Many centers still choose to admit and treat young febrile infants. Infection can spread … [Medline]. 2013 Dec. 132(6):990-6. Arditi M, Mason EO Jr, Bradley JS, et al. Pharmacoeconomics. 1993 Aug. 22(8):467-8, 470-3. Leclerc F, Cremer R, Noizet O. Procalcitonin as a diagnostic and prognostic biomarker of sepsis in critically ill children. The patients with bacteremia were treated with parenteral ampicillin. The researchers further identified a set of 10 genes that could distinguish infants with bacteremia from those without. Semin Pediatr Infect Dis. Obaro SK, Adegbola RA, Banya WA, et al. Children who appeared well and had no focus of infection received a urinalysis if appropriate for age, whereas all children received no other laboratory tests and no antibiotics and were followed up in 24 hours to assess for worsening or persistence of signs and symptoms of infection. Sometimes, however, children have fever and no other symptoms. Chisti MJ(1), Saha S, Roy CN, Salam MA. 1998 Dec. 19(12):401-7; quiz 408. The authors question the continued need for empiric L. monocytogenes coverage with ampicillin, however, this study excluded infants admitted to neonatal intensive care units, likely excluding early-onset … Emergence of 19A as virulent and multidrug resistant Pneumococcus in Massachusetts following universal immunization of infants with pneumococcal conjugate vaccine. 92(1):140-3. [29, 37, 81], Longitudinal studies of invasive pneumococcal disease show that the prevalence of intermediately ceftriaxone-resistant pneumococcus (MIC 0.1-1) has increased from 3% in 1993 to 9% in 1999. [Medline]. Pediatr Infect Dis J. Please confirm that you would like to log out of Medscape. 30 After repeating the blood culture and performing a lumbar puncture in patients with meningococcal bacteremia, it would … 26th ed. 1996 Jun. 1997 Mar. Tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6 levels in febrile, young children with and without occult bacteremia. The majority of infants become symptomatic by 12 to 24 hours of age11–13; during the 2006–2015 period of ABCs, 94.7% of 1993 Nov 11. [Medline]. Enteral lactoferrin supplementation for very preterm infants: a randomised placebo-controlled trial. Friedland IR. Management of fever without source in infants and children. Accessed: 12/14/09. Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Pediatric ResearchDisclosure: Nothing to disclose. 1987 Oct;62(10):1079-80. doi: 10.1136/adc.62.10.1079. Pickering LK, ed. Pediatr Infect Dis J. In 34 infants and children aged 1 month to 19 years with bacterial meningitis, ceftriaxone cured 88% of subjects and the overall clinical response was 96%. 15(6):541. 4:18-23. Low-Risk Criteria for Infants Younger than 3 Months, Table 12. Application of low-risk criteria and approach for the febrile infant: A reasonable approach for treating febrile infants younger than 3 months who have a temperature of greater than 38°C. Pediatr Infect Dis J. [Medline]. Lorin MI. In a retrospective cohort study of pediatric patients with gram-negative bacteremia, beta-lactam monotherapy resulted in a lower incidence of subsequent nephrotoxicity than combination therapy without compromising survival. C-reactive protein in febrile children 1 to 36 months of age with clinically undetectable serious bacterial infection. Previous reports have shown that the peak incidence occurs among infants less than 3 months of age. JAMA Pediatr. Low-risk children are generally monitored as outpatients. Krief WI, Levine DA, Platt SL, et al. Is Pediatric Subspecialty Training Financially Worth It? Bass JW, Vincent JM, Demers DM. [1, 10] However, a metaanalysis found no statistical change in occurrence of meningitis between patients with and without treatment with oral antibiotics. Antimicrobial treatment of occult bacteremia: a multicenter cooperative study. 26th ed. Two studies have analyzed the NNT to prevent meningitis for different laboratory screening criteria in febrile children aged 3-36 months with a temperature of more than 39°C. [Medline]. Empiric antibiotics used in practice vary in this age group. Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation The prevalence of serious bacterial infections by age in febrile infants during the first 3 months of life. Swindell SL, Chetham MM. Management of the young febrile child. These changes will impact the evaluation and management of young infants. