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Bacteraemia in febrile children presenting to a pae3iatric emergency department
R A Haddon1, P L Barnett, K Grimwood
1Department of Emergency Medicine, Royal Children's Hospital, Melbourne, VIC.
Insights
Occult bacteraemia (bacterial bloodstream infection) affects 3-4% of young febrile children in Australia. Clinical signs and white blood cell counts are unreliable for diagnosis, suggesting close monitoring over empiric antibiotics.
Area of Science:
- Pediatrics
- Infectious Diseases
- Clinical Microbiology
Background:
- Febrile young children presenting to emergency departments often have viral illnesses.
- Identifying bacterial bloodstream infections (bacteraemia) is crucial for appropriate management.
Purpose of the Study:
- To determine the prevalence of bacteraemia in young febrile children without a clear clinical focus.
- To evaluate the predictive accuracy of clinical features and white blood cell counts for bacteraemia.
Main Methods:
- Prospective observational study of 534 children aged 3-36 months with fever (≥39°C) at a paediatric emergency department.
- Blood cultures, white blood cell counts, and clinical assessments were performed.
Main Results:
- Bacteraemia was found in 3.4% of children, with Streptococcus pneumoniae being the most common pathogen.
- Increased white blood cell counts and brief fever duration were associated with bacteraemia.
- Clinical features and elevated white blood cell counts had low predictive accuracy (<10%) for bacteraemia.
Conclusions:
- Most febrile children in this age group without a clear focus have viral infections.
- Occult bacteraemia occurs in 3-4% of cases and is not reliably identified by current clinical assessments.
- Close monitoring and review are recommended over empiric antibiotic therapy to mitigate antibiotic resistance.
Objective:
To determine the prevalence of bacteraemia in young febrile children presenting to a paediatric emergency department.
Design:
Prospective observational case study.
Setting:
Emergency Department of the Royal Children's Hospital, Melbourne, between May 1996 and May 1997.
Participants:
Patients aged 3-36 months presenting to the Emergency Department with temperature > or = 39 degrees C and without specific viral illnesses (varicella, croup or herpes gingivostomatitis).
Outcome Measures:
Bacteraemia (defined as presence of pathogenic bacteria in a blood culture), white blood cell count (WCC), McCarthy score, and final diagnosis based on clinical features and investigations.
Results:
Bacteraemia was identified in 18 of 534 patients (3.4%). Pathogens isolated were Streptococcus pneumoniae (15), Neisseria meningitidis (2) and Klebsiella pneumoniae (1). Increased WCC counts (P < 0.001) and brief duration of fever (P < 0.001) were associated with bacteraemia. Nevertheless, clinical features, including McCarthy scores, and high WCC counts (> or = 20 x 10(9)/L) had < 10% predictive accuracy for bacteraemia. Overall, final diagnoses in the 534 febrile children included non-specific viral infections (25%), upper respiratory tract infections (24%), otitis media (10%), gastroenteritis (9%), pneumonia (7%), and urinary tract infection (5%).
Conclusions:
Most urban Australian children aged 3-36 months presenting to a paediatric emergency department with temperature > or = 39 degrees C without a clinical focus have a viral infection. However, 3%-4% have occult bacteraemia. Neither clinical features nor high WCC counts reliably identify these patients. As empiric antibiotics may contribute to increasing antibiotic resistance and have not been shown to prevent the rare complication of meningitis, we believe that close contact and regular review of these patients is preferable to empiric antibiotic therapy.