Peds

Bacteremia in Children

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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

  • Definitions
  • Fever Without Focus
  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
  • 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
  • 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
  2. Bacteremia occurs in even well appearing infants (<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 <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]
  • 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
  • Associated Conditions
  • Occult Bacteremia underlying causes
  • 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
  • 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]