoek, Tasnim Arif, Joshua Bennet, Kalvin Collings, Ilona van der Giessen, Alex Martin, Aqeela Rashid, Emily Rowlands, Gabriella de Vries, Fabian van der Velden, Lucille Valentine, Mike Martin, Ravi Mistry, Ulrich von Both, Laura Kolberg, Manuela Zwerenz, Judith Buschbeck, Christoph Bidlingmaier, Vera Binder, Katharina Danhauser, Nikolaus Haas, Matthias Griese, Tobias Feuchtinger, Julia Keil, Matthias Kappler, Eberhard Lurz, Georg Muench, Karl Reiter, Carola Schoen, François Mallet, Karen Brengel-Pesce, Alexandre Pachot, Marine Mommert, Marko Pokorn, Mojca Kolnik, Katarina Vincek, Tina Plankar Srovin, Natalija Bahovec, Petra Prunk, Veronika Osterman, Tanja Avramoska, Taco Kuijpers, Ilse Jongerius, J M van den Berg, D Schonenberg, A M Barendregt, D Pajkrt, M van der Kuip, A M van Furth, Evelien Sprenkeler, Judith Zandstra, G van Mierlo, J Geissler

Affiliations

¹ Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, P.O. Box 2060, 3000 CB, Rotterdam, the Netherlands.
² Department of Paediatric Infectious Diseases and Immunology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.
³ Division of Paediatric Infectious Diseases, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.
⁴ German Centre for Infection Research, DZIF, Partner Site Munich, Munich, Germany.
⁵ Institute of Infection, Veterinary and Ecological Sciences Liverpool, University of Liverpool, Liverpool, UK.
⁶ Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
⁷ Second Department of Paediatrics, National and Kapodistrian University of Athens, P. and A. Kyriakou Children's Hospital, Athens, Greece.
⁸ Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
⁹ Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
¹⁰ NIHR Newcastle Biomedical Research Centre Based at Newcastle Upon Tyne Hospitals NHS Trust and Newcastle University, Westgate Rd, Newcastle upon Tyne, NE4 5PL, UK.
¹¹ Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, RadboudUMC, Nijmegen, the Netherlands.
¹² Paediatric Infectious Diseases and Immunology, Amalia Children's Hospital, RadboudUMC, Nijmegen, the Netherlands.
¹³ Paediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands.
¹⁴ Section of Paediatric Infectious Diseases, Imperial College, London, UK.
¹⁵ Department of General Paediatrics, Medical University of Graz, Graz, Austria.
¹⁶ Department of Medicine, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.
¹⁷ Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, London, UK.
¹⁸ Vaccines, Infections and Paediatrics Research Group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela. Genetics, Santiago de Compostela, Spain.
¹⁹ Department of Infectious Diseases and Faculty of Medicine, University Medical Centre Ljubljana, University of Ljubljana, Ljubljana, Slovenia.
²⁰ London School of Hygiene and Tropical Medicine, Faculty of Tropical and Infectious Disease, London, UK.
²¹ Rīgas Stradiņa universitāte, Department of Paediatrics, Children Clinical University Hospital, Riga, Latvia.
²² Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, P.O. Box 2060, 3000 CB, Rotterdam, the Netherlands. h.a.moll@erasmusmc.nl.

PMID: 36178539
PMCID: PMC9649464
DOI: 10.1007/s00431-022-04606-5

Erratum in

Correction to: Guideline adherence in febrile children below 3 months visiting European Emergency Departments: an observational multicenter study.
Tan CD, van der Walle EEPL, Vermont CL, von Both U, Carrol ED, Eleftheriou I, Emonts M, van der Flier M, de Groot R, Herberg J, Kohlmaier B, Levin M, Lim E, Maconochie IK, Martinon-Torres F, Nijman RG, Pokorn M, Rivero-Calle I, Tsolia M, Yeung S, Zenz W, Zavadska D, Moll HA; PERFORM consortium (Personalised Risk assessment in febrile children to optimize Real-life Management across the European Union). Tan CD, et al. Eur J Pediatr. 2022 Dec;181(12):4211-4214. doi: 10.1007/s00431-022-04664-9. Eur J Pediatr. 2022. PMID: 36269427 Free PMC article. No abstract available.

Abstract

Febrile children below 3 months have a higher risk of serious bacterial infections, which often leads to extensive diagnostics and treatment. There is practice variation in management due to differences in guidelines and their usage and adherence. We aimed to assess whether management in febrile children below 3 months attending European Emergency Departments (EDs) was according to the guidelines for fever. This study is part of the MOFICHE study, which is an observational multicenter study including routine data of febrile children (0-18 years) attending twelve EDs in eight European countries. In febrile children below 3 months (excluding bronchiolitis), we analyzed actual management compared to the guidelines for fever. Ten EDs applied the (adapted) NICE guideline, and two EDs applied local guidelines. Management included diagnostic tests, antibiotic treatment, and admission. We included 913 children with a median age of 1.7 months (IQR 1.0-2.3). Management per ED varied as follows: use of diagnostic tests 14-83%, antibiotic treatment 23-54%, admission 34-86%. Adherence to the guideline was 43% (374/868) for blood cultures, 29% (144/491) for lumbar punctures, 55% (270/492) for antibiotic prescriptions, and 67% (573/859) for admission. Full adherence to these four management components occurred in 15% (132/868, range 0-38%), partial adherence occurred in 56% (484/868, range 35-77%).

