Management of the
Febrile Infant
Risk Minimizers vs. Test Minimizers
Steven E. Krug, M.D.
SAEM Annual Meeting
St. Louis, MO -- May, 2002
Fever, What’s The Big Deal ?

65% of children 0-2 years visit a physician for a
febrile illness
 10

to 20% of all pediatric visits to EDs
20 to 30% of pediatric office visits

Fever without a source accounts for as many
as 50% of these visits

A self limited illness in the vast majority

A small percentage will have a SBI
Occult Bacteremia in Febrile Children
How It All Began
McGowan JE, et al: NEJM 1973; 288:1309

Febrile children at Boston City Hospital

“24 hour pediatric walk-in clinic”
Temp > 38.3 0C -- all ages - 3 month study
 Results:



10,535 visits   2165 children with fever
708 blood cultures  31 (4.4%) true positives
Note: 43 cultures (6.1%) produced false positives
So, Are You a Risk-Minimizer ?
Green SM, Rothrock SG: Ann Emerg Med 1999; 33:211
Desire to lower the risk of adverse sequelae
from occult infections - “ROWS”
 Do not believe that clinical evaluation is
sufficient to reliably identify ill children
 Use risk stratification to target higher risk
patient groups for intervention
 Believe that the potential benefit of reducing
adverse sequelae justifies empiric diagnostic
testing and treatment

If Not, Perhaps a Test-Minimizer ?
Green SM, Rothrock SG: Ann Emerg Med 1999; 33:211
Believe the occurrence of adverse outcomes
is so low as to not justify time, expense and
invasiveness of risk stratification
 Believe that clinical evaluation and follow up
will serve to identify nearly all ill children
 Believe that parents prefer less testing and
treatment
 Are willing to accept a greater chance of
being wrong

Well Intentioned Risk Minimizers at Work
Can We Identify High Risk Children ?

Demographic and clinical parameters


Lab screening profiles




age, temperature, petechiae
CBC, ESR, CRP, UA, etc.
OB/SBI risk appears to correlate with some
sensitivity, specificity and positive predictive value
for OB and SBI were less than ideal
Clinical scoring systems (McCarthy, et al.)

initially very promising, ultimately disappointing
Identification of High Risk Patients
Sensitivity of the Physical Exam

McCarthy, et al. Pediatrics 1982; 70:802
 Yale Observation Score (AIOS)
 incidence of SBI related to score

< 10 = 2.7%, > 10 = 40.2%, > 16 = 92.3%
sensitivity 88%, specificity 77%, low PPV
 negative predictive value of normal Hx &
PE findings plus low AIOS was 96%

AIOS was fairly good in its ability to identify the sick,
but perhaps even better in identifying the well ?
Failure of Clinical Assessment
Teach SJ, Fleisher GR: J Pediatr 1995; 126:877

Prospective application of the Yale Obs. Scale
children 3 - 36 months with T > 39.0 0C
 611 children in study, 192 with bacteremia
 median YOS (6) was the same for both groups
 YOS > 10:




sensitivity 5.2%; specificity 96.7%,
positive predictive value 4.5%,
negative predictive value 97.1%
The YOS has performed similarly in other recent studies
 Social Smile & SBI 
Bass JW, et al: Pediatr Infect Dis J 1996; 15:541

Do smiling febrile children have bacteremia?
512 children aged 3 to 36 months of age
 T > 39.5 0C and WBC > 15,000
 social smile associated with shorter fever duration
 smile present in 45% of bacteremic children
 smile present in 49% of non-bacteremic pts.
 no demographic or laboratory differences found
between the groups

Yikes !! - So, is that a smile, or is it a grimace ?
Lessons Learned From the Search for OB/SBI
Risk Factors for OB/SBI
Age: neonates, 28-90 days, 3-36 months
 Fever: OB risk increases with temperature


hyperpyrexia (T > 40.5 0C) - 8 to 25% OB
Petechiae - 15 to 20% occurrence of SBI
 Immunodeficiency - e.g. HIV, SCD
 WBC > 15,000; Bands > 1000

