Guidelines Do Not Always Do the Trick: Implementation of the PECARN Clinical Prediction Rule for Febrile Infants At Low Risk for Serious Bacterial Illness

From the 2021 HVPAA National Conference

Gargi Mukherjee (Emory University/Childrens Healthcare of Atlanta), Evan Orenstein, Shabnam Jain, Nicole Hames

Background

Because of young febrile infants’ risk for serious bacterial infections (SBI), management often involves a lumbar puncture (LP), empiric antibiotics, and admission. Several clinical prediction rules exist to identify infants at low risk for SBI to avoid unnecessary interventions, including the recent PECARN prediction rule developed by Kuppermann et al that incorporates procalcitonin. While evidence supports that procalcitonin may improve identification of low-risk infants, the implementation of this prediction rule has not been studied.

Objective

To evaluate the impact of implementing the PECARN prediction rule on resource utilization, specifically LP rate, empiric antibiotic use, and admissions, in the management of young febrile infants.

Methods

This pre-post intervention study was performed at a single academic health system composed of three children’s hospitals. We included infants 29 to 60 days old who presented to the emergency department (ED) with a chief complaint of fever from November 2018 to January 2021 and had a blood and urine culture performed during that visit. These labs implied presence of true fever, no definite source, and clinical decision to assess for SBI. Our updated clinical practice guideline for infants 29 to 60 days, including procalcitonin based on the PERCARN prediction rule, was implemented in December 2019 (procalcitonin test was available at all three site by January 2020). LP attempts, antibiotic administration, ED disposition, and labs were extracted from EPIC Clarity Database. We utilized statistical process control charts to study the change in LP rates, empiric antibiotic administration, and admission rate.

Results

Out of 1200 infants who presented with fever, 807 were assessed for SBI and included in the study. The average age was 44±9 days old. The baseline mean LP rate, empiric antibiotic rate, and admission rate were 28.8%, 29.8%, and 27.3%, respectively. After implementation of the guideline, special cause variation was not observed in either of these three measures (Figure 1). Post-implementation mean LP, empiric antibiotic administration, and admission rates were 23.2%, 30.4%, and 34.3%, respectively. New guideline compliance was demonstrated by an average procalcitonin order rate of 86.2% (Figure 2). Also, there was no difference in missed SBI pre- and post-implementation (3 cases vs 1 case).

Conclusion

In this study, the addition of procalcitonin and compliance with the guideline did not result in a significant change in LP rates, empiric antibiotic rates, and admission rate. This may potentially be explained by low baseline rates of these interventions at our center compared to rates reported nationally.

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