Step-by-Step Approach to Febrile Infants

Why did you develop the Step by Step Approach to Febrile Infants? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

We decided to design this tool because we commonly used different biomarkers that were not adequately included in existing protocols, and we wanted to get a good tool to identify young febrile infants suitable for outpatient management.

What pearls, pitfalls and/or tips do you have for users of the Step by Step Approach to Febrile Infants? Do you know of cases when it has been applied, interpreted, or used inappropriately?

We have to clarify better the following:

1. What to to do with the intermediate group after observation in the ED.

2. The role of the ED observation in the low risk group. To identify infants that do not need to be observed in the ED.

3. We have the feedback form other hospitals using the "Step by Step" (abstracts in national meetings) without incidences.

What recommendations do you have for doctors once they have applied the Step by Step Approach to Febrile Infants? Are there any adjustments or updates you would make to the score based on new data or practice changes?

I have to remind them of the importance of the infant’s appearance - the first "box" of the algorithm.

How do you use the Step by Step Approach to Febrile Infants in your own clinical practice? Can you give an example of a scenario in which you use it?
We use it in all young febrile infants. It is better explained with a clinical scenario, such as this: Steinberg J. Young Febrile Infants: Step-by-Step Evaluation. Am Fam Physician. 2018 Jan 1;97(1):45-46.

Why did your research team decide to use the age cut-off of 21 days (versus 28 days) for high-risk patients in this study?

We decided to use it following the results of these two studies:

Garcia S, Mintegi S, Gomez B, Barron J, Pinedo M, Barcena N, Martinez E, Benito J. Is 15 Days an Appropriate Cut-Off Age for Considering Serious Bacterial Infection in the Management of Febrile Infants? Pediatr Infect Dis J. 2012 May;31(5):455-8

Martinez E, Mintegi S, Vilar B, Martinez MJ, Lopez A, Catediano E, Gomez B. Prevalence and Predictors of Bacterial Meningitis in Young Infants with Fever without a Source. Pediatr Infect Dis J. 2015 May;34(5):494-8

How could a risk-calculator like the Step-by-Step approach impact the management of febrile infants, if broadly applied by providers?

To better identify infants suitable for outpatient management and decrease errors.

Any thoughts on the Step-by-Step approach in comparison to similar risk-stratification tools like the Rochester Criteria, Philadelphia Criteria, Lab-score, etc?

We have commented this in some of our papers. The Step-by-Step is more adequate for identifying young febrile infants suitable for outpatient management. Using other risk-stratification tools, you will misclassify more patients.

Any other research in the pipeline that you’re particularly excited about?

We are trying to identify children with pleocytosis suitable for outpatient management. The following is the first step:

Garcia S, Echevarri J, Arana-Arri E, Sota M, Benito J, Mintegi S; Meningitis group of RISEUP-SPERG. Outpatient management of children at low risk for bacterial meningitis. Emerg Med J. 2018 Mar 21. pii: emermed-2017-206834. doi: 10.1136/emermed-2017-206834. [Epub ahead of print]

Santiago Mintegi, MD, PhD, is a pediatric emergency physician and quality manager at Cruces University Hospital in Bilbao, Spain. He also serves as a member of the Research in European Pediatric Emergency Medicine (REPEM) network. Dr. Mintegi's research interests include pediatric bacterial infections, febrile infants, and decision tools.