Prevalence of Occult Bacteremia in Children Aged 3 to 36 Months Presenting to the Emergency Department with Fever in the Postpneumococcal Conjugate Vaccine Era

Department of Emergency Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA.
Academic Emergency Medicine (Impact Factor: 2.01). 03/2009; 16(3):220-5. DOI: 10.1111/j.1553-2712.2008.00328.x
Source: PubMed


The goal of this study was to identify the prevalence of occult bacteremia (OB) in well-appearing, previously healthy children aged 3 to 36 months who present to the emergency department (ED) with fever without source in the post-pneumococcal conjugate vaccine (PCV) era.
This was a retrospective cohort study of children presenting to an urban pediatric ED between July 1, 2004, and June 30, 2007. Children were included if they were aged 3 to 36 months, febrile, and previously healthy; had no source of infection on examination; had a blood culture drawn; and were discharged from the ED. Outcome measures were rates of OB and contaminant rates.
A total of 8,408 children met all inclusion criteria. There were 21 true-positives, yielding an OB rate of 0.25% (95% confidence interval [CI] = 0.16% to 0.37%). There were 159 contaminant cultures yielding a contaminant rate of 1.89% (95% CI = 1.61% to 2.19%), or a ratio of 7.6 contaminants for each true-positive. There were 14 included patients who grew Streptococcus pneumoniae from the blood, for a rate of 0.17% (95% CI = 0.09% to 0.27%).
Given the current rate of OB in the post-PCV era, it may no longer be cost-effective to send blood cultures on well-appearing, previously healthy children aged 3 to 36 months who have fever without source.

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    • "The hypothesis that GEMPs rely more heavily on invasive testing to assess young febrile children of 3–36 months of age was not supported by our findings. This minimalistic approach is consistent with recent recommendations that recommend the elimination of routine invasive testing for well-appearing young febrile children based on very low rates of occult bacteremia (<0.5%) among vaccinated children [11, 12]. "
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    ABSTRACT: Background. The primary objective of this study was to compare management practices of general emergency physicians (GEMPs) and pediatric emergency medicine physicians (PEMPs) for well-appearing young febrile children. Methods. We retrospectively reviewed the charts of well-appearing febrile children aged 3–36 months who presented to a large urban children's hospital (PED), staffed by PEMPs, or a large urban general emergency department (GED), staffed by GEMPs. Demographics, immunization status, laboratory tests ordered, antibiotic usage, and final diagnoses were collected. Results. 224 cases from the PED and 237 cases from the GED were reviewed. Children seen by PEMPs had significantly less CXRs (23 (10.3%) versus 51 (21.5%), P = 0.001) and more rapid viral testing done (102 (45%) versus 40 (17%), P < 0.0001). A diagnosis of a viral infection was more common in the PED, while a diagnosis of bacterial infection (including otitis media) was more common in the GED. More GED patients were prescribed antibiotics (41% versus 27%, P = 0.002), while more PED patients were treated with oseltamivir (6.7% versus 0.4%, P < 0.001). Conclusions. Our findings identify important differences in the care of the young, well-appearing febrile child by PEMPs and GEMPs and highlight the need for standardization of care.
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    • "The evaluation and treatment of children with fever without a source is a challenging and controversial clinical problem [5]. Although most well appearing children with fever have benign viral illnesses, fever might represent the first sign of occult bacteremia and subsequent serious bacterial infection [6,7]. Discrimination based on clinical criteria has not been sufficient to determine management [8]. "
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