Top Papers Of The Month

Top Papers You May Have Missed in July 2021

AUTHOR:
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA

CITATION:
Vergano ST. Top papers you may have missed in July 2021. Consultant360.com. Published online August 18, 2021.

This month, I am excited to share 2 articles of significance that warrant specific attention. The American Academy of Pediatrics (AAP) has never previously published guidelines for the evaluation of the young febrile infant, and the Centers for Disease Control and Prevention (CDC) has not updated its guidelines for the treatment of sexually transmitted infections since 2015. As always, please discuss them with your colleagues and share your thoughts with us: editor@consultant360.com.

Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old1

The long-anticipated AAP Clinical Practice Guideline on the Management of the Well-Appearing Febrile ​Infant was released July 19, 2021. It is well worth a read with particular attention to the 3 algorithms included, which provide the main action points for the statement.​

To understand the appropriate use of the algorithms, the following comments are important:

  1. This guideline applies only to well-appearing term infants aged 8 to 60 days who do not have underlying conditions, risk factors for infection, or the presence of a focal bacterial infection (aside from otitis media).
  2. The guideline leans heavily on the use of inflammatory markers, with a preference for procalcitonin. If procalcitonin is not available, the combination of C-reactive protein and absolute neutrophil count is used. A temperature greater than 38.5 °C is also considered a positive inflammatory marker. Finally, the total white blood cell (WBC) count is not of sufficient discriminatory value to be used for risk stratification.
  3. The approach is different in each of the 3 age groups: 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age.​
  4. Because the incidence of urinary tract infection (UTI) is significantly higher than bacteremia or meningitis, the evaluation of a urine specimen is at the top of each algorithm. For febrile infants aged 29 days or older, the urine for urinalysis may be obtained by bag, spontaneous void, or stimulated void. If the urinalysis is negative for leukocyte esterase or WBCs, then a catheterized urine culture does not need to be obtained.

The bottom line is that any infant who does not appear well, any infant who is preterm, or any infant with risk factors for infection requires a full diagnostic evaluation.

Algorithm 1: Infants aged 8 to 21 days generally require a full diagnostic evaluation and empiric antibiotic therapy in the hospital.

Algorithm 2: Select infants aged 22 to 28 days may not require a full evaluation or admission but only if they are at low risk, have adequate follow-up, and the risks of not doing a full evaluation are discussed with the family.

Algorithm 3: Many infants aged 29 to 60 days can be safely managed without a lumbar puncture (LP), empiric antibiotic therapy, or hospital admission. In particular, if the urinalysis and inflammatory markers are both negative (which does not include infants with fever greater than 38.5 °C), the algorithm recommends against LP, antibiotics, or admission. The guideline does not comment on the need for evaluation in emergency departments vs in community-based practices.

Finally, the guideline recommends abandoning the term “serious bacterial infection” and instead prefers a discussion of UTI, bacteremia, and meningitis separately.

If you have the interest and time, and particularly if you are a community-based provider and might consider not sending a febrile infant to the emergency department, a careful read of the guideline and review of the algorithms is well worth your time.

2021 Treatment Guidelines for Sexually Transmitted Infections2

The CDC published updated guidelines for treatment of sexually transmitted infections (STIs) on July 23, 2021. The guidelines consolidate recommendations that have been issued since the most recent publication in 2015, including changes to the antibiotic recommendations for treatment of gonorrheal and chlamydial infections. Changes of note include:

  1. Because of altered resistance patterns, the recommended treatment for gonorrhea in the absence of other concurrent infections is ceftriaxone, 500 mg, intramuscular once for patients weighing less than 150 kg and ceftriaxone, 1 g, intramuscular once for patients weighing 150 kg or more.
  2. Because of decreasing efficacy of azithromycin, the recommended treatment for chlamydial infections is oral doxycycline, 100 mg, twice daily for 7 days.
  3. To provide better anaerobic coverage, metronidazole has been added to the recommended regimen for both parenteral and oral therapy of pelvic inflammatory disease.
  4. Diagnosis of gonorrheal and chlamydial infections has been facilitated by the approval of certain nucleic acid amplification tests for rectal and pharyngeal specimens, obviating the need for culture diagnosis from these sites.
  5. New screening recommendations for hepatitis C virus state that testing should be done for all pregnant women with each pregnancy and for all adults aged 18 years or older at least once.
  6. Links are provided to state-specific laws regarding adolescent consent for receipt of sexually transmitted infection services3 and the legality of expedited partner therapy for gonorrheal and chlamydial infections.4

References:

  1. Pantell RH, Roberts KB, Adams WG, et al; Subcommittee on Febrile Infants. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics. 2021;148(2):e2021052228. https://doi.org/10.1542/peds.2021-052228
  2. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. https://doi.org/10.15585/mmwr.rr7004a1
  3. State laws that enable a minor to provide informed consent to receive HIV and STD services. Centers for Disease Control and Prevention. Updated January 8, 2021. Accessed August 16, 2021. https://www.cdc.gov/hiv/policies/law/states/minors.html
  4. Expedited partner therapy. Sexually Transmitted Diseases. Centers for Disease Control and Prevention. Updated April 19, 2021. Accessed August 16, 2021. https://www.cdc.gov/std/ept/