Practice guideline for the management of infants and children 0 to 36 months of age with fever without source

Baraff, Larry J.; Bass, James W.; Fleisher, Gary; Klein, Jerome O.; McCracken, George H.; Powell, Keith R.; Schriger, David L.

doi:10.1016/s0196-0644(05)80991-6

Cited by 459 publications

(492 citation statements)

References 91 publications

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“…Several management protocols have been published. 9,10,15,[17][18][19] Some studies have shown that selected febrile infants may safely be managed as outpatients without the use of antibiotics. 10,18,19 Those infants had to meet more stringent risk criteria than ours to qualify for outpatient management, and 75% of the most recent study population of infants 29 to 60 days old using this strategy were admitted.…”

Section: Discussionmentioning

confidence: 99%

“…9 -19 No definitive data have been reported establishing the timing of detection of positive cultures. The practice guidelines by Baraff et al 17 for the management of infants and children 0 to 36 months of age with fever without source include recommendations that were made in the absence of these data. In 2 studies, low-risk infants were treated as outpatients with empiric antibiotics.…”

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confidence: 99%

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Time to Detection of Positive Cultures in 28- to 90-Day-Old Febrile Infants

Kaplan¹,

Harper²,

Baskin³

et al. 2000

Pediatrics

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ABSTRACT. Objective. To determine the time to detection of positive blood, urine, and cerebrospinal fluid (CSF) cultures among febrile 28-to 90-day-old infants.Study Design. Retrospective cohort of consecutive 28-to 90-day-old infants presenting with a temperature of >38°C to an urban pediatric emergency department. Positive cultures and times to detection were noted. Patients were categorized as being at high risk for serious bacterial illness (SBI) based on clinical and laboratory criteria.Results. Of the 3166 febrile infants seen in the emergency department during the study, 2733 had blood (86%), 2517 had urine (80%), and 2361 had CSF (75%) specimens obtained for culture, and 2190 had all 3 cultures (69%) sent. There were 224 positive cultures in 214 patients; of these, 191 had all 3 cultures (89%) sent. Subsequent analyses were confined to those who had all 3 cultures sent. The detected rate of SBI was 8.7% ( Conclusions. The risk of identifying SBI after 24 hours is 1.1% among all 28-to 90-day-old febrile infants and .3% in low-risk infants. Pediatrics 2000;106(6). URL: http://www.pediatrics.org/cgi/content/full/106/6/e74; serious bacterial illness, febrile infants.ABBREVIATIONS. SBI, serious bacterial illness; CSF, cerebrospinal fluid; ED, emergency department; CI, confidence interval; CBC, complete blood cell count. U p to 15% of 28-to 90-day-old febrile infants may have serious bacterial illness (SBI). 1-8 The patient's physical examination and laboratory evaluation may not detect all SBIs. 9 -19 No definitive data have been reported establishing the timing of detection of positive cultures. The practice guidelines by Baraff et al 17 for the management of infants and children 0 to 36 months of age with fever without source include recommendations that were made in the absence of these data. In 2 studies, low-risk infants were treated as outpatients with empiric antibiotics. 9,15 Baskin et al 15 showed that lowrisk febrile infants 28 to 89 days of age can be managed safely with the administration of a parenteral dose of ceftriaxone and discharged from the hospital with a scheduled follow-up within 24 hours for clinical reevaluation and a second dose of ceftriaxone to provide antibiotic coverage while the blood, urine, and cerebrospinal fluid (CSF) cultures incubate. This strategy is based on the assumptions that most pathogens are identified within 48 hours and 2 doses of ceftriaxone will provide sufficient protection for those children whose pathogens are identified later. Other authors, using more stringent risk criteria, advocate outpatient management of low-risk febrile infants without antibiotic treatment, and inpatient management of the rest. 10,18,19 We sought to determine the time to detection of positive cultures so that optimal strategies for management and follow-up can be devised and implemented. METHODS Design, Setting, and SubjectsThe investigation was a retrospective cohort study. Subjects were febrile infants seen in the emergency department (ED) of an urban pediatric teaching hospital. T...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Time to Detection of Positive Cultures in 28- to 90-Day-Old Febrile Infants

Kaplan¹,

Harper²,

Baskin³

et al. 2000

Pediatrics

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“…Previous studies indicated that white blood cell count is an imperfect tool for distinguishing between viral and bacterial infection, a distinction often used to determine whether to treat the patient with antibiotics (21,22). We compared classification based on transcriptional profiles with classification based on white blood cell count using a cutoff of 15,000/mm 3 as recommended by the American Academy of Pediatrics in their guideline for the management of febrile young children 0-36 mo of age (23). We also analyzed a different set of cutoffs based on age-specific normal values for white blood cell count used by the clinical laboratory at St. Louis Children's Hospital (Materials and Methods).…”

Section: Transcriptional Profile Was Superior To Traditional White Blmentioning

confidence: 99%

Gene expression profiles in febrile children with defined viral and bacterial infection

Hu¹,

Crosby

et al. 2013

Proc. Natl. Acad. Sci. U.S.A.

