Occult bacteraemia is uncommon in febrile infants who appear well, and close clinical follow-up is more appropriate than blood tests

Hernández-Bou, Susanna; Trenchs, Victoria; Batlle, Astrid; Gené, Amadeu; Luaces, Carles

doi:10.1111/apa.12852

Cited by 15 publications

(15 citation statements)

References 25 publications

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“…In a retrospective case series of all blood cultures obtained between 1998 and 2003 in northern California outpatient clinics and emergency departments from previously healthy children three to 36 months old, Herz et al showed that leukocytosis >15,000/mm 3 is a poor predictor of bacteremia in febrile toddlers (positive predictive value of 1.50%) and in children routinely immunized with PCV7 [ 15 ]. Hernandez-Bou [ 33 ] showed recently, in 591 children aged three to 36 months vaccinated with PCV13 in a tertiary-care medical center in Spain, that an elevated band count was the best predictor of the uncommon (six patients only, 1.0%) cases of OB that were diagnosed, with 66.70% sensitivity and 93.30% specificity, while the positive predictive values of a WBC count >15,000/mm 3 , C-reactive protein >40 mg/L and procalcitonin >0.5 ng/mL were low. It is clear, today, taking into consideration the low rates of OB in patients vaccinated with PCVs, that use of the white blood cell count alone to guide the empiric use of antibiotics is not indicated anymore, and that new guidelines advocating for a management change are needed in the approach to the previously healthy febrile toddler [ 7 , 8 , 16 , 20 , 28 , 33 , 34 ].…”

Section: Discussionmentioning

confidence: 99%

The Epidemiologic, Microbiologic and Clinical Picture of Bacteremia among Febrile Infants and Young Children Managed as Outpatients at the Emergency Room, before and after Initiation of the Routine Anti-Pneumococcal Immunization

Leibovitz¹,

David²,

Ribitzky-Eisner³

et al. 2016

IJERPH

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We described the occult bacteremia (OB) and bacteremia with diagnosed focus (BwF) picture among children managed as outpatients at the pediatric emergency room (PER) in southern Israel, before and after the introduction of pneumococcal conjugate vaccines (PCVs) introduction in a retrospective study enrolling all three- to 36-month-old patients with fever >38.0 °C during 2005–2014. Of 511 (0.82% of all febrile patients) true bacteremias, 230 (45%) were managed as outpatients; 96 of 230 (41.7%) had OB and 134 (3.59%) had BwF. OB and BwF rates were 0.22% and 3.02%, respectively. A significant decrease was noted in OB and BwF rates (p = 0.0008 and p = 0.02, respectively). S. pneumoniae (SP, 37.5%), K. kingae (11.4%) and Brucella spp. (8.7%) were the most common OB pathogens and SP (29.8%), S. viridans (13.4%), and Brucella spp. (12.7%) were the most common in BwF patients. PCV13 serotypes were not found among the serotypes isolated post-PCV13 introduction. During 2010–2014 there was an increase in non-PCV13 serotype isolation (p = 0.005). SP was the main pathogen isolated among patients with pneumonia, acute otitis media (AOM) and periorbital cellulitis (62.5%, 33.3% and 60%, respectively). OB and BwF decreased following the introduction of PCVs and SP was the main pathogen in both conditions. Vaccine-SP serotypes were not isolated in OB after PCV13 introduction and non-vaccine serotypes increased significantly.

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Section: Discussionmentioning

confidence: 99%

The Epidemiologic, Microbiologic and Clinical Picture of Bacteremia among Febrile Infants and Young Children Managed as Outpatients at the Emergency Room, before and after Initiation of the Routine Anti-Pneumococcal Immunization

Leibovitz¹,

David²,

Ribitzky-Eisner³

et al. 2016

IJERPH

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“…Patients with occult bacteremia had higher mean temperature (40.2 C ± 0.5 C) when compared with patients with negative or contaminated cultures (p value < 0.001) [31]. The introduction of the heptavalent pneumococcal conjugate vaccine (PCV7) led to further declines in the overall rates of occult bacteremia to <0.5-1% [83,84].…”

Section: Occult Bacteremiamentioning

confidence: 99%

“…Occult bacteremia may represent a lag in the clinical manifestation of the disease, and this has been documented in various studies [83][84][85][86]. It is difficult to ascertain the seriousness of occult bacteremia, but biomarkers such as neutrophil count, CRP and PCT are useful analytical parameters [84,85].…”

Section: Occult Bacteremiamentioning

confidence: 99%

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Bacteremia in children: epidemiology, clinical diagnosis and antibiotic treatment

