About J.D. Cambron, DO

Assistant Professor
Department of Emergency Medicine
Christus Health / Texas A&M University School of Medicine

Pigtail catheter for pleural drainage: Tips to minimize complications


Traditionally large-bore tube thoracostomy has been the standard of care for treating many acute intrathoracic pathologies [1]. However, the advent of less invasive small-bore chest tubes, also known as pigtail catheters, has gradually led to a paradigm shift. Pigtails provide a less invasive and often better tolerated alternative to traditional chest tubes and allow for adequate treatment of pneumothoraces and uncomplicated pleural effusions [1-5]. Unfortunately, these less invasive catheters are not without complications – both unique and similar to traditional chest tubes.


A 48 year-old male with a history of hypertension and polysubstance abuse presented to the emergency department (ED) for shortness of breath and was found to have a left sided parapneumonic pleural effusion (Figure 1). The patient underwent thoracentesis and placement of a pigtail catheter using the Seldinger technique to drain the fluid collection. Pigtail catheter placement was confirmed by chest x-ray (Figure 2).

pleural effusion chest x-ray

Figure 1: Chest x-ray with left sided pleural effusion

pleural effusion chest x-ray pigtail catheter

Figure 2: Chest x-ray with the pigtail catheter in the left chest

Case Progression

Despite pigtail catheter placement, there was minimal drainage from the catheter. In collaboration with the inpatient team, intrapleural thrombolytics were administered via the pigtail catheter did not resolve the issue. Although the patient’s chest x-ray did improve after the procedure, the patient continued to deteriorate clinically and became increasingly hypoxic.

A CT angiogram was then performed and showed that the pigtail catheter had been accidentally introduced through the lung parenchyma and was lodged in the left main stem bronchus (Figure 3). This was confirmed on bronchoscopy (Figure 4).

pigtail catheter chest ct in bronchus

Figure 3: Chest CT angiogram showing the pigtail catheter (arrow) in the left mainstem bronchus

bronchoscopy pigtail

Figure 4: Bronchoscopy view of the left mainstem bronchus showing the pigtail catheter

This case highlights one of the more rare and potentially severe complications of small-bore chest tubes. With the increasing utilization of such devices, this case  highlights the need for better education about the indications, complications, and troubleshooting approaches with these pigtail catheters. 


The overall complication rate for small-bore catheters is lower than their large-bore counterparts, partly because of their smaller caliber. Also unlike traditional large-bore tube thoracostomy, the lack of tactile feedback (not feeling the pleural puncture ‘pop’ with Kelly clamps and then identifying the intrapleural space with the finger) can lead to malpositioning complications. Both approaches, however, share common complications:

  • Most common complication: Chest tube kinking and obstruction [6, 7, 10]
    • Due to the small caliber of the pigtail catheter, it can easily become twisted or kinked between the pleura and lung parenchyma, obstructed within lung fissures, or kinked externally between the body and environment [9].
    • Obstruction may also occur from clotted blood [9] or pleural effusion loculations [12, 13] within the catheter lumen.
      • For loculated effusions and empyemas, an interdisciplinary inpatient discussion should weigh the pros and cons of intrapleural thrombolytics versus surgical drainage and pleurodesis.
      • One often used thrombolytic regimen is the MIST-II protocol, which involves the combination of alteplase (tPA) 10 mg BID plus dornase alfa (DNase) 5 mg BID [13, 14].
  • Laceration of tissue/vessel [2, 3, 6, 8]
    • Can be prevented by using standard landmarks and inserting above the rib margin
  • Air emboli [2, 3, 6, 9]
    • Thought to be due to parenchymal injury resulting in a fistula involving the pulmonary vessels
  • Parenchymal injury [9]