 5 fold increased risk for occult bacteremia

Ill patient or toxic appearence
The big question -- Are all of these still true ??
Identification of Low Risk Patients
Physical & Laboratory Screening Profiles

Rochester Criteria
Dagan et al: J Pediatr 1985; 107:855
T > 380C, term, well appearing, secure follow-up
 peripheral WBC between 5-15,000/mm3
 band count < 1500 /mm3
 urinalysis with < 10 WBC/hpf
 no evidence of ear, soft tissue or bone infection


Performance: 233 infants 0-2 months of age
1 of 144 (0.7%) low risk infants had SBI
 22 of 89 (25%) high risk infants had SBI

Identification of Low Risk Patients
Dagan R, et al: J Pediatr 1988; 112:355

Modified Rochester Criteria


added diarrhea to criteria:
 if present < 25 WBC/hpf on stool smear
Performance
237 infants 0-2 months of age
 0 of 148 low risk infants had SBI
 21 of 88 (24%) high risk infants had SBI

So, perhaps we can identify the low risk children !
Identification of Low Risk Patients
Baker MD, et al: NEJM 1993; 329:1437

CHOP Low Risk Criteria
 T > 38.20C, well appearing, low IOS





WBC < 15,000 /mm3 ; BNR < 0.2
urinalysis with < 10 WBC/hpf
CSF with < 8 WBC/mm3 & (-) gram stain
negative chest x-ray
Performance: 747 patients aged 29-56 days
 64/65 patients with SBI noted as high risk


1/287 assigned to low risk had SBI
OPD assignment saved $ 3,100/patient
CHOP Low Risk Protocol: More Data
Baker MD, et al: Pediatrics 1999; 103:627
Three year study (1994-1996) at CHOP
 Infants 29 to 60 days of age with T > 38.0 0C



422 infants
43 (10%) with SBI


UTI (4%); OB (2.1%); BM (1.2%); BGE (1.2%);
cellulitis (1.2%)
101 (24%) identified as low risk

no SBI in the low risk infants
Note: Over 8 years this protocol has shown a nearly perfect
100% negative predictive value for >1200 infants
Are Febrile Neonates Different
Baker M, Bell L: Arch Pediatr Adol Med 1999; 153:508

Can laboratory screening profiles reliably identify
febrile neonates with low risk for SBI ?
 applied CHOP protocol to 254 infants (3 - 28 days)

43% of infants qualified for OPD management

32 infants (12.6%) with SBI


17 UTI (6.7%); 8 OB (3.1%); 4 BM (1.6%), BGE (.8%)
5 “low risk” infants had serious infections

would miss 20 infants with SBI per 1,000
Yes, febrile neonates are indeed different
Identification of Low Risk Patients
Baskin M, et al: J Pediatrics 1992; 120:22

The BCH Low Risk Criteria
T > 380C, low IOS, presence of secure follow-up
 peripheral WBC < 20,000/mm3
 CSF WBC < 10/mm3
 urinalysis dip with (-) leukocyte esterase
 all patients treated with ceftriaxone


Performance: 503 patients aged 28 -89 days

27 of 503 (5.4%) who met the criteria had SBI


9 OB (1.8%), 8 UTI (1.6%), 10 BGE (2.0%)
all were treated and were well at follow-up
Components of Fever Protocols
Avner J, Baker MD: EMCNA 2002; 20:49
Boston
Age (days)
28-89
0
Temp ( C)
> 38.0
Infant Obs. Score
Yes
Peripheral WBC
< 20,000
CSF obtained
Yes
Antibiotic given
Yes
SBI in low risk pts (%) 5.4
NPV (%)
94.6
Sensitivity (%)
Not stated
Philadelphia
29-56
> 38.0
Yes
< 15,000
Yes
No
0
100
100
Rochester
0-60
> 38.0
No
5-15,000
No
No
1.1
98.9
92.4
Empiric Antibiotic Therapy
Does it Work?
Carroll WD, et al: Pediatrics 1983; 72:608


Small study (10 patients) - PCN vs. placebo
Difference between groups was not great
Jaffe DM, et al: NEJM 1987; 317:1175




