Laboratory Tests Are Important

The Febrile Child: Diagnosis and Treatment by Prof. Dr. med. Tim Niehues in Volume 45/2013

The medical standard for the diagnostic evaluation and treatment should be deduced from the published scientific literature, if possible. At least 5 studies published between 1982 and 1998 showed that the physical examination of a febrile infant has insufficient sensitivity to detect severe bacterial infections. To rely on this alone to determine the treatment of a child is therefore a mistake that we cannot really follow.

The answer to the question whether inpatient admission and immediate administration of antibiotics is necessary in sick children aged 1–3 months is a resounding yes. But when does an infant appear sick? The learning objective has to be: the physical examination alone is not enough to base decisions on as to whether outpatient treatment or admission to a pediatric hospital is needed

In terms of laboratory testing we wish to add that the interdisciplinary guideline on bacterial infections in neonates (No 024–008 in the registry of the Association of the Scientific Medical Societies [AWMF]) contains information on the sensitivity and specificity of the different variables that are appropriate for the early detection of bacterial infections and that have been deduced from 19 publications. Familiarity with this guideline and the approach to be concluded from it should be the learning objective

The last sentence in step 3: “The individual or combined testing […] seems unnecessary and unjustified anywhere but in the intensive-care setting” remains without any scientific proof. It further suggests that there are differences in the urgency of laboratory diagnostic evaluation in neonates in intensive care units and in outpatient care. This is not the case: the urgency is always the same, because physical examination is not enough. Furthermore, the sentence contradicts the results of randomized studies in neonates (1–3).

In sum, the learning objective is that the outpatient treatment of a febrile infant meets the medical standard only once bacterial infection has been excluded by means of laboratory testing.

DOI: 10.3238/arztebl.2014.0252a

Prof. Dr. med. F. Pohlandt

Ulm

Conflict of interest statement

The author is the guideline representative of the German Society for Neonatology and Pediatric Intensive Care Medicine (GNPI).

References

1. Franz AR, Steinbach G, Kron M, Pohlandt F: Reduction of unnecessary antibiotic therapy in newborn infants using interleukin-8 and C-reactive protein as markers of bacterial infections. Pediatrics 1999; 104: 447–53

2. Philip AG, Mills PC: Use of C-reactive protein in minimizing antibiotic exposure: experience with infants initially admitted to a well-baby nursery. Pediatrics 2000; 106: E4

3. Franz AR, Bauer K, Schalk A, et al.: Measurement of interleukin 8 in combination with C-reactive protein reduced unnecessary antibiotic therapy in newborn infants: a multicenter, randomized, controlled trial. Pediatrics 2004; 114: 1–8

4. Niehues T: The febrile child: diagnosis and treatment. Dtsch Arztebl Int 2013; 110(45): 764–74