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Treatment of occult bacteremia: a prospective randomized clinical trial
Insights
Expectant antibiotic therapy is recommended for children at risk for bacteremia without a clear infection source. This approach showed improved outcomes and no complications in a randomized trial.
Area of Science:
- Pediatrics
- Infectious Diseases
- Clinical Trials
Background:
- Antibiotic use in febrile children without a source of infection is debated.
- Identifying children at risk for occult bacteremia is crucial for appropriate management.
Purpose of the Study:
- To evaluate the efficacy and safety of expectant antibiotic therapy in children at risk for bacteremia.
Main Methods:
- A prospective randomized trial enrolled 96 children (6-24 months) with high fever, no infection source, and elevated inflammatory markers.
- Participants received either expectant antibiotic therapy or no antibiotics.
- Blood cultures, imaging, and cultures were performed; lumbar puncture was done for infants under 12 months.
Main Results:
- Ten of 96 children had bacteremia (Streptococcus pneumoniae, Haemophilus influenzae).
- Children receiving expectant antibiotic therapy showed improvement, while untreated children had poorer outcomes and developed focal infections (meningitis, otitis media).
- No adverse events were observed with expectant antibiotic therapy.
Conclusions:
- Expectant antibiotic therapy is a warranted approach for children meeting criteria for occult bacteremia.
- Early antibiotic intervention can prevent serious complications in at-risk children.
Abstract:
Antibiotic therapy for children without foci of infection and at risk for bacteremia is controversial. A prospective randomized clinical trial was conducted using expectant antibiotic therapy in children at risk for bacteremia. A total of 96 children (aged 6 to 24 months) with temperature of more than 40 degrees C, no identifiable source of infection, and a leukocyte count greater than or equal to 15,000/microL and/or sedimentation rate greater than or equal to 30 were enrolled. The following tests were performed on all children: blood culture, chest roentgenogram, urinalysis, and urine culture. A lumbar puncture was performed if a child was 12 months or less. Patients were randomized to receive either no antibiotic therapy or Bicillin C-R, 50,000 U/kg intramuscularly, followed by penicillin V, 100 mg/kg/d, orally four times a day for three days. Patients were examined at 24 and 72 hours. Fifty patients were treated expectantly and 46 received no antimicrobial therapy. Ten of the 96 patients were bacteremic (nine had Streptococcus pneumoniae, one had Haemophilus influenzae). Four of the five children treated for bacteremia showed improvement at the first follow-up visit (afebrile and no obvious focus of infection). The five untreated patients showed no improvement; four patients developed focal infections (two had meningitis, two had otitis media) (P less than or equal to .05, Fisher exact test). No complications of expectant therapy were detected. Thus, expectant antibiotic therapy for children who have no obvious source of infection and who meet these criteria associated with occult bacteremia is warranted.