Large multi-center study - amoxicillin vs. placebo
Enrolled 955 children 3-36 months with T > 39.0 0C
27 (2.8%) with bacteremia -- small number of cases
Outcome differences between groups were not great
Empiric Antibiotic Therapy
Does it Work?
Bass JW, et al: Pediatr Infect Dis J 1993; 12:466

Prospective study - augmentin vs. ceftriaxone



519 children aged 3-36 months -- 60 (11.6%) with OB
T > 40.0 0C - or - T > 39.5 0C and WBC > 15 K
Both Rx regimens appeared to be adequate
Fleisher GR, et al: J Pediatr 1994; 124:504

Multi-center study - ceftriaxone vs. amoxicillin


6733 patients -- 195 (2.9 %) with bacteremia
“...ceftriaxone eradicated bacteremia, had fewer
focal complications, and less persistent fever…”
Is There a Cost Effective Strategy?
Lieu TA, et al: Pediatrics 1992; 89:1135
 Decision analysis, cost-effectiveness model
6 strategies for management of febrile infants
 28 to 90 days with Temp > 38.0 0C
 used data from literature (e.g. Baskin, Baker)

 Clinical judgment alone appeared to be the least
effective clinical model and the 2nd least cost
effective strategy
 Full sepsis W/U and outpatient IM ceftriaxone
was judged to be the most effective strategy
Practice Guidelines
Baraff L, et al*: Ann Emerg Med 1993 & Pediatrics 1993
Expert consensus panel recommendations
 Based on meta-analysis of the literature
 Fever is defined as > 38.0 0C for 0-3 months
and > 39.0 0C for 3-36 months
 Infants at greatest risk during 0-3 months
 Rochester criteria selected as screening criteria
for high vs. low risk

* Note: Panel members confessed risk-minimizers
Consensus Panel Guidelines

Toxic-Appearing Infants and Children
Hospitalize, evaluate and treat for presumed
sepsis, meningitis, or SBI


This holds for all age groups

THIS SHOULD BE A NO BRAINER
Consensus Panel Guidelines

Febrile (low risk) Infants < 28 days of age
Despite low probability of sepsis and studies
showing favorable outcome for outpatient
observation, the panel recommends SBI
evaluation and hospital admission for all
infants with either parenteral therapy or close
observation

Consensus Panel Guidelines

Low-Risk Infants 28-90 Days of Age

Obtain urine culture and provide close follow-up
- OR -
Full sepsis evaluation (blood, urine, CSF) and
treat with IM ceftriaxone

 All
children who receive presumptive therapy
should have an LP
Consensus Panel Guidelines

Low-Risk Infants 3-36 Months of Age

Urine culture for males < 6 mo & females < 2 yrs

Stool culture if blood or mucus or > 5 WBC/hpf

Chest x-ray if decreased breath sounds or SOB

Blood culture if T > 39.0 0C and WBC > 15,000

Empiric therapy if T > 39.0 0C and WBC > 15,000

No diagnostic tests or antibiotics if T < 39.0 0C
The Febrile Infant
Variability in Management Approaches
Ros SP, et al. Pediatr Emerg Care 1994; 10:264
 Surveyed members of AAP Section on EM
 Numerous fever and age group definitions
 74% routinely screen with a CBC
 45% routinely draw blood cultures
 36% use clinical appearance as basis for culturing

53% routinely administer antibiotics
 44% use lab criteria as basis for antibiotic Rx
Despite published guidelines, no clear standard of care!
What Do Parents Prefer
Oppenheim PI, et al: Ann Emerg Med 1994; 24:836

Interviewed parents regarding management
options for febrile infant/child scenarios

Parents successfully identified the strategies
associated with a higher probability for an
adverse outcome

71% chose options with less testing and
treatment (and greater risk!)
So, perhaps parents are test minimizers??
What do Parents Prefer
Bennett JE, et al: Arch Pediatr Adol Med 2000; 154:43

Survey of parent utilities for outcomes of OB
convenience sample, single urban PED
 94 subjects interviewed
 provided with 8 possible outcomes
 blood drawing viewed to be of minimal risk and
concern