116

119

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Viral infections are common causes of fever without an apparent source in young children. Despite absence of bacterial infection, many febrile children are treated with antibiotics. Virus and bacteria interact with different pattern recognition receptors in circulating blood leukocytes, triggering specific host transcriptional programs mediating immune response. Therefore, unique transcriptional signatures may be defined that discriminate viral from bacterial causes of fever without an apparent source. Gene expression microarray analyses were conducted on blood samples from 30 febrile children positive for adenovirus, human herpesvirus 6, or enterovirus infection or with acute bacterial infection and 22 afebrile controls. Blood leukocyte transcriptional profiles clearly distinguished virus-positive febrile children from both virus-negative afebrile controls and afebrile children with the same viruses present in the febrile children. Virus-specific gene expression profiles could be defined. The IFN signaling pathway was uniquely activated in febrile children with viral infection, whereas the integrin signaling pathway was uniquely activated in children with bacterial infection. Transcriptional profiles classified febrile children with viral or bacterial infection with better accuracy than white blood cell count in the blood. Similarly accurate classification was shown with data from an independent study using different microarray platforms. Our results support the paradigm of using host response to define the etiology of childhood infections. This approach could be an important supplement to highly sensitive tests that detect the presence of a possible pathogen but do not address its pathogenic role in the patient being evaluated.

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“…upper respiratory tract infection, URTI, tonsillitis, asthma) but some were only established by radiological or laboratory means (such as pneumonia, urinary tract infection, UTI, and bacteraemia). If there was no focus of infection in a febrile child, a diagnosis of fever without focus was made, which is defined as an acute febrile illness in which the aetiology of fever was not apparent after a careful history and physical examination [6]. A diagnosis of presumed viral infection (PVI) was made when bacterial infection (e.g.…”

Section: Introductionmentioning

confidence: 99%

Aetiology of Febrile Illnesses Presenting to a District Hospital

El-Radhi¹,

Patel²

2017

Pediatric Infect Dis

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Little attention has been given to the patterns of diseases in children admitted to a hospital. We retrospectively studied 874 children (477 male, 397 female) who were hospitalised consecutively during a ten months period to determine the incidence and types of their illness with an emphasis on patterns and causes of fever.Respiratory symptoms of cough and wheezing were the single most common presenting cause of admission (20.3%). Fever (defined as one temperature record of >38.0°C or two successive record of 37.8°C) was the second most common presenting cause (15.8%) leading to admission, and within this group fever without focus was most common. Overall, fever was recorded in 35.9% of the study group. Urinary tract infection was the most common bacterial infection. Children with bacterial infections were usually febrile while the majority of those with presumed viral infections were afebrile. The mean body temperature in children with bacterial infections was significantly higher than in those with presumed viral infections. Overall, febrile children stayed significantly longer in hospital and underwent more laboratory tests compared with afebrile children. Although white blood count and C-reactive protein tended to be higher in bacterial than in presumed viral infections, both tests were sometimes normal in serious bacterial infections and abnormally high in presumed viral diseases. Mild hyponatraemia (<135 mmol/L) was a common laboratory finding in febrile illness, and severe hyponatraemia (<130 mmol/L), was more common in bacterial diseases.It is concluded that febrile illnesses are common and only second to respiratory diseases as the leading cause of hospitalisation. Children with bacterial infection are usually febrile and those with high fever should be evaluated for serious bacterial diseases. Those children who present with fever without focus should be evaluated for an underlying urinary tract infection and bacteraemia.

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Practice guideline for the management of infants and children 0 to 36 months of age with fever without source

Cited by 459 publications

References 91 publications

Time to Detection of Positive Cultures in 28- to 90-Day-Old Febrile Infants

Time to Detection of Positive Cultures in 28- to 90-Day-Old Febrile Infants

Gene expression profiles in febrile children with defined viral and bacterial infection

Aetiology of Febrile Illnesses Presenting to a District Hospital

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