In the ever-evolving landscape of pediatric medicine, where every guideline and recommendation can have a ripple effect across clinical practice, it’s crucial to keep a finger on the pulse of change. One of the more interesting shifts we've seen recently is in the evaluation and management of febrile infants, particularly in how we assess their risk for invasive bacterial infections (IBI) like bacteremia and bacterial meningitis.
Though the incidence of IBI has been on the decline1, the stakes are still high when it comes to identifying which infants are at greatest risk and need early intervention. As pediatricians, we all remember the buzz in August 2021 when the American Academy of Pediatrics (AAP) published its clinical practice guideline (CPG)2 on this very topic. Among its significant takeaways was the strong endorsement of inflammatory markers, including procalcitonin (PCT), in its age-based algorithms.
Fast forward to this month’s issue of Hospital Pediatrics, where a new study titled “Procalcitonin Use after Clinical Practice Guideline and QI Intervention for Febrile Infants” takes a deep dive into how the publication of this guideline has influenced the use of PCT at both patient and hospital levels (10.1542/hpeds.2024-007906). The study was part of a larger effort, the REducing Variability in Infant Sepsis Evaluation II (REVISE II) collaborative3, which aimed to standardize and improve the care of febrile infants across multiple sites.
The study found that over a two-year period, the proportion of infants who had a PCT obtained saw significant increases across all age groups specified in the CPG, with the most notable uptick among those aged 22–28 days. But let’s take a step back—why is this so intriguing? Well, the speed at which PCT usage ramped up after the CPG’s publication suggests that pairing guideline releases with quality improvement (QI) collaboratives like REVISE II could be a powerful strategy for ensuring the timely uptake of evidence-based practices.
As we continue to ride this wave of change, it’s clear that while guidelines and collaboratives can drive practice change, they also bring to light areas where we can improve. For instance, the youngest infants (those 8–21 days old) saw a significant increase in PCT use despite it being only a weak recommendation in the CPG. This raises questions about whether we might be over-testing in this age group, potentially driving up healthcare costs without a clear benefit. Furthermore, despite the overall increase in PCT use, there was substantial variation across hospitals, pointing to possible gaps in care delivery.
As we move forward, perhaps the next wave of studies should investigate how this increase in PCT use impacts clinician decision-making and outcome for well-appearing febrile infants.
References
- McCulloh RJ, McDaniel LM, Kerns E, Biondi EA. Prevalence of Invasive Bacterial Infections in Well-Appearing, Febrile Infants. Hospital Pediatrics. 2021;11(9):e184-e188. doi:10.1542/hpeds.2020-002147
- Pantell RH, Roberts KB, Adams WG, et al. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. 2021;148(2):e2021052228. doi:10.1542/peds.2021-052228
- McDaniel CE, Kerns E, Jennings B, et al. Improving Guideline-Concordant Care for Febrile Infants Through a Quality Improvement Initiative. Pediatrics. 2024;153(5):e2023063339. doi:10.1542/peds.2023-063339