Parents were intolerant of adverse outcomes
Okay, so maybe parents are risk-minimizers
Parents, Physicians & Antibiotics
Bauchner H, et al: Pediatrics 1999; 103:395

Survey of AAP general pediatricians
610 responses (67%)
 40% indicated that parents frequently ask for
antibiotic when the MD feels it is not needed


48% stated parents often pressure them to
prescribe antibiotic therapy
nearly 1/3 stated they occasionally or frequently
comply with that pressure
 parental pressure viewed as #1cause of the
unnecessary use of antibiotics

Risk Minimizers vs. Test Minimizers
- Published
guidelines
- “ROWS”
- Risk of OB
sequelae
- Parental
preferences
“To Test/Treat
- or Not To Test/Treat”
- Cost of care
- Changing Hx
of OB/SBI
- Risk of testing
- Risk of Rx
- Parental
preferences
Attorneys, Payors, and Other Predators
Management of the Febrile Infant
What’s Controversial, What’s Changed?

Eradication of Hemophilus influenzae



what is the current risk of OB and SBI
what is the natural history of pneumococcal OB
do the 1993 consensus guidelines make sense
Continuous blood culture monitoring systems
 True efficacy of empiric antimicrobial therapy
 The febrile infant with a viral infection
 OB/SBI risk with hyperpyrexia; petechiae

Disappearance of H. influenzae

Prior to introduction of Hib vaccine (1987)


10-15% of OB and majority of OB related SBI
12,000 cases/yr invasive H. flu in children < 5 yrs.
33-60% develop focal infection, 15-25% develop BM
 12 times more likely than pneumococcus


Currently about 300 cases per year (94/95)


no longer a leading cause of sepsis/meningitis
incidence now greatest in children < 5 months
Median age for BM: 1986 = 15 mo.  1995 = 25 yrs.
Risk of Bacteremia in the Post-Hib Era
Lee GM: Arch Pediatr Adol Med 1998; 152:624

Three year study (1993-1996) at BCH*

Children aged 3 - 36 months with T > 39.00C



11,911 patients
75% received CBC, 74% had blood cultures
149 positive blood cultures (1.6%)
 92% pneumococcal
 no H. influenzae isolates!!
*Is BCH the center of the risk-minimizer universe ?
Bacteremia in Boston
Lee GM: Arch Pediatr Adol Med 1998; 152:624

Prevalence greatest in 6 - 24 month age group

WBC and absolute neutrophil counts were the
most accurate predictors for bacteremia



OB risk associated with temperature


WBC > 15 x 109 -- {Sens. = 86%, Spec. = 77%}
attributed to higher WBC with pneumococcal OB
OR: > 40.0 =1.9; > 40.5 = 2.6; > 41.0 = 3.7
Lower OB rate not explained by Hib vaccine
Outcome of Pneumococcal Bacteremia
Bachur R, Harper MB: Pediatrics 2000; 105:502
Re-evaluation of children in ED with OPB
 Nine year study at BCH (1987-96)
 548 episodes of OPB


40 (7%) with PB or new focal infection
 14 PB(2.5%); 8P(1.5%); 8M**(1.5%);
6C(1.0%); 4 PC(0.7%)
 patients not initially Rx, and those treated who
remained febrile were are greatest risk for PB
 majority with OPB can be managed as outpatients
** Three diagnoses/cases of BM were controversial
Persistent Bacteremia/Meningitis in OPB
Bachur R, Harper MB: Pediatrics 2000; 105:502
Rx Group
N__
__PB___
NoAntibx
68
19 (28%) 1 (1.5%)
OrAntibx
208
11 (5%)
2 (1%)
PaAntibx 195
10 (5%)
2 (1%)
TOTAL
40 (8%)
5 (1%)
471
BM__
Prevalence/Outcome of Occult Bacteremia
Alpern ER, et al: Pediatrics 2000; 106:505

Three year retrospective study (1993-1996)


Prevalence of OB = 1.9%


83% pneumococcal; H. influenzae not isolated
Focal bacterial infections in 17 (0.3%)


