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Occult bacteremia in toxic-appearing, febrile infants. A prospective clinical study in an office setting
Insights
Toxic-appearing infants with high fever are at risk for occult bacteremia, even in outpatient pediatric settings. Clinical toxicity in febrile infants warrants blood tests to identify serious infections.
Area of Science:
- Pediatrics
- Infectious Diseases
- Clinical Microbiology
Background:
- Occult bacteremia, a bloodstream infection without an obvious source, is a concern in febrile infants.
- Differentiating between serious and non-serious febrile illnesses in children is crucial for timely and appropriate management.
Purpose of the Study:
- To prospectively evaluate the prevalence of occult bacteremia in infants presenting with a toxic appearance and high fever.
- To compare the risk of bacteremia in toxic-appearing febrile infants versus non-toxic febrile infants.
Main Methods:
- Prospective evaluation of infants with fever (>38.8 C), categorized by toxic appearance using clinical assessment.
- Collection of peripheral white blood cell (WBC) counts and blood cultures for all participating infants.
- Infectious source identification through history, physical examination, and diagnostic tests.
Main Results:
- Of 52 toxic-appearing infants, 50% had an identified infectious source (e.g., otitis media), and 12% had documented bacteremia (Streptococcus pneumoniae, group C Streptococcus).
- Five bacteremic infants had toxic, febrile illnesses with no identifiable focus.
- None of the 31 febrile infants without a toxic appearance had bacteremia.
Conclusions:
- Highly febrile, toxic-appearing infants are at significant risk for occult bacteremia.
- Clinical assessment of toxicity in febrile infants is essential and should prompt WBC count and blood culture for early detection of bacteremia.
Abstract:
The prevalence of occult bacteremia was evaluated prospectively in two groups of infants: those with a toxic appearance and temperature greater than 38.8 C and a comparison group with similar fever but without a toxic appearance. All patients were diagnosed by one physician employed in a suburban, middle-class, private ambulatory pediatric practice. Toxicity scores were assigned based on the results of history and physical examination. Peripheral white blood cell (WBC) counts and blood cultures were obtained for every child. Of 52 toxic infants involved in the study, an infectious source, commonly otitis media, was found in 26 (50%). Eighteen patients (35%) had WBC counts above 15,000. Bacteremia was documented in six patients (12%), due to Streptococcus pneumoniae in five and to group C Streptococcus in one. Five bacteremic infants had toxic, febrile illnesses for which no overt focus could be identified. None of 31 febrile infants without a toxic appearance had bacteremia. We conclude that highly febrile, toxic-appearing infants are at risk for occult bacteremia even when they are seen in the pediatrician's office. Toxicity diagnosed on the basis of clinical findings in a febrile infant warrants obtaining a white blood cell count and a blood culture.