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvOTYxMTY5LXRyZWF0bWVudA==. The NPV of various low-risk criteria for serious bacterial infection and occult bacteremia are as follows[10, 14, 16, 19, 74, 75, 76] : 1. Statistically, this translates into a high NPV (ie, a very high proportion of true negative cultures is observed in patients deemed to be at low risk). [Medline]. Salmonella infections in infants and children. Although these values have an NPV of approximately 99% for occult bacteremia, numerous reviews have noted that these cutoff values may still miss 25% of children with occult bacteremia because of the large numbers of febrile children presenting for evaluation. Baker MD. [Medline]. The risk of developing meningitis with no antibiotic therapy is 50%, the risk is 29% with oral antibiotic therapy, and it is 0% with intramuscular and/or intravenous antibiotic therapy. Mandl KD, Stack AM, Fleisher GR. Previous reports have shown that the peak incidence occurs among infants less than 3 months of age. Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University Pediatrics. In very young infants, bacterial causes are most commonly acquired from the mother during childbirth. Clinical Pediatric Emergency Medicine. [Medline]. 23(6):485-9. Pediatr Infect Dis J. Early studies of empiric coverage with oral antibiotics examined various agents, including amoxicillin and penicillin. If you log out, you will be required to enter your username and password the next time you visit. [Medline]. Rothrock SG, Harper MB, Green SM, et al. In most cases, bacteremia is transient and does not alter the course of NTSal GE, but it may result in life-threatening complications such as septicemia and meningitis. [Medline]. Bethesda, MD 20894, Copyright A combination of age, temperature, and screening laboratory test results is used to determine the risk for serious bacterial infection or occult bacteremia. 1999 Mar. Walson PD, Galletta G, Chomilo F, et al. [Medline]. Chancey RJ, Jhaveri R. Fever without localizing signs in children: a review in the post-Hib and postpneumococcal era. [Medline]. Am J Dis Child. Pediatr Infect Dis J. [Medline]. New tools to improve recognition are necessary for prompt, effective antimicrobial administration. Philadelphia NPV - 95-100% 2. The causes, evaluation, and management of possible occult bacteremia vary by children's age and immunization status. Baskin MN, O'Rourke EJ, Fleisher GR. Harper MB, Bachur R, Fleisher GR. Of the 13 children 3 to 24 months of age, 7 (54%) had positive blood cultures. Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta KappaDisclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics, Novavax, Regeneron, Diassess, Actelion
Received income in an amount equal to or greater than $250 from: Sanofi Pasteur. Pediatr Infect Dis J. [1, 10, 21, 24] See Lab Studies for statistics associated with different laboratory values used as screening tools for occult bacteremia; most studies determined that ROC curves were most favorable for WBC counts fewer than 15 per HPF or ANCs fewer than 10, criteria that were used to define low-risk children. 26(6):468-72. 1999 Dec. 46(6):1061-72. Pediatr Rev. Several authors have examined how well screening works in identifying infants and young children with occult bacteremia and how efficient empiric treatment is in preventing sequelae of bacteremia, namely meningitis. As recently as 1984, guidelines for treating febrile young infants recommended evaluation, treatment, and hospitalization because of the increased risk of bacterial infection and the inability to clinically distinguish infants at an increased risk for serious bacterial infection. Consultant for Pediatr. Spraycar M, ed. Pediatrics. /viewarticle/949556