  1. Gammie JS, Banks MC, Fuhrman CR, et al. The pigtail catheter for pleural drainage: a less invasive alternative to tube thoracostomy. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 1999;3(1):57-61. PMID: 10323171
  2. Saqib A, Ibrahim U, Maroun R. An unusual complication of pigtail catheter insertion. Journal of Thoracic Disease. 2018;10(10):5964-5967. doi:https://doi.org/10.21037/jtd.2018.05.65
  3. Broder JS, Al-Jarani B, Lanan B, Brooks K. Pigtail Catheter Insertion Error: Root Cause Analysis and Recommendations for Patient Safety. The Journal of Emergency Medicine. 2020;53(3). doi:https://doi.org/10.1016/j.jemermed.2019.10.003
  4. Vetrugno L, Guadagnin GM, Barbariol F, et al. Assessment of Pleural Effusion and Small Pleural Drain Insertion by Resident Doctors in an Intensive Care Unit: An Observational Study. Clinical Medicine Insights Circulatory, Respiratory and Pulmonary Medicine. 2019;13:1179548419871527. doi:https://doi.org/10.1177/1179548419871527
  5. Kulvatunyou N, Vijayasekaran A, Hansen A, et al. Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend. J Trauma. 2011;71(5):1104-1107. doi:https://doi.org/10.1097/ta.0b013e31822dd130
  6. Remérand F, Luce V, Badachi Y, Lu Q, Bouhemad B, Rouby JJ. Incidence of Chest Tube Malposition in the Critically Ill. Anesthesiology. 2007;106(6):1112-1119. doi:https://doi.org/10.1097/01.anes.0000267594.80368.01
  7. Horsley A, Jones L, White J, Henry M. Efficacy and Complications of Small-Bore, Wire-Guided Chest Drains. Chest. 2006;130(6):1857-1863. doi:https://doi.org/10.1378/chest.130.6.1857
  8. Hyo Jin Kim, Yang Hyun Cho, Gee Young Suh, Jeong Hoon Yang, Jeon K. Subclavian Artery Laceration Caused by Pigtail Catheter Removal in a Patient with Pneumothorax. The Korean Journal of Critical Care Medicine. 2015;30(2):119-122. doi:https://doi.org/10.4266/kjccm.2015.30.2.119
  9. Anderson D, Chen SA, Godoy LA, Brown LM, Cooke DT. Comprehensive Review of Chest Tube Management: A Review. JAMA surgery. 2022;157(3):269-274. doi:https://doi.org/10.1001/jamasurg.2021.7050
  10. Aho JM, Ruparel RK, Rowse PG, Brahmbhatt RD, Jenkins D, Rivera M. Tube Thoracostomy: A Structured Review of Case Reports and a Standardized Format for Reporting Complications. World Journal of Surgery. 2015;39(11):2691-2706. doi:https://doi.org/10.1007/s00268-015-3158-6
  11. Gayer G, Rozenman J, Hoffmann C, et al. CT diagnosis of malpositioned chest tubes. Br J Radiol. 2000;73(871):786-790. doi: https://doi.org/10.1259/bjr.73.871.11089474
  12. Altmann, E. S., Crossingham, I., Wilson, S., & Davies, H. R. (2019). Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema. The Cochrane database of systematic reviews, 2019(10), CD002312. https://doi.org/10.1002/14651858.CD002312.pub4
  13. Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365(6):518-526. https://doi.org/10.1056/NEJMoa1012740
  14. Chaddha U, Agrawal A, Feller-Kopman D, et al. Use of fibrinolytics and deoxyribonuclease in adult patients with pleural empyema: a consensus statement. Lancet Respir Med. 2021;9(9):1050-1064. doi:10.1016/S2213-2600(20)30533-6. PMID 33545086
By |2024-04-14T09:44:45-07:00Apr 12, 2024|Pulmonary, Trauma|

Phenobarbital as First-Line Medication for Alcohol Withdrawal: Have You Switched From Benzodiazepines Yet?

phenobarbital first line monotherapy for alcohol withdrawal

Are you using phenobarbital instead of benzodiazepines as the first-line monotherapy for patients in alcohol withdrawal in the Emergency Department (ED)? If not, you probably should be. Another old drug for a new indication, right? Well not exactly. Phenobarbital is indeed an older and relatively cheap drug (less than $20 per loading dose) that has gained some press recently for the treatment of acute alcohol withdrawal [1-3].

Why should you consider using phenobarbital as monotherapy rather than benzodiazepines?

Phenobarbital used to be one of the standard treatments for ethanol (EtOH) withdrawal prior to the introduction of benzodiazepines. However, there are key advantages over benzodiazepines.

  1. Phenobarbital has a dual mechanism of action, binding both the GABA receptor and glutamate receptors in the CNS [3]. This helps EtOH withdrawal symptoms by up-regulating GABA activity and down-regulating excitatory glutamate activity.
  2. Phenobarbital has a predictable metabolization with a long half-life of approximately 3-5 days, which allows the drug to self-taper after the initial loading dose and symptom control in the ED [1, 2]. This contrasts the relatively shorter half-life of many available benzodiazepines, which often require more frequent redosing.

Is phenobarbital safe for the treatment of EtOH withdrawal in the ED?

