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Reevaluation of outpatients with Streptococcus pneumoniae bacteremia
1Division of Emergency Medicine, Children's Hospital, Boston, MA 02115, USA. bachur@a1.tch.harvard.edu
Insights
A standardized reevaluation process for children with Streptococcus pneumoniae bacteremia is needed. Well-appearing children without focal infections can often be managed as outpatients, with management guided by initial antibiotic use and follow-up fever.
Area of Science:
- Pediatrics
- Infectious Diseases
- Bacteriology
Background:
- The management of outpatients with Streptococcus pneumoniae bacteremia lacks standardization.
- Children requiring reevaluation due to illness or focal infections need admission and parenteral antibiotics.
- Limited data guide the follow-up of occult pneumococcal bacteremia in children.
Purpose of the Study:
- To characterize outcomes of outpatients with pneumococcal bacteremia based on follow-up evaluation.
- To propose a management scheme for reevaluating well-appearing children without serious focal infections.
Main Methods:
- Retrospective review of 548 outpatient Streptococcus pneumoniae bacteremia episodes.
- Exclusion of immunocompromised children, those with focal infections, or initial admission.
- Decision tree analysis to predict persistent bacteremia (PB).
Main Results:
- Persistent bacteremia (PB) or new focal infections occurred in 41 patients.
- PB was associated with initial antibiotic treatment, follow-up temperature, and white blood cell (WBC) count.
- A management scheme using initial antibiotic treatment and follow-up temperature predicted PB with 84% sensitivity and 86% specificity.
Conclusions:
- Prompt reevaluation is crucial for all patients with pneumococcal bacteremia.
- For well-appearing patients without focal infections, follow-up testing and admission decisions can be guided by initial antibiotics and follow-up fever.
- Children not initially treated or orally treated but still febrile are at highest risk for PB.
Background:
The reevaluation process for outpatients recalled for Streptococcus pneumoniae bacteremia has not been standardized. Children who return ill or with new serious focal infections require admission and parenteral antibiotic therapy. Limited data exist to guide the follow-up management of those patients identified as having occult pneumococcal bacteremia.
Objectives:
Characterize the outcomes of outpatients with pneumococcal bacteremia based on their evaluation at follow-up. For patients who are well-appearing without serious focal infection, propose a management scheme for reevaluation.
Methods:
Retrospective review of outpatients with pneumococcal bacteremia. Patients with immunocompromise, those identified with focal bacterial infection at the initial visit, or those admitted at the initial visit were excluded. Data were collected from the initial visit (when blood culture drawn) and follow-up visit with regard to clinical parameters, laboratory data, diagnoses, and any antibiotic treatment. Decision tree analysis was used to generate a model to predict children at high risk for persistent bacteremia (PB).
Results:
A total of 548 episodes of pneumococcal bacteremia were studied. Seventy-three children received no antibiotic, 239 oral antibiotic, and 236 parenteral antibiotic at the initial visit. Median age, temperature, and white blood cell (WBC) count were 13.5 months, 40.0 degrees C, and 20 400/mm(3). Forty-one patients had PB or new focal infections (15 with PB alone, 4 had focal infection and PB). Eight patients had meningitis at follow-up. Ninety-two percent returned because of notification of the positive blood culture result. A repeat blood culture was obtained in 92%, 23% had a lumbar puncture, 33% had a chest radiograph, and 12% were admitted. PB was associated with the antibiotic treatment group, elevation of temperature, and WBC count at follow-up. A simple management scheme using 2 sequential decision nodes of antibiotic treatment (none vs any) and then temperature at follow-up (>38.8 degrees C) would have predicted 16/19 patients with PB (sensitivity =.84 and specificity =.86).
Conclusions:
All patients with pneumococcal bacteremia need prompt reevaluation. For well-appearing patients without new focal infection, the utility of diagnostic testing (specifically repeat blood cultures) and the need for admission may be determined by the use of antibiotics at the initial evaluation and the presence of fever at follow-up. The majority of patients can be managed as outpatients entirely. Patients who did not receive antibiotics at the initial evaluation and those treated with oral antibiotics but remain febrile are at the highest risk for persistent bacteremia.