Ambulatory Care of Selected Febrile Outpatient Neonates Unlikely to Have Bacterial Infections

A prospective study was undertaken to evaluate the usefulness of the low risk criteria for identifying febrile neonates unlikely to have bacterial infections, particularly bacteremia and meningitis. One hundred and twelve consecutive infants 7-28 days of age who had rectal temperatures of at least 38°C were enrolled. After a complete history, physical examination, and laboratory work-up, the 112 febrile neonates with clinical and laboratory findings indicating at low risk for bacterial infections were not routinely hospitalized, except those who had a persistent fever >48 h or a clinical deterioration at follow-up visits. The low risk criteria used to identify these neonates included well appearance, absence of physical signs of an ear, eye or soft tissue infection, a white blood cell count of 5,000 to 15,000/ mm ³, a band-form count of less than 1,500/mm³, a spun urine specimen that had fewer than 10 white blood cells per high-power field on microscopy, and a C-reactive protein value of less than 20 mg/L. The overall incidence of bacterial infections in the 112 selected febrile neonates was 2.7% (3 neonates) with bacteremia and/or meningitis occurring in 0.9% (1 neonate). Seventy-two infants enrolled were subsequently admitted because of the following reasons: parents' concern or anxiety (29), a continued fever only (37), and decreased activity and/or feeding (6). Among them, only two were diagnosed to have a urinary tract infection and one, bacteremia and meningitis. All the three neonates recovered fully with no relapses observed after the antimicrobial therapy. For those 40 neonates who were cared at home and received no antibiotics throughout the course, fever resolved spontaneously or after supportive treatment. A substantial number of febrile neonates at low risk for bacterial infections can be identified by the low risk criteria. Management of these neonates as outpatients without antibiotic therapy seems feasible, provided careful observation at home and close follow-up can be assured.