Delayed ED presentation may increase SBI risk in febrile infants

Delayed presentation to the emergency department (ED) >24 hours after fever onset was associated with an increased risk of serious bacterial infection (SBI) in febrile infants, according to a Singapore study.

“Delayed presentation potentially leads to delayed investigations and administration of empirical antibiotics, resulting in a higher risk of sepsis and death,” according to the researchers.

Fever is one of the most common paediatric ED presentations. Identifying a focus of infection can be challenging, especially for very young children. While most children fully recover, infection remains the leading cause of death in children aged <5 years. [https://www.childrens.health.qld.gov.au/for-health-professionals/queensland-paediatric-emergency-care-qpec/queensland-paediatric-clinical-guidelines/febrile-illness]

The researchers conducted a prospective study involving 1,911 febrile infants (aged ≤90 days) seen in the paediatric ED of KK Women’s and Children’s Hospital in Singapore between November 2017 and July 2022. [Ann Acad Med Singap 2024;53:286-292]

A total of 198 infants had delayed presentation (defined as presentation to the ED >24 hours from fever onset) and 337 infants had SBIs, such as urinary tract infection (UTI; 89 percent) or meningitis or bacteraemia (11 percent).

Compared with infants without delayed presentation, infants with delayed presentation were more likely to have SBIs (28.8 percent vs 16.3 percent; p<0.001), particularly UTIs (25.8 percent vs 14.5 percent; p<0.001).

Consequently, a significantly higher percentage of infants with delayed presentation required intravenous antibiotic therapy than those without (64.1 percent vs 51.9 percent; p=0.001), but the length of hospital stay was similar between the two groups (median 3–4 and 2–4 days, respectively).

“Early identification enables the timely initiation of antibiotics, which reduces mortality and shortens the duration of hospitalisation,” noted the researchers.

After adjusting for age, sex, and severity index score (SIS), the delayed presentation was independently associated with the presence of SBI (adjusted odds ratio [AOR], 1.78, 95 percent confidence interval [CI], 1.26–2.52; p<0.001).

In particular, male sex and low SIS were associated with SBIs (AOR, 2.47, 95 percent CI, 1.89–3.23 and 0.66, 95 percent CI, 0.57–0.77, respectively; p<0.001 for both).

“Our results showed that febrile infants are at risk of SBIs, with a reported prevalence of 9–25 percent,” the researchers noted. “We chose to focus on the young infant population ≤90 days old, who are at high risk of SBIs due to their immature immunity system, and this group warrants close monitoring and prioritization of investigations and early management.”

“Although the specific association between delayed presentation to the ED and risk of SBI has not been evaluated, several other studies have reported the relationship between duration of fever and SBIs in febrile children,” the researchers noted.

“As such, clinicians should take this into account when assessing febrile infants,” said the researchers. “Future studies should also evaluate the association between delayed presentation and specific types of SBIs.”