Background: Evaluation of children with fever without localizing signs (FWLS) is largely unchanged in the United States since 1993 despite reduced invasive disease after Haemophilus influenzae type b conjugate vaccine and conjugate Pneumococcal vaccine (PCV7). PCV7 is now recommended in the United Kingdom for children under 2 years, and new NICE guidelines have been issued for managing feverish children in the UK in anticipation of PCV7's efficacy. We compared rates of bacterial infections in children 3-36 months with FWLS in the pre- and post-PCV7 eras to define current trends and evaluate the guidelines that exist.
Methods: We identified all pediatric blood cultures performed in the emergency department in the years pre- and post-PCV7. We subsequently identified all children 3-36 months with FWLS and reviewed their medical records.
Results: We identified 148 patients with FWLS in the pre-PCV7 period and 275 patients post-PCV7. There were 17 positive cultures pre-PCV7: 10 pathogens and 7 contaminants. Post-PCV7, there were 14 positive cultures, but only 1 pathogen. This represented a 94.6% decrease overall (p=0.009), and a 100% decrease in Streptococcus pneumoniae. Rates of UTIs were unchanged (6.8% vs. 7.6%) and UTIs are now the most prevalent bacterial infection in this group. Over 50% of patients still received empiric antibiotics.
Conclusions: Based on our data, the emphasis in management of children with FWLS should be on diagnosing UTI. Guidelines for evaluating children with FWLS in countries using PCV7 should emulate the NICE model and reflect the trends identified in this study.