In short, yes. Several studies have indicated that dosing with phenobarbital (PO or IV) is safe and effective at decreasing the need for escalating doses of benzodiazepines for EtOH withdrawal [1-6]. In comparison to benzodiazepines, it demonstrated:

  • Fewer episodes of hypotension and apnea [1-6]
  • Decreased hospital and ICU stay duration in admitted patients [1]
  • Decreased requirement for ICU level care [1]

Dosing regimens

  • Common regimen: 10-15 mg/kg of IDEAL body weight (IBW) IV bolus over 30 minutes and administering 130-260 mg aliquots every 15-30 minutes for persistent symptoms [2]
    • Note that the patient’s IBW may be much lower than the actual body weight.
    • Use the MD Calc calculator for a patient’s IBW
    • Examples based on the average American height:
      • Male: 5’9” –> 71 kg IBW –> phenobarbital 710-1065 mg IV initial bolus
      • Female: 5’4” –> 55 kg IBW –> phenobarbital 550-825 mg IV initial bolus
  • Alternative lower dosing regimen: 130-260 mg IV boluses with repeated dosing as needed [3]
  • Maximum dose
    • No established maximum, but the absolute upper limit for dosing in epilepsy is 20-30 mg/kg [11]
    • Some sources recommend limiting the dose of phenobarbital in alcohol withdrawal to 15 mg/kg/day [3]
  • Adjuncts: Benzodiazepines may be added without decreasing safely [1]

Do patients need phenobarbital dosing adjustments if they have liver dysfunction?

  • Phenobarbital undergoes metabolization primarily in the liver, mostly by CYP2C9 [9].
  • “Dose adjustment” is recommended by the manufacturer in hepatic dysfunction, but no value is provided [10].
    • Since there is no recommended dosing adjustment in patients with cirrhosis and liver dysfunction, a conservative approach starting with the 130 mg boluses and titrating to the minimum effective dose would likely be the safest approach.
  • Clinical pearl: Hepatic encephalopathy is a strong contraindication to phenobarbital [9, 10].
    • Before administering a barbiturate to a cirrhotic patient for EtOH withdrawal, first ensure that hepatic encephalopathy is not the cause of the agitation or altered mental status.
    • Because patients with hepatic encephalopathy experience excess GABA stimulation, they are very sensitive to GABAergic medications (e.g., barbiturates or benzodiazepines).
    • Administration of benzodiazepines or barbiturates to these patients risk inducing a prolonged comatose state.

Is it safe to give phenobarbital to a patient who has already received benzodiazepines?

  • The concern with concurrent phenobarbital and benzodiazepine administration is oversedation. There is a paucity of evidence for this question, although preliminary data suggests that it is safe without significant mortality risk [1].
  • As a corollary, exercise caution when administering phenobarbital to patients at risk for sedation from any cause, such as hepatic encephalopathy, benzodiazepine abuse, and opioid abuse.
  • Suggested approach: If benzodiazepines have already been given, consider using the alternative, more conservative, lower dose regimen protocol (130-260 mg doses) up to 10-15 mg/kg total with close monitoring after every up-titration. Avoid giving benzodiazepines concurrently during the phenobarbital up-titration period to minimize the risk of oversedation and apnea [11].

Which patients treated with phenobarbital require admission?

There is a dearth of evidence about which patients require medical admission in the setting of phenobarbital administration. The American Society of Addiction Medicine has developed a tool to assist providers with disposition planning for patients with alcohol withdrawal syndrome for all-comers (not necessarily those treated with phenobarbital) [2]. Their recommendations are as follows:

  • Outpatient management
    • Able to follow return precautions
    • Likely to continue with alcohol use disorder treatment
    • Supportive living environment
  • Inpatient management
    • Requires frequent physician and nursing intervention
    • Heavy sedation requirements or active delirium tremens
    • Coexisting medical diagnoses that require inpatient management (severe electrolyte anomalies, infections, pancreatitis, hepatic encephalopathy, etc.)
    • History of severe withdrawals, pregnancy, or concurrent medical condition requiring treatment


Phenobarbital has gained significant popularity for use in EtOH withdrawal in the last few years. Several factors make it ideal for use in EtOH withdrawal, primarily its long half-life allowing for a multi-day, self-tapering effect. The most commonly recommended dosing regimen starts with a 10 mg/IBW kg bolus followed by titration every 30 minutes afterwards. Patients in the ED often can be safely phenobarbital-loaded and discharged, assuming hemodynamic stability, normal alertness, and resolution of withdrawal symptoms. More rigorous studies are needed determine dose thresholds that warrant hospital admission.


