Hi Rich,

Thanks for this information, nicely done. I too have often quoted the 
_Fever is not an antibiotic deficiency_, and I think it may have started 
with Dr Oski. I remember reading it in an editorial in one of the 
_throwaway_ journals I think, a long time ago in a galaxy far, far way. 
. . . . :-)

Tacoma WA

Richard Scarfone MD wrote:
> Hi Jay,
> 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
> I assessed:
> -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 
> None hospitalized
> 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.
> Rich 
>>>> 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
> 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
> 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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