Choosing Wisely:

Don’t continue hospitalization in well-appearing febrile infants once bacterial cultures (i.e., blood, cerebrospinal, and/or urine) have been confirmed negative for 24 to 36 hours, if adequate outpatient follow-up can be assured.

Rationale and Comments: Routinely continuing hospitalization beyond 24 to 36 hours of confirmed negative bacterial cultures for well-appearing infants admitted for concern of serious bacterial infection does not improve clinical outcomes. Blood culture yield is highest in the first 12 to 36 hours after incubation with multiple studies demonstrating > 90% of pathogen cultures being positive by 24 hours. If adequate outpatient follow-up can be assured, discharging well-appearing febrile infants at 24 to 36 hours if cultures are confirmed to be negative will decrease length of stay, antibiotic exposure, and iatrogenic complications.
Sponsoring Organizations:
  • Pediatric Hospital Medicine – SHM, AAP, APA
  • Sources:
  • Retrospective cohort study
  • Disciplines:
  • Pediatric
  • References: • Vachani JG, et al. Current evidence on the evaluation and management of fever without a source in infants aged 0-90 days: a review. Rev Recent Clin Trials. 2017;12(4):240-245.
    • Biondi EA, et al.; Pediatric Research in Inpatient Settings (PRIS) Network. Blood culture time to positivity in febrile infants with bactremia. JAMA Pediatr. 2014;168(9):844-849.
    • Fielding-Singh V, et al. Ruling out bacteremia and bacterial meningitis in infants less than one month of age: is 48 hours of hospitalization necessary? Hosp Pediatr. 2013;3(4):355-361.
    • Greenhow TL, et al. Changing epidemiology of bacteremia in infants aged 1 week to 3 months. Pediatrics. 2012;129(3):e590-596.
    • Mahajan P, et al.; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). Risk of bacterial coinfections in febrile infants 60 days old and younger with documented viral infections. J Pediatr. 2018;203:86-91.e2.
    • Lefebvre CE, et al. Time to positivity of blood cultures in infants 0 to 90 days old presenting to the emergency department: is 36 hours enough? J Pediatric Infect Dis Soc. 2017;6(1):28-32.

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