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, 

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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