5900 children aged 2-24 months, T > 39.0
pneumonia (8), cellulitis (4), osteo (2), others (3)
Serious adverse outcome in 2 (0.03%)

meningitis (1), sepsis/death (1)
Note: 96% OB with spontaneous resolution without Rx
Occult Bacteremia in Philadelphia
Alpern ER, et al: Pediatrics 2000; 106:505

Mean time to culture shorter for true positives



mean times: true (+) = 14.9 hrs; false (+) = 31.1
< 18 hours 13x more likely to be true pathogen
Nearly all true positives re-evaluated in ED




average time from notification 10.6 (+ 9.7) hrs
33% were still febrile
53% admitted to the hospital
4.8% found to have persistent bacteremia

oral antibiotics Rx at 1st visit did not affect rate of PB
Perhaps blood cultures can be an effective screen?
Prevalence/Outcome of False (+) Blood Cultures
Alpern ER, et al: Pediatrics 2000; 106:505

Overall contamination rate was 2.1%

85% were re-evaluated in ED

35% were still febrile and were admitted

1.9% of repeat cultures also contaminated!
At least in Philadelphia, the risk of a contaminated blood
culture equals or exceeds that of a true positive !
Remember the data from McGowan, 1973?
Prevalence of False (+) Blood Cultures
Alpern ER, et al: Pediatrics 2000; 106:505
Age
(Months) N__
OB Rate
False + Rate
(95% CI)____ (95% CI)____
2-5
728
1.0% (0.4-2.0) 3.6% (2.3-5.2)
6-11
2181
1.8% (1.3-2.4) 1.8% (1.3-2.5)
12-17
1722
2.3% (1.6-3.1) 1.8% (1.2-2.5)
18-24
1270
2.0% (1.3-3.0) 2.0% (1.3-3.0)
Use of Antibiotics to Prevent SBI
Bulloch B, et al: Acad Emerg Med 1997; 4:679

Meta-analysis of published RCCT’s


Antibiotic use trended to  risk for SBI




4 studies: Carroll, Jaffe, Fleisher, Bass
odds ratio = 0.60 (P.O.) & 0.38 (I.M.)
need to treat 414 kids to prevent 1 SBI case
no significant effect of antibiotic therapy
Concluded that widespread antibiotic use
should not replace clinical judgement
Outcomes in Occult Bacteremia
Bulloch B, et al: Acad Emerg Med 1997; 4:679
Study
Occult Bacteremia (n) Serious Bacterial Infections
Carroll, et al.
5 in IM + PO PCN
5 in no antibiotic
None
2 meningitis
Jaffe, et al.
19 in PO amoxicillin
8 in placebo
1 periorb. cellulitis, 1 bacteremia
1 persistent bacteremia
Fleisher, et al. 76 in PO amoxicillin
Bass, et al.
71 in IM ceftriaxone
3* meningitis, 1 septic arthritis,
1 sepsis, 1 pneumonia
2** meningitis, 1 osteomyelitis
22 in PO augmentin
38 in IM ceftriaxone
3 pneumonia
None
Does empiric therapy truly reduce the risk for SBI?
Predictors of Pneumococcal Bacteremia
Kuppermann N, et al: Ann Emerg Med 1998; 31:679

With invasive H. influenzae infections out of the
picture, are there unique predictors for OPB

Multivariate analysis - 6,500 children 3-36 months


164 children (2.5%) with OPB
Three variables retained association with OPB

ANC: OR of 1.15 for each 1,000 cells/mm3 



if ANC > 10,000 -- OPB rate 8.2%
temp: OR of 1.77 for each 10 C 
age < 2 years: OR of 2.43 vs. 2-3 years of age
Band Counts in Young Febrile Children
Kuppermann N, et al: Arch Pediatr Adol Med 1999; 153:261

Compared CBC findings in febrile children
with a documented SBI (bacteremia or UTI)
versus a proven respiratory viral infection

Children with SBI had a greater mean ANC
 11.3

x 109 vs 5.9 x 109
No differences in percentage band count or
absolute band count between the groups
Identification of Children with
UMD
Kuppermann N, et al: Pediatrics 1999; 103:e20

