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AAP Guidelines for Managing Febrile Infants: What if You Cannot Get a Timely C-Reactive Protein or Procalcitonin?

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Last year, Pediatrics published a new American Academy of Pediatrics Clinical Practice Guideline (CPG) for managing well-appearing febrile infants from 8 to 60 days of age. This guideline calls for the integration of several inflammatory markers, including C-reactive protein (CRP) and procalcitonin (PCT), to help determine who has an increased risk for having an invasive bacterial infection. But what if you do not have access to a CRP or PCT value in a timely manner? Can the CPG still perform well without those test results? To answer that question, Nguyen et al (10.1542/peds.2022-058495) from Kaiser Permanente Northern California share with us the results of their retrospective study involving 1,433 infants seen in their emergency departments between 2010 and 2019 with temperatures ≥ 38 C who met CPG inclusion criteria and had complete blood counts, blood cultures, and urinalyses performed. Of these, 57 infants had bacteremia and 9 had bacterial meningitis. How accurate was the CPG without CRP or PCT values? 

The authors point out that while the sensitivity for detection remains high for the use of the CPG to predict who is at risk for severe bacterial infection, the specificity is lower, meaning more infants are subjected to lumbar punctures and potentially unnecessary hospitalizations. They compare the CPG without CRP and PCT with other diagnostic protocols published over the past several decades that also do not include the CRP or PCT and find the CPG results in more invasive interventions than 4 other approaches to the work-up of febrile infants (the Roseville, Rochester, Philadelphia, and Boston guidelines). Are you using the new CPG in your practice without access to timely CRP or PCT? This study emphasizes the benefit of these tests. We welcome your sharing with us which febrile infant protocol you are using and why by responding to this blog or posting a comment on our website or our social media platforms (Instagram, Facebook, or Twitter).

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