Infectious Disease Book

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Bacteremia in Children

Aka: Bacteremia in Children, Fever Without Focus, Fever Without Source, Occult Bacteremia, Streptococcal Bacteremia, Serious Bacterial Illness in Children
  1. See Also
    1. Fever Without Focus Labs
    2. Toxic Findings Suggestive of Occult Bacteremia
    3. Fever Without Focus Management Birth to 3 Months
    4. Fever Without Focus Management 3 to 36 months
    5. Pediatric Sepsis
    6. Neonatal Sepsis
    7. Rochester Criteria for Febrile Infant 0 to 60 days
    8. Philadelphia Criteria for Febrile Infant 29-60 days
    9. Milwaukee Criteria for Febrile Infant 28-56 days
    10. Boston Criteria for Febrile Infant 28-89 days
    11. Yale Scale for Febrile Child 3 to 36 months
  2. Definition
    1. Age under 36 months old
      1. Highest risk in younger infants (especially <29 days) and unimmunized
    2. Significant Fever (based on Rectal Temperature)
      1. Age <90 days: >38 C (100.4 F)
      2. Age >90 days and unimmunized: >39 C (102.2 F) - 3% Occult Bacteremia risk
      3. Age >90 days and immunized: No defined Temperature cutoff (lower risk)
    3. No localizing signs
      1. Acute onset of fever persisting <1 week
      2. Findings dictating assessment for Occult Bacteremia or serious Bacterial illness
  3. Precautions
    1. Decision rules in Occult Bacteremia assume an otherwise well child
      1. Sepsis evaluation is required in a toxic appearing child regardless of decision criteria
      2. Children with chronic disease risk factors (see below) also require Sepsis evaluation
  4. Causes: Common etiologies of Occult Bacteremia
    1. Newborns and age 1-3 months
      1. Urinary Tract Infections are the most common cause of serious Bacterial Infections in this age group
      2. Group B Beta-hemolytic Streptococcus (Group B Strep)
      3. Escherichia coli K1 (ECK1)
      4. Klebsiella species
      5. Listeria monocytogenes
        1. Rare in the United States
        2. Predominant in Spain
      6. Neonatal Herpes Simplex Virus (HSV)
        1. Incidence similar to Bacterial Meningitis (25 to 50 cases per 100,000 live births in U.S.)
    2. Children 3-36 months
      1. Pneumonia and Urinary Tract Infections
        1. Most common cause of serious Bacterial Infections in this age group
      2. Most common prior to Prevnar (PCV7) and Hib Vaccines (down to <0.2% Incidence)
        1. Streptococcus Pneumoniae
          1. Accounted for 80-90% of Occult Bacteremia pre-PrevnarVaccine (PCV7)
        2. HaemophilusInfluenzae
          1. Prior to Hib Vaccine
            1. Most common cause of Meningitis and invasive disease <5 years old
          2. Since Hib Vaccine
            1. Incidence of Hib-related serious Bacterial Infections has dropped 99%
      3. Other causes of serious Bacterial illness in ages 3-36 months
        1. Group A Beta-hemolytic Streptococcus
        2. Neisseria Meningitidis
  5. Associated Conditions: Occult Bacteremia underlying causes
    1. Urinary Tract Infection
    2. Otitis Media
    3. Bacterial Pneumonia
    4. Streptococcal Pharyngitis
    5. Bacterial Meningitis
    6. Skin or soft tissue infection
    7. Bone or joint infection
  6. Risk Factors: High risk conditions for Occult Bacteremia regardless of patient appearance
    1. Serious underlying chronic diseases
      1. Immunosuppression
      2. Sickle Cell Disease
      3. Asplenia
      4. Congenital Heart Disease
      5. Ventriculoperitoneal Shunt
    2. Assumes no regular medical interventions
      1. Hemodialysis
      2. Ongoing intravenous therapy
      3. Indwelling catheter
  7. Signs
    1. See Toxic Findings Suggestive of Occult Bacteremia
    2. Fever height no longer correlates with seriousness of illness
      1. Pneumococcus and H. Influenzae were asscociated with fevers over 105 F prior to Prevnar and Hib Vaccines
      2. Fever to 105 or 106 F should now be approached the same as lower Temperature spike without focus
  8. Labs
    1. See Fever Without Focus Labs
  9. Management
    1. Age 0 months to 1 month
      1. See Fever Without Focus Management Birth to 3 Months
      2. See Rochester Criteria for Febrile Infant 0 to 60 days
      3. See Neonatal Sepsis
    2. Age 1 month to 3 months
      1. See Fever Without Focus Management Birth to 3 Months
      2. See Rochester Criteria for Febrile Infant 0 to 60 days
      3. See Philadelphia Criteria for Febrile Infant 29-60 days
      4. See Milwaukee Criteria for Febrile Infant 28-56 days
      5. See Boston Criteria for Febrile Infant 28-89 days
    3. Age 3 months to 36 months
      1. See Fever Without Focus Management 3 to 36 months
      2. See Yale Scale for Febrile Child 3 to 36 months
  10. References
    1. Herman (2015) Crit Dec Emerg Med 29(12):14-19
    2. Wang and Claudius in Majoewsky (2013) EM:Rap 13(6): 1-2
    3. Baraff (2000) Ann Emerg Med 36:611 [PubMed]
    4. Baraff (1993) Pediatrics 92(1): 1-12 [PubMed]
    5. Daaleman (1996) Am Fam Physician 54(8):2503 [PubMed]
    6. Hamilton (2013) Am Fam Physician 87(4): 254-60 [PubMed]
    7. Kimmel (1996) Fam Pract Recert 18(7):69-85 [PubMed]
    8. Lee (1998) Arch Pediatr Adolesc Med 152:624-8 [PubMed]
    9. Lopez (1997) Postgrad Med 101(2):241-52 [PubMed]
    10. (1993) Ann Emerg Med 22(3):628-37 [PubMed]

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