Clinical/hematologic features of children with
unsuspected meningococcal disease (UMD)




retrospective, four center study,1985-96
381 children with meningococcal disease
45 (12%) with UMD [discharged home !!]
compared to 6400 culture negative children



no difference in Temp, WBC, ANC
significantly higher band counts in UMD
predictive value of band count was low (PPV 0.06%)
Bad news… There is still no crystal ball for UMD
Febrile Children with Bronchiolitis
Kuppermann N: Arch Ped Adoles Med 1997; 151:1207

Evaluated risks of bacteremia and UTI in febrile
children with/without bronchiolitis


432 children aged 0-24 months
Children with bronchiolitis had significantly
fewer positive cultures
blood 0% vs. 2.7%; urine 1.9% vs. 13.6%
 none of the children < 2 months of age with
bronchiolitis (36) had bacteremia or UTI

SBI Risk in Children With
Recognizable Viral Syndromes
Greene DS, Harper MB: Pediatr Infect Dis J 1999;18:258

Five year retrospective study (1993 -1998)

Children aged 3-36 months with T > 39 0C

1347 children diagnosed with a “RVS”



croup, varicella, bronchiolitis, stomatitis
blood cultures obtained in 65%
2 of 876 (0.2%) blood cultures were positive
Office-based physicians have known this for a very long time.
Bacteremia in Fever & Petechiae
Mandl KD, et al: J Pediatr 1997; 131:398

Prior studies suggest a high risk for bacteremia


7 to 11% incidence of meningococcemia
Enrolled 411 children -- (58% 3-36 mo.)

8 (1.9%) with bacteremia or clinical sepsis





six with serious invasive bacteremia
none of 357 well-appearing children had OB
toxic appearance had sensitivity of 100%
WBC > 15 K or < 5K had sensitivity of 100%
all children with meningococcemia had purpura
Occult Pneumonia in Febrile Children
Bachur R, et al: Ann Emerg Med 1999; 33:166

What is the incidence of occult pneumonia in
febrile children with high WBC ?

Prospective cohort ED study



age < 5 years, T > 39 0C, WBC > 20,000
radiographs obtained in 225 of 278 patients
positive radiographic findings in



40% of those with a suggestive clinical exam
26% of those without clinical evidence for pneumonia
recommends empiric chest radiography
UTI’s in Febrile Infants
Shaw KN, et al: Pediatrics 1998; 102:e16.

UTI is by far the most frequent SBI


fever may be only presenting sign of UTI
What is the prevalence of UTI in febrile infants

2400 febrile infants -- overall 3.3%
gender -- male: 1.8%; female: 4.3%
 race -- white: 10.7%; AA: 2.1%; others: 5.7%
 other source -- yes: 2.7%; no: 5.9%
 temperature -- < 39.0: 2.2%; > 39.0: 3.9%

Should we screen all febrile children for UTI ?
UTI’s in Febrile Children
Gorelick, Shaw: Arch Ped Adol Med 2000;154:386.

Developed clinical decision rule []



T > 39.0 0C
 fever > 2 days
white race
 age < 1 year
absence of another potential source
All with UTI had at least one risk factor
 Presence of any two factors



sensitivity 95%, specificity 31%
Rule eliminated 30% of unneeded cultures
Risk of SBI in Febrile Seizures
Trainor J, et al: Clin Pediatr Emerg Med 1999; 1:13

Multi-center study of ED management of
simple febrile seizures (Chicago, 1998)

455 children with febrile seizure




1.3% with bacteremia
5.9% UTI
12.5% with abnormal chest x-ray
normal CSF in all who had an LP (135)
Meningitis Risk in Simple Febrile
Seizures: What’s Been Reported ?