Conclusion: There is large practice variation in management. The guideline adherence was limited, but highest for admission which implies a cautious approach. Future studies should focus on guideline revision including new biomarkers in order to optimize management in young febrile children.

What is known: • Febrile children below 3 months have a higher risk of serious bacterial infections, which often leads to extensive diagnostics and treatment. • There is practice variation in management of young febrile children due to differences in guidelines and their usage and adherence.

What is new: • Full guideline adherence is limited, whereas partial guideline adherence is moderate in febrile children below 3 months across Europe. • Guideline revision including new biomarkers is needed to improve management in young febrile children.

Keywords: Children; Emergency care; Fever; Guideline; Pediatrics.

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Conflict of interest statement

The authors declare no competing interests.

Figures

**Fig. 1**
Guideline adherence in children below 3 months (N = 868)

**Fig. 2**
Guideline adherence stratified for working diagnosis (N = 868)

See this image and copyright information in PMC

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[1] Massin MM, Montesanti J, Gérard P, Lepage P. Spectrum and frequency of illness presenting to a pediatric emergency department. Acta Clin Belg. 2006;61(4):161–165. doi: 10.1179/acb.2006.027. - DOI - PubMed

[2] Massin MM, Montesanti J, Gérard P, Lepage P. Spectrum and frequency of illness presenting to a pediatric emergency department. Acta Clin Belg. 2006;61(4):161–165. doi: 10.1179/acb.2006.027. - DOI - PubMed

[3] Sands R, Shanmugavadivel D, Stephenson T, Wood D. Medical problems presenting to paediatric emergency departments: 10 years on. Emerg Med J. 2012;29(5):379–382. doi: 10.1136/emj.2010.106229. - DOI - PubMed

[4] Sands R, Shanmugavadivel D, Stephenson T, Wood D. Medical problems presenting to paediatric emergency departments: 10 years on. Emerg Med J. 2012;29(5):379–382. doi: 10.1136/emj.2010.106229. - DOI - PubMed

[5] Poropat F, Heinz P, Barbi E, Ventura A. Comparison of two European paediatric emergency departments: does primary care organisation influence emergency attendance? Ital J Pediatr. 2017;43(1):29. doi: 10.1186/s13052-017-0339-y. - DOI - PMC - PubMed

[6] Poropat F, Heinz P, Barbi E, Ventura A. Comparison of two European paediatric emergency departments: does primary care organisation influence emergency attendance? Ital J Pediatr. 2017;43(1):29. doi: 10.1186/s13052-017-0339-y. - DOI - PMC - PubMed

[7] Borensztajn DM, Hagedoorn NN, Rivero Calle I, Maconochie IK, von Both U, Carrol ED, et al. Variation in hospital admission in febrile children evaluated at the Emergency Department (ED) in Europe: PERFORM, a multicentre prospective observational study. PLoS ONE. 2021;16(1):e0244810. doi: 10.1371/journal.pone.0244810. - DOI - PMC - PubMed

[8] Borensztajn DM, Hagedoorn NN, Rivero Calle I, Maconochie IK, von Both U, Carrol ED, et al. Variation in hospital admission in febrile children evaluated at the Emergency Department (ED) in Europe: PERFORM, a multicentre prospective observational study. PLoS ONE. 2021;16(1):e0244810. doi: 10.1371/journal.pone.0244810. - DOI - PMC - PubMed

[9] Hagedoorn NN, Borensztajn DM, Nijman R, Balode A, von Both U, Carrol ED, et al. Variation in antibiotic prescription rates in febrile children presenting to emergency departments across Europe (MOFICHE): a multicentre observational study. PLoS Med. 2020;17(8):e1003208. doi: 10.1371/journal.pmed.1003208. - DOI - PMC - PubMed

[10] Hagedoorn NN, Borensztajn DM, Nijman R, Balode A, von Both U, Carrol ED, et al. Variation in antibiotic prescription rates in febrile children presenting to emergency departments across Europe (MOFICHE): a multicentre observational study. PLoS Med. 2020;17(8):e1003208. doi: 10.1371/journal.pmed.1003208. - DOI - PMC - PubMed

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Guideline adherence in febrile children below 3 months visiting European Emergency Departments: an observational multicenter study

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Guideline adherence in febrile children below 3 months visiting European Emergency Departments: an observational multicenter study

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