Baraff wrote an excellent review of this topic in Pediatric Annals
A Somber Florida Gator
On Mar 18, 2009, at 7:23 PM, JaPe wrote:
> Rich & All,
> Well said! While I agree with your overall philosophy & rationale of
> care for "most febrile
> toddlers (2-24 months old, non-toxic appearing)" I have reservations
> about it being embraced enthusiastically.
> I would refer all to an excellent commentary by Dr.'s Avner and
> Baker in response to the retrospective study by Wilkinson that you
> cited in AEM 2009. As you mentioned, they discuss the issue of a
> smaller denominator in these type of studies rendering the overall
> prevalence lower than cited. By the same token, they also highlight
> that one of the challenges is what constitutes a "non toxic" or
> "well appearing" infant? For an experienced clinician like yourself,
> working at a high volume, tertiary level pediatric facility, this
> threshold may be much higher than say, a general EP or FP, who may
> be more conservative in their approach.
> For instance, I can understand the difficulty assessing a highly
> febrile infant with an influenzal illness who frequently will appear
> "unwell." There is also some evidence from the TCH in Houston that
> hyperpyrexic patients have a higher incidence of SBI and they
> advocate emperic ABX even in the absence of leucocytosis. The curve
> ball in this discussion is unsuspected meningococcemia.
> Any thoughts? Thanks in advance!
> Jay Pershad,
> GO MEMPHIS TIGERS!
> From: Richard Scarfone MD <[log in to unmask]>
> I believe that we have entered an era in which one should not
> routinely obtain a blood culture for a febrile 8-month-old, just as
> one would not do so for a febrile 8-year-old. My approach is to
> perform a careful H and P, assess for UTI if certain risk factors
> are present and arrange for follow-up.
> Rich Scarfone
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