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Adherence to Guidelines for Managing the Well-Appearing Febrile Infant: Assessment Using a Case-Based, Interactive Survey

Meehan, William Paul III MD; Fleegler, Eric MD, MPH; Bachur, Richard G. MD

doi: 10.1097/PEC.0b013e3181fe90d1
Original Articles

Objectives: The objectives of the study were (1) to determine the relative use of strategies for managing the well-appearing febrile infant and (2) to determine clinician adherence to protocol recommendations.

Methods: Members of the American Academy of Pediatrics Section on Emergency Medicine were asked to complete an online, interactive, case-based questionnaire. Infants with a temperature of 38.6°C who were otherwise completely well were presented. Respondents ordered laboratory studies and received results. Treatment and disposition decisions based on those results were queried. Clinicians reported which published set of guidelines they followed. Major discriminating features of guidelines were used to assess adherence.

Results: Two hundred ninety-nine (30%) clinicians completed the survey. The relative use of the 3 main guidelines was as follows: Philadelphia, 20%; Rochester, 15%; and Boston, 13%. Of respondents reporting that their practice is based on the Rochester criteria, 98% performed a lumbar puncture, 86% administered antibiotics, and 93% admitted the 25-day-old infant to the hospital, despite recommendations that a lumbar puncture was unnecessary and that the infant be managed as an outpatient without antibiotics. Similar deviations were seen among respondents who reported using the other criteria.

Many respondents treated the infants with antibiotics, without obtaining cerebrospinal fluid for culture, despite recommendations against this practice.

Conclusions: Although most physicians report following published guidelines for the management of the well-appearing febrile infant, compliance with recommendations is poor. The effect that deviating from the guidelines has on patient outcome is unknown. Despite recommendations to the contrary, many physicians administer antibiotics without obtaining cerebrospinal fluid for culture.

From the Division of Emergency Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA.

Reprints: William Paul Meehan, III, MD, Division of Emergency Medicine, MA-001, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115 (e-mail:

Results from this study were presented at the Pediatric Academic Societies' Annual Meeting, May 2009, Baltimore, MD.

The authors have no financial interests or conflicts of interest to disclose.

© 2010 Lippincott Williams & Wilkins, Inc.