  1. Rosenson J, Clements C, Simon B, et al. Phenobarbital for Acute Alcohol Withdrawal: A Prospective Randomized Double-blind Placebo-controlled Study. The Journal of Emergency Medicine. 2013;44(3):592-598.e2. doi:10.1016/j.jemermed.2012.07.056. PMID: 22999778
  2. Wolf C, Curry A, Nacht J, Simpson SA. Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives. Open Access Emerg Med. 2020;12:53-65. doi:10.2147/OAEM.S235288. PMID: 32256131
  3. Long D, Long B, Koyfman A. The Emergency Medicine Management of Severe Alcohol Withdrawal. The American Journal of Emergency Medicine. 2017;35(7):1005-1011. doi:10.1016/j.ajem.2017.02.002. PMID: 28188055
  4. Staidle A, Geier C. Phenobarbital and/or Benzodiazepines for Recurrent Alcohol Withdrawal: A Self-Controlled, Retrospective Cohort Study. The American Journal of Emergency Medicine. 2022;54:263-266. doi:10.1016/j.ajem.2022.02.020. PMID: 35219012
  5. Lebin JA, Mudan A, Murphy CE, Wang RC, Smollin CG. Return Encounters in Emergency Department Patients Treated with Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal. J Med Toxicol. 2022;18(1):4-10. doi:10.1007/s13181-021-00863-2. PMID: 34697777
  6. Hendey GW, Dery R, Barnes R, Snowden B, Mentler P. A Prospective, Randomized, Trial of Phenobarbital Versus Benzodiazepines for Acute Alcohol Withdrawal. The American Journal of Emergency Medicine. 2011;29(4):382-385. doi:10.1016/j.ajem.2009.10.010. PMID: 20825805
  7. Hoffman PL, Grant KA, Snell LD, Reinlib L, Iorio K, Tabakoff B. NMDA Receptors: Role in Ethanol Withdrawal Seizures. Annals of the New York Academy of Sciences. 1992;654(1):52-60. doi:10.1111/j.1749-6632.1992.tb25955.x. PMID: 1321581
  8. Young GP, Rores C, Murphy C, Dailey RH. Intravenous Phenobarbital for Alcohol Withdrawal and Convulsions. Annals of Emergency Medicine. 1987;16(8):847-850. doi:10.1016/S0196-0644(87)80520-6. PMID: 3619162
  9. Patsalos PN, Spencer EP, Berry DJ. Therapeutic Drug Monitoring of Antiepileptic Drugs in Epilepsy: A 2018 Update. Therapeutic Drug Monitoring. 2018;40(5):526-548. doi:10.1097/FTD.0000000000000546. PMID: 29957667
  10. Lewis CB, Adams N. Phenobarbital. In: StatPearls. StatPearls Publishing; 2023. Accessed April 16, 2023.
  11. Farkas J. Alcohol withdrawal. EMCrit Project. Published March 29, 2023. Accessed April 18, 2023.
By |2023-05-31T19:25:45-07:00Jun 1, 2023|Neurology, Tox & Medications|

The Febrile Infant: Incorporating the 2021 American Academy of Pediatrics guidelines

Can you trust a febrile infant?

“No” has been, and continues to be, the resounding answer over the last 40 years as researchers and clinicians work to determine the optimal evaluation and management of the well-appearing young febrile infant [1].

The goal remains to identify infants with bacterial infections in this at-risk cohort of patients while also considering the balance of cost-effectiveness on a population scale and the potential for iatrogenic harm with evaluation such as unnecessary lumbar punctures, unnecessary antibiotics, and unnecessary hospitalization. Fortunately, bacteremia and bacterial meningitis in this age group are uncommon [2]. Unfortunately, delayed or missed diagnosis can be devastating [1-3].

In the most recent 2021 Clinical Practice Guideline, the American Academy of Pediatrics (AAP) aims to provide guidance with 3 separate age-based algorithms for the evaluation and management of the well-appearing febrile infant [4]. These guidelines were made possible by the recent PECARN, Step by Step, and other studies and the invaluable information they have provided [5-7].

Who’s included?

  • Well-appearing febrile infants
    • The AAP acknowledges that clinician experience is likely the best determinate of what is “well-appearing”, further admitting that there is no measure or definition of either “experience” or “well-appearing”
  •  Febrile
    • Rectal temperatures of  38.0C or 100.4F at home in the past 24 hours or determined in a clinical setting
    • Subjective fevers at home are excluded
  •  Gestation
    • Between 37-42 weeks
    • Premature infants excluded
  • Age
    • Days 8 to 60 and have been discharged home following birth

Who is not included?

