State of the Art
Management of fever without source in infants and children*,**

https://doi.org/10.1067/mem.2000.110820Get rights and content

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°C (102.2°F) or greater and in approximately 10% of children with FWS with a temperature of 39.5°C (103.1°F) or greater and a WBC count of 15,000/mm3 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. [Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med. December 2000;36:602-614.]

Introduction

Febrile infants and children frequently present to primary care and emergency physicians. The majority of these children are younger than 3 years. Most have an apparent source of infection (ie, a viral respiratory infection, acute otitis media, or enteritis).1, 2 However, 20% of febrile children have fever without source (FWS) of infection after history and physical examination.3, 4 Occult bacteremia occurs in approximately 3% of children younger than 3 years with FWS with a temperature of 39.0°C (102.2°F) or greater and is more frequent in children with higher fevers and WBC counts of 15,000/mm3 or greater.5, 6, 7, 8 Urinary tract infections (UTIs) are almost always occult in children younger than 2 years of age. In 1993, a published practice guideline defined criteria for laboratory testing and empiric antibiotic therapy of infants and young children with FWS.9 Several subsequent surveys have demonstrated variable compliance with different aspects of this guideline.10, 11, 12, 13, 14, 15 The guideline is generally followed for infants younger than 3 months but has been questioned as calling for unnecessary testing and empiric antibiotic therapy in children 3 to 36 months old.16, 17 The introduction of the new conjugate Streptococcus pneumoniae vaccine should make this controversy moot within 1 or 2 years. This article reviews the significant scientific evidence on which decisionmaking for the management of infants and young children younger than 36 months with FWS should be based, including those who have received the new conjugate pneumococcal vaccine.

Section snippets

Definition of fever without source

Clinical assessment is crucial in the evaluation of febrile infants and young children.18, 19, 20 Evaluation and documentation of vital signs, skin color and exanthems, behavioral state, and state of hydration are essential. Measurement of blood pressure is indicated in this age group only when hypotension is suspected. Pulse oximetry may be obtained as a fifth vital sign and is a more reliable predictor of pulmonary infection than respiratory rate in patients of all ages, especially infants

Infants younger than 3 months with fever without source

Until the early 1980s, there was a tradition at most teaching hospitals that all febrile infants younger than 2 months of age should be admitted for a sepsis workup.32 Not all practitioners, including university housestaff, followed this rule.33, 34 In 1985, the group at Rochester led by Dagan et al35 questioned the necessity of this approach and developed low-risk criteria (Rochester criteria) for the selection of a group of infants who might be carefully observed as outpatients without

Occult UTI

All of the large prospective clinical trials of FWS exclude children with UTIs. UTI is among the most common occult bacterial infections in children, especially in young girls, occurring in 2% of febrile children younger than 5 years.67, 68, 69, 70 A UTI is present in nearly 5% of febrile infants younger than 12 months, including 6% to 8% of girls and 2% to 3% of boys.67, 71 The rate is higher in those with FWS and higher temperatures.71 The prevalence is greater in boys younger than 6 months

Acknowledgements

I thank the following clinical investigators for providing me with unpublished data that I have used to prepare this article: Nathan Kuppermann, M. Douglas Baker, and Henry Shinefield. I also thank one of our UCLA undergraduates, Neetal Jivan, who was helpful in finding and organizing references and helping prepare a comprehensive bibliography.

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    Editors Note:This article continues a series of special contributions addressing state-of-the-art techniques, topics, or concepts. State-of-the-art articles will be featured in Annals on a regular basis in the next several volumes.

    **

    Address for reprints: Larry J. Baraff, MD, Professor of Pediatrics and Emergency Medicine, UCLA Emergency Medicine Center,924 Westwood Boulevard, Suite 300, Los Angeles, CA 90024; 310-794-0580, fax 310-794-0599; E-mail [email protected].

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