4:2-3. [Medline]. [Medline]. [81], Antibiotic pressure likely has a large role in selecting for antibiotic-resistant pneumococci, and a longitudinal study of invasive pneumococcal disease found an increased risk of penicillin resistance in patients who have used antibiotics in the last 30 days. Available at http://www.medscape.com/viewarticle/841079. The NPV of various low-risk criteria for serious bacterial infection and occult bacteremia are as follows Bachur RG, Harper MB. Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases SocietyDisclosure: Nothing to disclose. The risk of serious complications in previously healthy children aged 3-36 months with Salmonella bacteremia is small. All 20 infants recovered, and no focal infectious com plications occurred. 99(3):438-44. News, encoded search term (Bacteremia) and Bacteremia, Treatment of Sepsis and Septic Shock in Children, Multiple Organ Dysfunction Syndrome in Sepsis, Low-risk Preterm Infants May Not Need Antibiotics, Inflammation a Core Feature of Depression, Corticosteroid Bursts May Increase GI Bleeding, Sepsis Risk in Children, 8 Causes of Altered Mental Status in the Elderly, Pediatric COVID-19: Data to Guide Practice, COVID-19 Isolation and an Infant's Immune System. 1989 Jun;8(6):364-7. doi: 10.1097/00006454-198906000-00008. 100(1):137-8. This resistance can be overcome by sufficiently high doses of antibiotic. Pediatrics. J Pediatr. [Medline]. Of the 170 patients with evidence of acute kidney injury, 135 (25.1%) were treated with combination therapy and 35 (10.2%) with monotherapy. Incidence of bacteremia in infants and children with fever and petechiae. Although acknowledging the ongoing concerns over the appropriate approach to infants and children with FWS, the authors conclude that this new approach is reasonable based on the best available information. 2001 Oct. 108(4):835-44. [3] This guideline is also based on the low risk of occult bacteremia in infants immunized against H influenza type b and S pneumoniae. [Medline]. It recommends that routine screening laboratory tests should not be performed for well-appearing febrile infants who have received 3 doses of 7-valent pneumococcal vaccine and 3 doses of Hib vaccine. [77], To understand the role of penicillin-resistant pneumococcus in serious bacterial infection and occult bacteremia, realize that all pneumococci are not equal, antibiotic resistance patterns are not static, and resistance does not necessarily equal virulence. Risk of bacteremia for febrile young children in the post-Haemophilus influenzae type b era. Bacteremia remains a major cause of morbidity and mortality in young infants. UTIs are the commonest bacterial infection in young infants. [74], Screening febrile infants and children aged 3-36 months based on age, degree of fever, and laboratory results has also been found to be a cost-effective and reasonable approach. Utility of the serum C-reactive protein for detection of occult bacterial infection in children. The patients with bacteremia were treated with parenteral ampicillin. The prevention of pneumococcal disease in children. 329(20):1437-41. 1993 Aug. 22(8):462-6. 1 One of those reports describes 3 additional patients whose illnesses resolved spontaneously without any initial treatment. 135 (4):635-42. To the Editor —We read with great interest the article by Bertelli et al [], which reported 2 cases of Bifidobacterium species bacteremia in newborns receiving probiotics. The authors reported that pediatric bacteremia in the ED is health care associated, which increases length of inpatient stay. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. [Medline]. All these possible antibiotic regimens have excellent coverage against the other childbirth-acquired or community-acquired bacterial pathogens in this age group. Pediatrics. 2001 Feb. 160(2):95-100. Carriage of penicillin-resistant Streptococcus pneumoniae by children in day-care centers during an intervention program in Malmo, Sweden. 1997 Sep. 131(3):398-404. [Medline]. Enhanced urinalysis improves identification of febrile infants ages 60 days and younger at low risk for serious bacterial illness. Irwin AD, Drew RJ, Marshall P, Nguyen K, Hoyle E, Macfarlane KA, et al. One used a WBC count greater than 15,000/μL and found an NNT of 500 to prevent one case of meningitis, and the other used an ANC greater than 10,000/μL and found an NNT of 240. Jaye DL, Waites KB. In our study, there were 79 serum measurements of the drug during vancomycin treatment, with an average of 2.19 doses per patient. The three extremely preterm infants (patients 13 to 15) had received a probiotic product containing B. longum, aiming to prevent necrotizing … Antibiotics can eliminate the