I would hope that we have moved away from the "automatic" approach and
have embraced a more selective approach. Even within that model though,
"non-toxic" is a subjective assessment and we recognize that there will
be a range of clinical practice. Two docs might each encounter the same
100 febrile toddlers. Doc 1 might obtain a blood culture on 5 of the
children, while doc 2 might do so for 10. Each doc is bringing their
training and experience to the bedside.
Regarding hyperpyrexia (and leukocytosis), 2 seemingly contradictory
statements are true:
Hyperpyrexic toddlers do have a higher incidence of OB
Hyperpyrexic toddlers overwhelmingly have viral illness
For me, the positive predictive value of either hyperpyrexia or
leukocytosis is too low (and dropping as the prevalence of OB drops) to
be clinical useful in most situations.
Thankfully, unsuspected meningococcemia is extremely uncommon among
those without signs of sepsis. I recently reviewed this. The papers that
-Herz AM, Greenhow TL, Alcantara J, et al. Changing epidemiology of
outpatient bacteremia in 3- to 36-month-old children after the
introduction of the heptavalent-conjugated pneumococcal vaccine.
Pediatr Infect Dis J 2006;25:293-300.
-Alpern ER, Alessandrini EA, Bell LM, Shaw KN, McGowan KL. Occult
bacteremia from a pediatric emergency department: current prevalence,
time to detection, and outcome. Pediatrics 2000;106:505-511.
-Bandyopadhyay S, et al. Risk of serious bacterial infection in
children with fever without a source in the post-Haemophilus influenza
era when antibiotics are reserved for culture-proven bacteremia. Arch
Pediatr Adolesc Med 2002;156:512-519.
-Wilkinson M, et al. Prevalence of occult bacteremia in children aged
3-36 months presenting to the ED with fever in the postpneumococcal
conjugate vaccine era. Acad Emerg Med 2008;16:1-6.
-Cartairs KL, et al. Pneumococcal bacteremia and meningitis in febrile
infants in the post PCV7 era (abstract). Ann Emerg Med 2007;50:S38.
-Stoll ML, Rubin LG. Incidence of occult bacteremia among highly
febrile young children in the era of the pneumococcal conjugate vaccine.
Arch Pediatr Adolesc Med 2004;158:671-675.
These 6 retrospective studies had similiar inclusion criteria:
2-24 (or 3-36) months old, febrile
Previously healthy, no source
Present to ED, blood culture obtained
Some of these studies were performed pre-PCV7 and some post-PCV7. In
each, the authors reported prevalence of OB. Among those with positive
blood cultures, specific microorganisms were identified. Collectively,
over 53,660 blood cultures were obtained- just 11 grew N meningitidis.
>>> JaPe <[log in to unmask]> 03/18/09 7:23 PM >>>
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
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!
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
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