State of the ArtManagement of fever without source in infants and children*,**
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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Cited by (248)
Prevalence and Management of Invasive Bacterial Infections in Febrile Infants Ages 2 to 6 Months
2022, Annals of Emergency MedicineSerious bacterial infections in young children with fever without source after discharge from emergency department: A National Health Insurance database cohort study
2022, Pediatrics and NeonatologyCitation Excerpt :Febrile young children who appeared ill or had unstable vital signs in the ED were usually treated as SBI and arranged for hospitalization. When a complete history and physical examination could not identify a specific source of fever in young, well-appearing children, ancillary studies such as complete blood count with differential, serum procalcitonin, blood culture, urine dipstick or microscopic urinalysis and a urine culture were usually performed to determine children who might be a victim of SBI and who could be discharged from the ED.2,7 Young children with fever aged 2–24 months accounted for the majority of the ED visits.
Association of Bacteremia with Vaccination Status in Children Aged 2 to 36 Months
2021, Journal of PediatricsThe JAID/JSC guidelines for management of infectious diseases 2017 – Sepsis and catheter-related bloodstream infection
2021, Journal of Infection and ChemotherapyRisk factors for urinary tract infections in children aged 0–36 months presenting with fever without source and evaluated for risk of serious bacterial infections
2020, Archives de PediatrieCitation Excerpt :These discrepancies could be explained by a hospital admittance bias, as 50% of our patients were hospitalized versus only 34% of our non-included patients and 19.7% of patients in the previous study [13]. The predominance of UTI and the low rate of OB in our population, however, are consistent with recent studies conducted in the post-pneumococcal vaccine era in which there was a decrease in the rate of OB from 3–12% to less than 1% [14–16]. All our patients with UTI were either less than 9 months of age, had fever for more than 2 days, or reported chills.
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Editor ’s 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.
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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].