infection. McMullan BJ, Bowen A, Blyth CC, Van Hal S, Korman TM, Buttery J, et al. [Guideline] Baraff LJ, Bass JW, Fleisher GR, et al. Low risk of bacteremia in febrile children with recognizable viral syndromes. However, recent epidemiologic data suggest that the incidence of bacteremia is decreasing and the pathogens responsible for invasive disease are changing. [72]. Biondi E, Evans R, Mischler M, Bendel-Stenzel M, Horstmann S, Lee V, et al. One child (8 months old) appeared septic. Greenhow TL, Hung YY, Herz AM. Lacour AG, Gervaix A, Zamora SA, et al. Infants suffering from bacterial infections may require intensive care and treatment. [10, 11, 12, 32, 77] (Open Table in a new window), Intramuscular/Intravenous Antibiotic Therapy, %. Kaplan SL, Mason EO Jr, Wald E, et al. Less Is More: Combination Antibiotic Therapy for the Treatment of Gram-Negative Bacteremia in Pediatric Patients. Semin Pediatr Infect Dis. During 1981, we treated 20 infants, less than 24 months old, for nontyphoid Salmonella (NTSal) gastroenteritis (GE). 2009 Jan. 25(1):19-25. Reuters Health Information. 2001 Dec. 20(12):1105-7. [Medline]. All material on this website is protected by copyright, Copyright © 1994-2021 by WebMD LLC. The above guidelines are presented to define a group of febrile young infants who can be treated without antibiotics. Most infants and young children who are evaluated for occult bacteremia present with a fever. Kuppermann N. Occult bacteremia in young febrile children. 1991 Sep;119(3):506-8. 1997 Jul. [Medline]. Treatment courses in the bacteremic group were variable and predicted by age but not severity of illness. 2000 Dec. 36(6):602-14. Pediatr Ann. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Nothing to disclose. Aronson PL, Wang ME, Shapiro ED, Shah SS, DePorre AG, McCulloh RJ, et al. Demographic and clinical data are listed in Table 1.Six patients were above 80 years of age, and four patients were born prematurely, before 33 weeks of gestational age. No bacteremic infant had recurrent UTI or bacteremia with the same organism within 30 days of discharge. Evaluation and management of infants with fever. Black S, Shinefield H, Baxter R, et al. This third-generation cephalosporin has broad-spectrum gram-positive and gram-negative coverage, is active against all likely community-acquired pathogens in this age group, and is resistant to beta-lactamases produced by some pathogenic organisms. Management of infants at risk for occult bacteremia: a decision analysis. The incidence of bacteremia in NTSal GE is highest in children under 2 years of age. Pediatrics. Downs SM(1), McNutt RA, Margolis PA. 2002 Feb. 21(2):141-7. Pediatrics. [25] : Tissue plasminogen activator (TPA) for acute myocardial infarction - $32,678, Medical treatment for hypertension - $20,000, Coronary artery bypass grafting (CABG) for myocardial infarction - $7,000, Empiric testing and treatment in febrile children when rate of occult bacteremia is 1.5% - $72,300, Empiric testing and treatment in febrile children when rate of occult bacteremia is 0.5% - Over $300,000, Treatment based on clinical judgment, sensitivity 28% and specificity 82%, when rate of OB is 0.5% - $38,000, If the rate of bacteremia declines to 0.5%, this analysis concluded that clinicians should reevaluate their approach to highly febrile children and eliminate strategies that use empiric testing and treatment. 2000 Aug. 19(8):679-87; quiz 688. What is clear is that risk-based estimates of likelihood of bacteremia were almost without exception obtained in a largely prevaccination era. 152(7):624-8. AAP … [12, 16] Ceftriaxone has the longest half-life of the third-generation cephalosporins, and high serum concentrations can be sustained for 24 hours with a single dose. 1992 Jan. 120(1):22-7. Black SB, Shinefield HR, Hansen J, et al. 1999. Low-Risk Criteria for Infants Younger than 3 Months Studies have shown that ibuprofen (10 mg/kg/dose every 8 h) or acetaminophen (10-15 mg/kg/dose every 4-6 h) are both effective and well tolerated. [Medline]. Isaacman DJ, Kaminer K, Veligeti H, et al. Children 3 to 36 months of age Pediatr Infect Dis J. Urine cultures were recommended for males younger than 6 months and females younger than 2 years, stool cultures were recommended for children with blood or mucus in the stool or more than 5 WBCs per HPF on stool smear, and chest radiography was recommended for children with dyspnea, tachypnea, rales, or decreased breath sounds. 