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Management of fever without source in infants and children
1Department of Pediatrics and Emergency Medicine, University of California, Los Angeles Emergency Medicine Center, Los Angeles, CA, USA. lbaraff@ucla.edu
Insights
Fever without source (FWS) in children can indicate occult bacterial infections like UTIs or bacteremia. The pneumococcal vaccine significantly reduces invasive infections, potentially making current diagnostic methods for FWS obsolete.
Area of Science:
- Pediatrics
- Infectious Diseases
- Vaccinology
Background:
- Twenty percent of febrile children present with fever without source (FWS) after initial evaluation.
- A small subset of these children may have occult bacterial infections, including bacteremia, urinary tract infections (UTIs), occult pneumonia, or meningitis.
- Current management strategies for FWS in infants and young children are age-based, with specific criteria (e.g., Rochester, Philadelphia) used for infants under 3 months to guide hospitalization decisions.
Purpose of the Study:
- To review the incidence of occult bacterial infections in children with FWS.
- To evaluate the impact of the new conjugate pneumococcal vaccine on the management of FWS.
Main Methods:
- Literature review of studies on fever without source in children.
- Analysis of the epidemiology of UTIs and bacteremia in febrile infants and young children.
- Assessment of the efficacy of the 7-valent conjugate pneumococcal vaccine.
Main Results:
- Occult UTIs are found in 3-4% of boys <1 year and 8-9% of girls <2 years with FWS.
- Occult pneumococcal bacteremia occurs in approximately 3% of children <3 years with FWS and T 39.0°C, rising to 10% with T ≥39.5°C and WBC ≥15,000/mm³.
- The conjugate pneumococcal vaccine demonstrates 90% efficacy against invasive Streptococcus pneumoniae infections.
Conclusions:
- The conjugate pneumococcal vaccine is expected to significantly decrease the incidence of invasive pneumococcal disease.
- Widespread vaccination may render current diagnostic practices for FWS, including WBC counts, blood cultures, and empiric antibiotic use, obsolete.
Abstract:
Twenty percent of febrile children have fever without an apparent source of infection after history and physical examination. Of these, a small proportion may have an occult bacterial infection, including bacteremia, urinary tract infection (UTI), occult pneumonia, or, rarely, early bacterial meningitis. Febrile infants and young children have, by tradition, been arbitrarily assigned to different management strategies by age group: neonates (birth to 28 days), young infants (29 to 90 days), and older infants and young children (3 to 36 months). Infants younger than 3 months are often managed by using low-risk criteria, such as the Rochester Criteria or Philadelphia Criteria. The purpose of these criteria is to reduce the number of infants hospitalized unnecessarily and to identify infants who may be managed as outpatients by using clinical and laboratory criteria. In children with fever without source (FWS), occult UTIs occur in 3% to 4% of boys younger than 1 year and 8% to 9% of girls younger than 2 years of age. Most UTIs in boys occur in those who are uncircumcised. Occult pneumococcal bacteremia occurs in approximately 3% of children younger than 3 years with FWS with a temperature of 39.0 degrees C (102.2 degrees F) or greater and in approximately 10% of children with FWS with a temperature of 39.5 degrees C (103.1 degrees F) or greater and a WBC count of 15, 000/mm(3) or greater. The risk of a child with occult pneumococcal bacteremia later having meningitis is approximately 3%. The new conjugate pneumococcal vaccine (7 serogroups) has an efficacy of 90% for reducing invasive infections of Streptococcus pneumoniae. The widespread use of this vaccine will make the use of WBC counts and blood cultures and empiric antibiotic treatment of children with FWS who have received this vaccine obsolete.