Serious bacterial infection risk in recently immunized febrile infants in the emergency department

Kyla Casey; Erin R Reilly; Katherine Biggs; Michelle Caskey; Jonathan D Auten; Kevin Sullivan; Theodore Morrison; Ann Long; Sherri L Rudinsky

doi:10.1016/j.ajem.2024.03.025

Serious bacterial infection risk in recently immunized febrile infants in the emergency department

Am J Emerg Med. 2024 Mar 24:80:138-142. doi: 10.1016/j.ajem.2024.03.025. Online ahead of print.

Authors

Kyla Casey¹, Erin R Reilly², Katherine Biggs³, Michelle Caskey⁴, Jonathan D Auten³, Kevin Sullivan², Theodore Morrison², Ann Long², Sherri L Rudinsky⁵

Affiliations

¹ Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, United States of America. Electronic address: kyla.j.casey.mil@health.mil.
² Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, United States of America.
³ Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, United States of America; Department of Emergency Medicine, Naval Medical Center Portsmouth, 620 John Paul Jones Cir, Portsmouth, VA 2370, United States of America.
⁴ Department of Emergency Medicine, Naval Medical Center Portsmouth, 620 John Paul Jones Cir, Portsmouth, VA 2370, United States of America.
⁵ Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, United States of America; Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, 4301 Jones Bridge Rd, Bethesda, MD 20814, United States of America.

PMID: 38583343
DOI: 10.1016/j.ajem.2024.03.025

Abstract

Study objectives: Fever following immunizations is a common presenting chiefcomplaint among infants. The 2021 American Academy of Pediatrics (AAP) febrile infant clinical practice guidelines exclude recently immunized (RI) infants. This is a challenge for clinicians in the management of the febrile RI young infant. The objective of this study was to assess the prevalence of SBI in RI febrile young infants between 6 and 12 weeks of age.

Methods: This was a retrospective chart review of infants 6-12 weeks who presented with a fever ≥38 °C to two U.S. military academic Emergency Departments over a four-year period. Infants were considered recently immunized (RI) if they had received immunizations in the preceding 72 h prior to evaluation and not recently immunized (NRI) if they had not received immunizations during this time period. The primary outcome was prevalence of serious bacterial infection (SBI) further delineated into invasive-bacterial infection (IBI) and non-invasive bacterial infection (non-IBI) based on culture and/or radiograph reports.

Results: Of the 508 febrile infants identified, 114 had received recent immunizations in the preceding 72 h. The overall prevalence of SBI was 11.4% (95% CI = 8.9-14.6) in our study population. The prevalence of SBI in NRI infants was 13.7% (95% CI = 10.6-17.6) compared to 3.5% (95% CI = 1.1-9.3) in RI infants. The relative risk of SBI in the setting of recent immunizations was 0.3 (95% CI = 0.1-0.7). There were no cases of invasive-bacterial infections (IBI) in the RI group with all but one of the SBI being urinary tract infections (UTI). The single non-UTI was a case of pneumonia in an infant who presented with respiratory symptoms within 24 h of immunizations.

Conclusion: The risk of IBI (meningitis or bacteremia) in RI infants aged 6 to 12 weeks is low. Non-IBI within the first 24 h following immunization was significantly lower than in febrile NRI infants. UTIs remain a risk in the RI population and investigation with urinalysis and urine culture should be encouraged. Shared decision making with families guide a less invasive approach to the care of these children. Future research utilizing a large prospective multi-center data registry would aid in further defining the risk of both IBI and non-IBI among RI infants.

Keywords: Bacteremia; Bacterial infections; Fever; Immunization; Infant; Pediatric emergency medicine.