1997 Jul. According to the data presented above, the recommendation of a single protocol for the evaluation and treatment of febrile infants is not possible.6 The management of fever in newborns is outside the scope of this article, but it involves aggressive conduct, with the collection of all cultures, including cerebrospinal fluid (CSF), as well as hospital admission and parenteral antibiotic therapy … Comparison of multidose ibuprofen and acetaminophen therapy in febrile children. Pediatrics. [1, 24]. A gradual shift toward community-acquired causes occurs as age increases; the causes of bacteremia in infants aged 1-3 months are a combination of organisms (see Causes). Nilsson P, Laurell MH. Pneumococcal Bacteremia - Relationship Between Outpatient Antibiotic Use and Complications. 139 (4):[Medline]. Baraff LJ, Oslund S, Prather M. Effect of antibiotic therapy and etiologic microorganism on the risk of bacterial meningitis in children with occult bacteremia. 1999 Mar. Screening febrile infants younger than 3 months by means of history, physical examination, and laboratory tests and treating low-risk infants as outpatients has been shown to be cost-effective. Bacterial infections in infants can be quite worrisome as their condition tend to worsen quickly. 2001 Aug. 108(2):E23. 345(16):1177-83. 2013 Aug 5. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. 165 (6):390-8. 2000 Feb. 39(2):81-8. 1991 Jan;118(1):11-20. 1999 Oct. 18(10):875-81. 5. Hence, among neonates and infants, needed to modify vancomycin doses at least once on average (ranging from 1 to 4 times) in order to achieve adequate serum levels. [10, 74, 75, 76] (Open Table in a new window). Pediatrics. Antibiotics: It includes both oral and intravenous antibiotics. [5, 22, 34, 45, 85]. Definitions. Fever with bacteremia: a disappearing classic. JAMA Pediatr. Follow-up in 24-48 hours was recommended for children who had cultures drawn. 100(1):134-6. The severity of bacteremia was defined as occurrence of death or transfer to intensive care unit. 1 These patients often present with fever alone, and because of the infants’ immature immune system and risk for serious complications, they need urgent … [Medline]. [Medline]. Table 11. Children Aged 3-36 Months - Fever and Occult Bacteremia, Table 3. Population-based surveillance for childhood invasive pneumococcal disease in the era of conjugate vaccine. Baskin MN. 1993 Jun. A recent formal estimate of cost-effectiveness compares the cost of screening and treatment of febrile children using numerous criteria. In a study on length of IV antibiotic therapy in over 12,000 infants <6 months old with UTI, the presence of bacteremia predicted longer IV treatment length (bacteremia was present in 0.5% of the short IV group vs 0.8% of the long IV group, P=0.02) but did not predict treatment failure, defined as readmission within 30 days. Occult Bacteremia - Relationship Between Outpatient Antibiotic Use and Complications This website also contains material copyrighted by 3rd parties. March 09, 2015; Accessed: June 23, 2015. Pediatr Crit Care Med. In this setting, the likelihood of a concomitant bacterial is lower in nearly all instances, with the exception of a concurrent UTI. [23, 24] At this rate of bacteremia, empiric testing and treatment were found to be the most cost-effective approaches for treatment of febrile children; the cost is $72,000 per life-year saved. The first step in the treatment of children with FWS is to use a combination of age, temperature, and screening laboratory test results to determine the risk for serious bacterial infection or occult bacteremia. Mariscalco MM. Please enable it to take advantage of the complete set of features! Effect of antibiotic therapy on the outcome of outpatients with unsuspected bacteremia. , 501-4 is used to treat bacterial meningitis DePorre AG, Gervaix a, Wilson,. Been reported in day-care centers during an intervention program in Malmo, Sweden OS, M. Received longer parenteral treatment courses than nonbacteremic infants ( mean 6.7 vs 2.4 days,
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