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A New Approach to Managing Young Non–Toxic-Appearing Febrile Children
Researchers suggest an emphasis on more-limited evaluation, now that vaccines have greatly reduced the likelihood of serious bacterial infections.
Since the 1970s, considerable attention has been paid to the management of febrile children aged 3 years without an obvious focus of infection. Recommendations have emphasized detection of serious bacterial infections (SBIs), including occult bacteremia (OB), and empirical antibiotic treatment for children considered to be at high risk. Management has been determined using a combination of clinical appearance, age, and laboratory tests, with more testing recommended for infants aged <3 months than for those aged 3 to 36 months.
Effective vaccines against Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae, the two major causes of occult SBIs, have been universally available in the U.S. since 1988 and 2000, respectively. The incidence of invasive Hib infection in children aged <5 years dropped by 99% between 1987 and 2007, and the incidence of pneumococcal OB is currently <0.5%. Urinary tract infections (UTIs) are now the most common SBI in febrile children without localizing signs. Considering these changes, researchers from four major pediatric departments suggest that recommendations for managing such children be updated.
These researchers state that new guidelines should emphasize the importance of immediate antimicrobial therapy for an infant who is seriously ill or toxic appearing and a complete clinical and laboratory evaluation for high-risk febrile infants aged 30 days, as we have been doing. However, for intermediate-risk infants aged 31 to 90 days, acceptable management can range from complete evaluation to simply observation and follow-up. And for infants aged 3 to 36 months who have received 2 doses of both Hib and pneumococcal conjugate vaccines, evaluation only for UTI is warranted.
Comment: Although these recommendations don't carry the stamp of any official organization, they are supported by evidence. If they are put into practice, venipunctures, lab tests, cultures, and hospitalizations would all be reduced.
— Robert S. Baltimore, MD
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