Bacteremia in Children

Aka: Bacteremia in Children, Fever Without Focus, Fever Without Source, Occult Bacteremia, Streptococcal Bacteremia, Serious Bacterial Illness in Children, Approach to Fever in Children Under 36 months, Pediatric Fever Age Under 3 Years

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II. Definitions: Fever Without Focus

  1. Age under 36 months old (guidelines are shifting to under 24 months)
    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

III. Epidemiology

  1. Well appearing, term infants age <60 days with fever (>38 C or 100.4 F)
    1. Bacteremia Prevalence 1.8% (up to 3.1% if under age 28 days)
    2. E. coli (39.3%) and Group B Streptococcus (24%) were most common
    3. Bacteremia was accompanied by Urinary Tract Infection in 43%, and by Meningitis in 13%
    4. Meningitis primarily occured in infants <28 days, with a 0.2% rate in those 29 to 60 days old
    5. Powell (2017) Ann Emerg Med +PMID: 28988964 [PubMed]
  2. Immunizations and peripartum antibiotic prophylaxis have dramatically decreased serious infections age <5 years
    1. Occult Bacteremia in febrile children <36 months have decreased to 2% (previously 12%)
      1. Powell (2018) Ann Emerg Med 71(2):211-6 [PubMed]
    2. Invasive pneumococcus decreased 90% after Pneumococcal Conjugate Vaccine
    3. HaemophilusInfluenzae Type B decreased 99% after Hib Vaccine
      1. (1996) MMWR Morb Mortal Wkly Rep 45(42):901-6 [PubMed]
    4. Peripartum GBS Prophylaxis has significantly decreased Group B Streptococcal Sepsis and ListeriosisIncidence
  3. Unimmunized and underimmunized children have an increased risk of Occult Bacteremia
    1. See precautions below, esp. unimmunized age <24 months

IV. 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
    3. Exercise caution in the unimmunized child under age 24 months
  2. Bacteremia occurs in even well appearing infants (esp. <60-90 days), despite reassuring decision rule results
    1. See epidemiology above
    2. Exercise caution in age <90 days (esp. <28 days)
    3. Most infants <21 to 28 days undergo full workup (including Lumbar Puncture) and are admitted
    4. Mason, Claudius and Behar in Herbert (2018) EM:Rap 18(2): 6-7
  3. Urinary Tract Infection
    1. Urinalysis abnormalities do not exclude other source
    2. Urinary Tract Infection is increasing in Incidence
      1. Now the most common cause of serious Bacterial Infection in age<36 months
      2. Rudinsky (2009) Acad Emerg Med 16(7): 585-90 [PubMed]
      3. Copp (2011) J Urol 186(3): 1028-34 [PubMed]
    3. Urinary Tract Infection Amoxicillin resistance is increasing
    4. Ciofreddi (2016) JAMA Pediatr 170(8): 794-800 [PubMed]

V. 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 (guidelines shifting toward 2-24 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

VI. 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

VII. 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

VIII. Signs

  1. Experienced clinical gestalt of an ill Appearing Child is a strong predictor of serious Bacterial Infection (LR>5)
    1. See Toxic Findings Suggestive of Occult Bacteremia
    2. See Fever decision rules specific for age as below
  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
  3. Exam findings suggestive of serious Bacterial Infection
    1. Capillary Refill >3 seconds
    2. Pertechial Rash
    3. Increased Respiratory effort
    4. Decreased Arousability
  4. References
    1. Verbakel (2014) Pediatr Emerg Care 30(6): 373-80 [PubMed]

IX. Labs

  1. See Fever Without Focus Labs

X. Management

  1. Age <3 to 7 days (Early onset Sepsis)
    1. See Neonatal Sepsis
  2. Age 3 to 30 days
    1. See Neonatal Sepsis
    2. See Fever Without Focus Management Birth to 3 Months
    3. See Step-By-Step Protocol for Febrile Infants
    4. See Rochester Criteria for Febrile Infant 0 to 60 days
  3. Age 1 month to 3 months (guidelines are shifting toward 1 to 2 months)
    1. See Fever Without Focus Management Birth to 3 Months
    2. See Laboratory Score for Febrile Infants
    3. See Rochester Criteria for Febrile Infant 0 to 60 days
    4. See Philadelphia Criteria for Febrile Infant 29-60 days
    5. See Milwaukee Criteria for Febrile Infant 28-56 days
    6. See Boston Criteria for Febrile Infant 28-89 days
  4. Age 3 months to 36 months (guidelines are shifting toward 2 to 24 months)
    1. See Fever Without Focus Management 3 to 36 months
    2. See Yale Scale for Febrile Child 3 to 36 months

XI. 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. Hamilton (2020) Am Fam Physician 101(12): 721-9 [PubMed]
  8. Kimmel (1996) Fam Pract Recert 18(7):69-85 [PubMed]
  9. Lee (1998) Arch Pediatr Adolesc Med 152:624-8 [PubMed]
  10. Lopez (1997) Postgrad Med 101(2):241-52 [PubMed]
  11. (1993) Ann Emerg Med 22(3):628-37 [PubMed]

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