  • Preterm or infants with congenital/chromosomal abnormalities
  • Infants with focal bacterial infections
  • Cellulitis, omphalitis, septic arthritis, osteomyelitis
  •  Bronchiolitis
    • With or without a positive RSV test
  •  Immunocompromised
    • Either suspected or known deficiency
  • Immunizations in the previous 48 hours

It should also be noted that the AAP has named the following as high-risk inflammatory markers that will be referenced in the soon-to-be-discussed guidelines [4,5].

  • Temperature >101.3F (38.5C)
  • C-reactive protein (CRP) > 20 mg/L
  • Procalcitonin >0.5 ng/mL
  • Absolute neutrophil count (ANC) >4000 mm3  (or 5200 mm3 if your facility does not have procalcitonin available)

The Groups

While the AAP makes the distinction of an age 0-7 days group from the age 8-21 days, they provide no specific recommendations about emergency department (ED) management in the youngest group [4]. Despite this, these infant groups are likely best evaluated and managed similarly in the ED:

  • Urinalysis (UA) +/- urine culture if indicated by UA
  • Blood culture
  • Lumbar puncture (LP)
    • Cell count, Gram stain, glucose, protein, bacterial culture, and enterovirus PCR (if available)
  • Admission

Inflammatory markers are not required to determine ED management in this age group but may guide inpatient clinicians.


  • Ampicillin IV or IM
  • Ceftazidime IV or IM or gentamicin IV or IM

The addition of acyclovir to IV antibiotics depends on the following risk factors which increase the likelihood of HSV:

  • Maternal genital HSV lesions or fever 48 hours before or after delivery
  • Infants with vesicles, seizures, hypothermia, mucous membrane ulcers
  • CSF pleocytosis with a negative Gram stain result
  • Leukopenia, thrombocytopenia, or elevated AST/ALT levels

Although many febrile infants in this group will still require a full evaluation for sepsis, there are some new alternatives in patients meeting certain criteria. At the minimum, all 22-28 day old infants will need:

  • UA +/- culture
  • Blood culture
  • Inflammatory markers (ANC, CRP, procalcitonin)

Further management of a well-appearing infant in this group can be based on the following pathways:

    1. If UA positive with negative inflammatory markers
      • LP may be performed but is not required
      • IV antibiotics and admission are required regardless
    2. If UA negative with negative inflammatory markers, then there are 2 options
      • Perform LP
        • If LP negative, then the patient can be given a dose of parenteral antibiotics and discharged home with close follow-up in 24 hours.
        • If LP is traumatic or pleocytosis is present, administer antibiotics and admit.
      • Defer LP
        • Antibiotics may be administered, but the patient should be admitted.
    3. If UA negative and ANY positive inflammatory marker (procalcitonin > 0.5 mg/mL, CRP >20 mg/L, ANC >4000, or temperature >101.3F), LP is required
      1. If LP positive
        • Admit with IV antibiotics
      2. If LP negative
        • Admit +/- antibiotics, OR
        • Discharge home after one dose of parenteral antibiotic with 24-hour follow-up


  • Same antibiotic options as the day 0-21 infants

The nuances of this group’s decision tree revolve around the inflammatory markers.

Each infant in this group should have the following completed:

  • Urinalysis
  • Blood Cultures
  • Inflammatory markers (CRP, ANC, and procalcitonin)

If everything is negative (UA & inflammatory markers):

  • Infants may be discharged home without antibiotics and with close follow-up within 36 hours.

If inflammatory markers are negative:

  • Infants with a positive urinalysis and negative inflammatory markers may be treated with oral antibiotics.
    • They may be either admitted to the hospital for observation or discharged with 24-hour follow-up.
    • No LP needed.

If inflammatory markers are positive:

  • A LP may be performed if the clinician feels it necessary but is not required.
    • If performed and CSF is negative the infant may be discharged with close follow-up.
    • Given high risk of bacteremia with elevated inflammatory markers in this age group, a dose of parenteral antibiotics prior to discharge is appropriate.
  • If LP deferred:
    • Administer parenteral antibiotics, and likely admit to hospital.
    • The caveat to this is if they have viral testing completed that is positive and are well appearing.
      • Example: A 48-day-old infant presents with a fever of 100.6F, CRP of 22 mg/L, and otherwise normal procalcitonin, ANC, and UA. The mother reports that an older brother has had a runny nose. Viral PCR testing is positive for rhinovirus. Seeing as the UA is negative, the infant appears well with a positive viral test, they may go home with shared decision-making and close outpatient follow-up, despite a positive inflammatory marker (CRP 22 mg/L) [3].