Pai¹,

Enoch

Aliyu

2015

Expert Review of Anti-infective Therapy

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The diagnosis of bacteremia in children is important and it can be clinically challenging to recognize the signs and symptoms. The reported rates of bacteremia are higher in young children but with the increasing vaccine coverage, there has been a decrease in bacteremia due to the three vaccine preventable bacteria (Streptococcus pneumoniae, Haemophilus influenzae group b and Neisseria meningitidis). Notably, there have been increases in healthcare-associated bacteremias with a rise in Staphylococcus aureus and Gram negative bacteremias. This review provides a brief overview of the clinical diagnosis of bacteremia in children, focusing on the epidemiology, clinical characteristics, risk factors, antibiotic treatment, outcomes and preventative measures to reduce the incidence of bacteremia and improve morbidity and mortality.

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“…The clinical characteristics of these patients, including age, sex, onset of fever, temperature, and white blood cell counts, were comparable to those of patients in other studies reporting FWS among children aged 3 to 36 months in Asia 12 and Europe. 13-15 One major issue in this study was the immunization status of the enrolled children. We obtained an immunization history for 60 patients (90%); all of them had received only the basic immunizations included in Thailand’s national immunization schedule according to their ages, except the PCV and Hib vaccine.…”

Section: Discussionmentioning

confidence: 99%

Etiology, Treatment, and Outcome of Children Aged 3 to 36 Months With Fever Without a Source at a Community Hospital in Southern Thailand

Phasuk

Nurak

2020

J Prim Care Community Health

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Background: Fever without a source (FWS) in young children can result from occult bacteremia, urinary tract infection (UTI), meningitis, or certain viral infections. In rural areas of Thailand, where bacterial cultures are not available in some community hospitals, the appropriate examination and management of FWS remain controversial. Methods: We retrospectively searched electronic medical records for medical diagnoses associated with FWS and evaluated the characteristics and clinical courses of children aged 3 to 36 months with FWS who were admitted to a community hospital in southern Thailand between January 2015 and December 2016. Results: Sixty-seven children aged 3 to 36 months with an initial diagnosis of FWS were enrolled. The median age was 11 months (interquartile range [IQR] 8-21 months). Complete blood counts, blood cultures, urine analysis results and urinary cultures were obtained from 67 (100.0%), 31 (46.3%), 47 (70.1%), and 7 (10.5%) patients, respectively. The most common empirical antibiotic administered to these patients was ceftriaxone (71.6%); however, 4 patients recovered without antibiotic administration. The median duration of intravenous antibiotic administration was 4 days (IQR 2-4 days). Intravenous antibiotics were replaced by oral antibiotics in 38 patients (62.3%). The median time to fever subsidence was 30 hours (IQR 12-60 hours). Regarding final diagnoses, 5 patients (7.5%) were diagnosed with culture-confirmed UTI, and 2 (3.0%) had bacteremia (due to contamination). The majority of the children (60, 89.6%) retained the diagnosis of FWS. Presentation at the hospital was significantly earlier in children with culture-confirmed UTI (median 1 day) than in those with culture-negative FWS (median 3 days) ( P = .019). Discussion: We evaluated the characteristics and clinical courses of young children with FWS presenting at a community hospital and the treatment approaches utilized by physicians. Although all patients had good prognoses during the study period, we identified several areas for improvement in conducting proper examinations (especially assessments for UTI in children presenting within the first day of fever onset).

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Occult bacteraemia is uncommon in febrile infants who appear well, and close clinical follow-up is more appropriate than blood tests

Abstract: In the era of the 13-valent pneumococcal conjugated vaccine, occult bacteraemia is an uncommon event in febrile children aged three to 36 who otherwise appear well and close follow-up should replace blood analysis in such cases.

Cited by 15 publications

References 25 publications

The Epidemiologic, Microbiologic and Clinical Picture of Bacteremia among Febrile Infants and Young Children Managed as Outpatients at the Emergency Room, before and after Initiation of the Routine Anti-Pneumococcal Immunization

The Epidemiologic, Microbiologic and Clinical Picture of Bacteremia among Febrile Infants and Young Children Managed as Outpatients at the Emergency Room, before and after Initiation of the Routine Anti-Pneumococcal Immunization

Bacteremia in children: epidemiology, clinical diagnosis and antibiotic treatment

Etiology, Treatment, and Outcome of Children Aged 3 to 36 Months With Fever Without a Source at a Community Hospital in Southern Thailand

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