Management of infants presenting with fever: a review of pan-London hospital guidelines and national guidelines

Abstract

Febrile infants often have self-limiting conditions. Differentiating them from infants with serious bacterial infections can be challenging. We aimed to understand how febrile infants are managed across London, by analysing the management steps from local clinical practical guidelines (CPGs) and comparing them to the national guideline 143 (NG143). The ten hospitals using local CPGs recommended doing blood tests for febrile infants and often had more cautious advice about performing lumbar punctures and starting antibiotics. All CPGs scored lower on quality, as per AGREE-II tool, when compared with NG143. CPGs giving more cautious advice, exposes more infants to invasive investigations and treatments.

Keywords: Infant; Mortality.

Figure 1

This graph displays the AGREE-II scoring on the quality of all local CPGs analysed, along with NICE NG143. Local CPGs score lower on quality than NG143 in all domains but clarity of presentation. There are particularly low scores on the domains of rigour of development, applicability and editorial independence. NICE NG143 consistently scores between 80% and 100% across all domains. CPGs, clinical practical guidelines; NG143, national guideline 143.

Figure 2

This graph displays to which degree 10/25 London hospital local CPGs were compliant with the recommended management steps of the gold-standard NICE NG143 guideline for infants under 3 months. NG143 recommends RS as per the green, amber red traffic-light system and all infants<3 months fall under the red RS, all<3 months should have an FBC, CRP, bloods culture and urine culture; CXR and stool culture if clinically indicated with respiratory signs or diarrhoea, respectively; LP to be performed and parenteral antibiotics to be administered if: <1 m, 1–3 months and unwell, 1–3 months with WCC<5×105 /L or WCC>15×105 /L. There should be no contraindications to LP and LP should ideally be performed prior to administration of antibiotics. NG143 recommends IV acyclovir if febrile and signs suggestive of HSV (Herpes Simplex Virus) encephalitis and gives the clinician the autonomy regarding the decision to admit or ambulate the infant. CPGs, clinical practical guidelines; CRP, C reactive protein; CXR, chest X-ray; FBC, full blood count; LP, lumbar puncture; NG143, national guideline 143; RS, risk stratification, WCC, white cell count.