Prevalence of Occult Bacteremia in Infants With Very High Fever Without a Source

Gangoiti, Iker; Rodriguez, Elva; Zubizarreta, Ane; Benito, Javier; Mintegi, Santiago

doi:10.1097/inf.0000000000001955

Cited by 7 publications

(9 citation statements)

References 7 publications

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“…While a clear focus of bacterial infection may be present with presentations of acute otitis media (AOM) or urinary tract infection (UTI), occult bacteremia can also occur in children who appear otherwise well, and fever without focus is a common presentation, particularly so in those aged < 36 months [4–6]. However, occurring in as few as 1% of febrile children [4, 5], these ‘hidden’ bacterial infections represent a needle in the haystack, and the challenge for clinicians is to accurately identify children at risk of bacterial infections. While it is possible that they may resolve spontaneously, for those in whom they do not, life-threatening and potentially life-changing complications can develop [4, 7, 8], with adverse outcomes in each survivor of severe meningococcal disease resulting in lifelong treatment costs of ~ £1.3m [9].…”

Section: Introductionmentioning

confidence: 99%

The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department

Leigh

Grant

Murray

et al. 2019

BMC Med

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Background Paediatric fever is a common cause of emergency department (ED) attendance. A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes. Methods We studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children’s Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing. Results Infants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39–£2993.37] per child, ( p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0–5.1-fold] higher resource use than consultants ( p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5–13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate ‘red flag’, treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations. Conclusion The economic impact of diagnostic uncertainty when managing paediatric febrile illness is significant, and the precautionary use of antibiotics is strongly associated with increased costs. The use of ED resources is highest among infants (aged less than 3 months) and those infants managed by lesser experienced doctors, independent of clinical severity. Diagnostic advances which could increase confidence to withhold antibiotics may yield considerable efficiency gains in these groups, where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest. ...

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Section: Introductionmentioning

confidence: 99%

The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department

Leigh

Grant

Murray

et al. 2019

BMC Med

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“…However, the UTI rate of 7.5% in this study corresponded to the rates of UTI in other studies on patients in the same age group (6.8%-9.9%). 2,14 No occult pneumonia was identified in this study, as chest radiographs are not routinely performed in febrile young children who have normal lung signs on examination, even if white blood cell counts were greater than 20,000, as suggested by some recommendations. 6,20 We performed a comparison of clinical characteristics and outcomes between children with culture-confirmed UTI and those with culture-negative FWS to differentiate children with and without invasive bacterial infections.…”

Section: Discussionmentioning

confidence: 75%

“…Currently, many countries around the world have incorporated multiple vaccines into their national immunization programs, resulting in a significant reduction in the rate of bacteremia among febrile children (0.25%-1.1%). [2][3][4][5] The introduction of the Haemophilus influenzae type B (Hib) vaccine and PCV in many countries has led to a decrease in the practice of performing blood tests in seemingly healthy children with FWS. 6,7 In Thailand, although the Hib vaccine was recently included in the National Expanded Programme on Immunization (EPI) in 2019, the PCV has not yet been incorporated into the EPI; thus, young children are still at risk of pneumococcal diseases.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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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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“… 1 2 Though most display signs and symptoms suggestive of specific infections; in ~20% of cases, there is no obvious cause. 3 4 These children are a concern to healthcare providers (HCPs), due to a small but significant risk of life-threatening bacterial infections, 5 which can have catastrophic consequences if undetected.…”

Section: Introductionmentioning

confidence: 99%

What matters when managing childhood fever in the emergency department? A discrete-choice experiment comparing the preferences of parents and healthcare professionals in the UK

et al. 2020

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Background Fever among children is a leading cause of emergency department (ED) attendance and a diagnostic conundrum; yet robust quantitative evidence regarding the preferences of parents and healthcare providers (HCPs) for managing fever is scarce. Objective To determine parental and HCP preferences for the management of paediatric febrile illness in the ED. Setting Ten children's centres and a children's ED in England from June 2018 to January 2019. Participants 98 parents of children aged 0-11 years, and 99 HCPs took part. Methods Nine focus-groups and coin-ranking exercises were conducted with parents, and a discrete-choice experiment (DCE) was conducted with both parents and HCPs, which asked respondents to choose their preferred option of several hypothetical management scenarios for paediatric febrile illness, with differing levels of visit time, out-of-pocket costs, antibiotic prescribing, HCP grade and pain/discomfort from investigations. Results The mean focus-group size was 4.4 participants (range 3-7), with a mean duration of 27.4 min (range 18-46 min). Response rates to the DCE among parents and HCPs were 94.2% and 98.2%, respectively. Avoiding pain from diagnostics, receiving a faster diagnosis and minimising wait times were major concerns for both parents and HCPs, with parents willing-to-pay £16.89 for every 1 hour reduction in waiting times. Both groups preferred treatment by consultants and nurse practitioners to treatment by doctors in postgraduate training. Parents were willing to trade-off considerable increases in waiting times (24.1 min) to be seen by consultants and to avoid additional pain from diagnostics (45.6 min). Reducing antibiotic prescribing was important to HCPs but not parents. Conclusions Both parents and HCPs care strongly about reducing visit time, avoiding pain from invasive investigations and receiving diagnostic insights faster when managing paediatric febrile illness. As such, overdue advances in diagnostic capabilities should improve child and carer experience and HCP satisfaction considerably in managing paediatric febrile illness.

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Prevalence of Occult Bacteremia in Infants With Very High Fever Without a Source

Cited by 7 publications

References 7 publications

The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department

The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department

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

What matters when managing childhood fever in the emergency department? A discrete-choice experiment comparing the preferences of parents and healthcare professionals in the UK

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