Urinary Tract Infection:

  • Ceftriaxone (IV/IM) or cephalexin/cefixime as oral options.

Concern for Bacteremia/Meningitis:

  • Ceftriaxone + vancomycin
  • May add acyclovir for the above-mentioned antiviral treatment indications.

What should be done if the viral panel is positive?

  • Children 29 days or older with fever from a documented viral source can be managed according to their clinical presentation and can go outside the algorithm.
  • This requires a documented positive viral swab and not just a presentation consistent with a viral syndrome.
  • UTI is common in this age group, and a UA should be obtained [8].


Over the course of nearly the last half century there has been a lack of clear evidence-based guidelines in evaluating the young febrile infant [1]. Although serious bacterial infections in these young, febrile infants are uncommon, studies show that in the first month of life, bacteremia can be present in nearly 3% of febrile infants, with bacterial meningitis occurring in about 1% [2]. The absence of consensus regarding management has led to significant costs due to hospitalizations and their associated iatrogenic complications [9]. In the movement to create new recommendations, shifting epidemiology pushed changes in previous guidelines with a new focus on the use of the now widely available inflammatory markers [10].  With the advent of multiple large-scale studies and the recent improvements in lab testing, the newly updated AAP guidelines provide recommendations on how to manage this challenging population [4-7].

Take Home Points

  • These management strategies can only be used in WELL-APPEARING infants – if they’re ill-appearing, do a complete workup.
  • Evaluation of febrile infants 0-21 days remains the same – do everything (blood culture, UA +/- culture, LP with CSF studies), give antibiotics, and admit.
  • For those infants 22-28 days, get the UA, blood culture, and inflammatory markers to guide management.
    • Not all febrile infants in the 22-28 day subset need an LP, though it should still be obtained in certain clinical circumstances, and discussed between  provider and parents in other situations
  • In infants ≤28 days, a complete workup is still needed even if a viral source is present.
  • Febrile infants 29-60 days old may be sent home after a negative workup with close follow-up.


    1. Roberts KB. Young, febrile infants: a 30-year odyssey ends where it started. JAMA. 2004 Mar 10;291(10):1261-2. PMID: 15010450.
    2. Biondi EA, Lee B, Ralston SL, et al. Prevalence of Bacteremia and Bacterial Meningitis in Febrile Neonates and Infants in the Second Month of Life: A Systematic Review and Meta-analysis.JAMA Network Open. 2019 Mar; 2(3). PMID: 30901044.
    3. Baker MD, Avner JR, Bell LM. Failure of infant observation scales in detecting serious illness in febrile, 4- to 8-week old infants. Pediatrics. 1990;85(6):1040–1043. PMID: 2339027
    4. Pantell RH, Roberts KB, Adams WG, et al. Clinical Practice Guideline: Evaluation and Management of Well Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. 2021;148(2):e2021052228. PMID: 34281996
    5. Kuppermann N, Dayan PS, Levine DA, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019;173(4):342-351. PMID: 30776077
    6. Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” approach in the management of young febrile infants. The Journal of Pediatrics. 2016 Aug; 138(2):e20154381. PMID: 27382134
    7. Nguyen THP, Young BR, Poggel LE, et al. Roseville Protocol for the Management of Febrile Infants 7-60 Days. Hosp Pediatr. 2020 Dec 17:hpeds.2020-0187. PMID: 33334815
    8. Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008;27(4):302-308. PMID: 18316994
    9. Coyle C, Brock G, Wallihan R, Leonard JC. Cost Analysis of Emergency Department Criteria for Evaluation of Febrile Infants Ages 29 to 90 Days. J Pediatr. 2021 Apr;231:94-101.e2. doi: 10.1016/j.jpeds.2020.10.033. Epub 2020 Oct 31. PMID:33130155.

    Milcent K, Faesch S, Gras-Le Guen C, et al. Use of Procalcitonin Assays to Predict Serious Bacterial Infection in Young Febrile Infants [published correction appears in JAMA Pediatr. 2016 Jun 1;170(6):624].JAMA Pediatr. 2016;170(1):62-69. doi:10.1001/jamapediatrics.2015.3210 PMID: 26595253

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