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There has been some thought provoking questions and issues raised
regarding this subject recently by the group.It seems, variability
regarding management of a child with fever between 3-36 mo of age
without a source, does exist.The pioneers of occult bacteremia study
group would definitely justify the workup to identify OB early and their
subsequent treatment to prevent serious bacterial infections, on the
other hand a clinician would try to justify his or her own clinical
skills to identify a sick vs.an well child.This is probably one major
area where community pediatricians always disagree with us as a
caregiver in the emergency room.This is one area where we have
differences amongst ourselves and probably that impedes proper resident
education in this subject.
In my personal believe from the teaching that I so far I have received,
OB  really does not correspond to how the child looks,(it is bacteremia
not sepsis).I also believe and it is a statistical fact that a high
leukocyte count of >15000 or ANC>10000 increases the possibility of
bacterimia. It is also the fact that although very small number, SBI do
occur as a complication of OB.That is even after excluding the
possibility of Hib.
I do agree that a close follow up of the patient is time saving and cost
effective but the follow up might not be possible in each and every
case.We do reccomend a 24 hr. follow up by the pediarician/ED who gets
work up and + ceftriaxone.
I think it is very difficult to generate a consensual standard of care
in this subject.I do not know who would want to take a chance to see a
meningitic kid in his or her ED, where he or she might have seen the
same child the day before with fever.Child indeed looked great!Would
you?
Flip side: A five year old may come to the ED looking great with fever,
sent home and presents the following day with strep pneumo meningitis.It
is possible.
Dr.Herman mentioned of getting a CXR with WBC of 18000.Is that even
without a respiratory symptom? Although anecdotally I have seen few
cases where a small infiltrate was detected in CXR with very high white
count even without respiratory symptom, but is there any data to support
it?
Dr.Sacchetti mentioned about getiing urine culture.Did you imply boys
upto 6mo and girls upto 24 mo?
I think a child with  fever and without a source have always mesmerised
us as pediatricians.This is the most common complaint of the population
we serve and it will always continue to be deceptive.
 
Subhankar Bandyopadhyay,MD
Fellow, Pediatric EM
Children's Hospital, Buffalo.
 
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