Literature review of reported cases of febrile
seizures and meningitis
2,870 cases of febrile seizures with LP’s
 1.7% with bacterial meningitis
 17% of those with meningitis described as
clinically inapparent
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Is occult bacterial meningitis a significant
clinical entity ?
Meningitis Risk in Febrile Seizures
Green SM, et al: Pediatrics 1993; 92:527
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Studied children with meningitis -- how many
presented solely with seizures?
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486 children with bacterial meningitis
complex seizures present in 79%
93% of those with seizures were obtunded
of the few with “normal” LOC, 78% had nuchal rigidity
 the two patients without meningismus had
other straightforward indications for LP
Occult meningitis is more myth than fact
What is the Cost Effective Strategy?
Yamamoto LG, et al: Am J Emerg Med 1998; 16:193

Updated decision analysis which considered:
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low incidence of H. influenzae infections
emergence of resistant S. pneumoniae
negative consequences of unnecessary Rx
Assuming zero or low Rx consequences -empiric therapy associated with best outcomes
 Assuming realistic Rx consequences - no
testing and no treatment option may be best
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Cost Effectiveness Post-Vaccine?
Lee GM, et al: Pediatrics 2001; 108:835
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Updated prior decision analysis, considering:
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Elimination of H. influenzae
Lower rate of occult bacteremia (1.5%)
Published efficacy of empiric Rx
Negative consequences of unnecessary Rx
At current rate of OB, CBC plus selective blood
culture and treatment is still best
If OB rate < 0.5%, strategies employing empiric
testing & treatment should be eliminated
Serotyping of Pneumococcal OB
Alperin ER, et al: Pediatrics 2001; 108:e23
What is potential efficacy of pneumococcal
vaccine in the prevention of OB
 S pneumoniae accounts for the vast majority
(83%) of pathogens in children with OB
 Eight serotypes isolated:
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6A, 9V, 19F, 18C, 4, 6B, 23F, 14
98% of serotypes would be covered by the
currently licensed vaccine -- all except 6A
Good news…We may soon erradicate OPB
Food For Thought And A Little Math

Current risk of OB: 1.5 to 1.9%

92% pneumococcal
Risk of meningitis in OPB: 1 to 2%
 Risk of adverse sequelae in BM: 33 - 50%
 Need to treat 2500 febrile kids to prevent one
case of BM; 5000-7500 per adverse sequelae
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remember that antibiotics may not prevent BM!
incidence of ADR’s: 150 - 600(?)/ case of BM
alarming growth rate of antibiotic resistance
Evolving Pneumococcal Resistance
Kaplan, et al: Pediatrics 1998; 102:538.

Prospective surveillance study of invasive
pneumococcal infections

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three year (1993-1996), eight center study
1291 systemic pneumococcal infections
Proportion of non-susceptible isolates (PCN,
ceftriaxone) increased annually

nearly doubled over the three year period
penicillin resistance 21%
 ceftriaxone resistance 9.3%

So, What Do We Actually Know

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Extremely common presenting complaint
Much concern (phobia?) regarding fever
Fairly effective strategies to identify low risk
infants - these do not apply to neonates
#1 bad actor (H. flu) effectively erradicated
UMD - “pediatrician’s nightmare” - still out there
Risk of OB, now under 2%, primarily OPB
Can apply risk stratification to OPB
93-96% spontaneous resolution of OPB
So, What Do We Actually Know
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No consensus regarding optimal approach
to the febrile infant
Not entirely clear what parents want
Empiric Rx does not prevent sequelae
Rising rates of antimicrobial resistance
UTI remains the most common occult “SBI”
RVS are a reasonable explanation for fever
Pneumovax may make this all a moot point
Some Friendly Advice
Keep abreast of the literature
 Discuss this with colleagues & mentors
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local practice variations
institutional practice guidelines
antimicrobial resistance rates
Both approaches (RM & TM) are defensible
 Choose the best strategy for you
 Be consistent
 Always treat the ill appearing child with fever

Notable Quotes

“Unfortunately, many practitioners have become
reluctant to rely on clinical judgement, preferring
diagnostic tests and frequent use of antibiotics.”…….
“We should resist the urge to use antibiotics
empiricially, especially in a patient who looks well, for
whom antibiotics have not been shown clearly to be
beneficial”
-- JK Stamos, ST Shulman: Lancet 1997

“Antibiotics are not antipyretics”
-- SE Krug: Overheard many evenings in CMH ED