Mukherjee Gargi, Orenstein Evan, Jain Shabnam, Hames Nicole
From the Department of Pediatrics, Emory University/Children's Healthcare of Atlanta, Atlanta, GA.
Pediatr Emerg Care. 2023 Oct 1;39(10):739-743. doi: 10.1097/PEC.0000000000002905. Epub 2023 Jan 21.
The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule identifies febrile infants at low risk for serious bacterial infection (SBI). However, its impact on avoidable interventions in the emergency department remains unknown.
To study the impact on lumbar puncture (LP) performance, empiric antibiotic use, and admissions after implementing a febrile infant clinical practice guideline for infants aged 29 to 60 days based on the PECARN prediction rule in the pediatric emergency department.
This single center preintervention to postintervention study included infants 29 to 60 days old who presented with a chief complaint of fever from November 2018 to November 2021 and were assessed for SBI via blood culture and either urinalysis or urine culture. A new clinical practice guideline based on the PECARN prediction rule was implemented on December 2019. Lumbar puncture attempts, antibiotic administration, and admissions were compared preimplementation and postimplementation and in subgroups of low- and high-risk patients.
Of 1597 (PRE: 785, POST: 812) infants presenting with fever, 1032 (PRE: 500, POST: 532) met inclusion criteria. Adoption of guideline recommendations (measured as procalcitonin order rate) was 89.7% in eligible infants postimplementation. Overall, there was a significant decrease in LPs (PRE: 30.6%, POST: 22.6%, P < 0.05) and no significant change in antibiotics or admissions. Among low-risk infants, there was a significant reduction in LPs (PRE: 17.2%, POST: 4.4%, P < 0.05) and antibiotics (PRE: 14.5%, POST: 4.1%; P < 0.05). There was no change in missed SBI (PRE: 3, POST: 2, P = 0.65). No cases of missed meningitis preimplementation or postimplementation were observed.
After implementation of a guideline based on the PECARN prediction rule, we observed a reduction of LPs and antibiotics in low-risk infants. Overall, a decrease in LPs was observed, whereas antibiotic use and admissions remained unchanged.
儿科急诊护理应用研究网络（PECARN）预测规则可识别严重细菌感染（SBI）低风险的发热婴儿。然而，其对急诊科可避免干预措施的影响尚不清楚。
研究在儿科急诊科实施基于PECARN预测规则的29至60日龄发热婴儿临床实践指南后，对腰椎穿刺（LP）操作、经验性抗生素使用及住院情况的影响。
本单中心干预前至干预后的研究纳入了2018年11月至2021年11月以发热为主诉就诊的29至60日龄婴儿，并通过血培养及尿液分析或尿培养评估是否存在SBI。基于PECARN预测规则的新临床实践指南于2019年12月实施。比较实施前后以及低风险和高风险患者亚组中的腰椎穿刺尝试、抗生素使用及住院情况。
在1597名（干预前：785名，干预后：812名）发热婴儿中，1032名（干预前：500名，干预后：532名）符合纳入标准。实施后符合条件的婴儿中采用指南建议（以降钙素原检测率衡量）的比例为89.7%。总体而言，LP操作显著减少（干预前：30.6%，干预后：22.6%，P<0.05），抗生素使用及住院情况无显著变化。在低风险婴儿中，LP操作（干预前：17.2%，干预后：4.4%，P<0.05）和抗生素使用（干预前：14.5%，干预后：4.1%；P<0.05）均显著减少。漏诊的SBI情况无变化（干预前：3例，干预后：2例，P=0.65）。干预前后均未观察到漏诊脑膜炎病例。
实施基于PECARN预测规则的指南后，我们观察到低风险婴儿的LP操作和抗生素使用减少。总体而言，LP操作减少，而抗生素使用和住院情况保持不变。
