Songs of guidelines and experience

Doctors can rely on their own know-how rather than guidelines when it comes to fever in kids, according to a US think tank

By Tony Craig

It's not often you hear a government health agency telling doctors to ignore clinical guidelines, but that's the message the US Agency for Healthcare Research and Quality (AHRQ) is sending American pediatricians on the treatment of fever in young infants.

Diagnosing the underlying causes of fever in young children is notoriously difficult, and over the years diagnostic guidelines have grown more and more complicated and expensive to implement. At the same time, the possibility of serious bacterial infection has led some guidelines to suggest taking no chances and using intravenous antibiotics in uncertain cases.

The result has been a steady trend toward more lab tests, more drugs, and more hospitalizations, all of which can carry risks and don't come cheap. American clinical practice guidelines for treating infants with fevers recommend hospitalization and treatment with antibiotics for all infants under one month of age. Laboratory tests are routinely performed on all feverish infants younger than three months.

But fewer than 3% of infants with fevers actually have bacterial meningitis or bacterial blood infections. For the rest, overtreatment simply increases the cost, the spread of antibiotic resistance — and the danger of nosocomial infection, an infection that can occur during hospitalization.

A new study sponsored by the AHRQ and published in the March 10 issue of the Journal of the American Medical Association asked a question that might seem rather bold in this age of litigation: what would happen if experienced pediatricians were simply allowed to get on with treating children based on their own clinical judgement, regardless of clinical guidelines?

Researchers worked with more than 573 doctors' offices in 44 states from 1995 to 1998. The infants in the study, who numbered more than 3,000, were aged three months or younger and had no health problems other than a fever of at least 38¹C.

The researchers found that 42% of the time, clinicians followed clinical practice guidelines to treat infants with fevers. Those clinicians performed lab tests in 75% of the infants and treated 57% with antibiotics. But in the first month of life, 40% fewer infants were hospitalized when clinicians did not follow guidelines.

Overall, 63 of the infants (2.3%) were found to have bacteremia or bacterial meningitis. No fewer than 61 of these had been treated with antibiotics on their first visit to the doctor, even though the doctors gave antibiotics to slightly more than half of all the infants in the study.

Instead of admitting them to hospital, these clinicians saw many infants in repeated office visits and had frequent telephone follow-up. It turned out that the infants who were treated in the office and with follow-up visits were no more likely to suffer adverse outcomes than those treated following the guidelines.

"While clinical guidelines are an important part of everyday practice, they are only one element of the foundation of evidence available to clinicians," said AHRQ Director Dr Carolyn Clancy. "Clinicians should rely on their training and judgement and work closely with parents to tailor evidence-based recommendations to patients' needs."