OCCULT BACTEREMIA FROM A PEDIATRIC EMERGENCY
DEPARTMENT: CURRENT PREVALENCE, TIME TO DETECTION, AND OUTCOME.
Alpern ER, et al. Pediatrics 2000 Sep;106(3):505-11.
OBJECTIVE: To evaluate selected characteristics of occult bacteremia in the
post-Haemophilus influenzae type b (HIB) vaccine era.
METHODS: A retrospective cohort study was performed
involving 5901 children 2 to 24 months old with fever >/=39.0 degrees C
evaluated with a blood culture at an urban tertiary care children's hospital
emergency department (ED) between February 1993 and June 1996. Patients were
excluded if immune-suppressed, diagnosed with a focal infection, evaluated by
lumbar puncture, or admitted to the hospital during initial evaluation.
Prevalence of occult bacteremia, distribution of current pathogenic organisms,
and time to positive culture in a continuously monitored system were
determined. All patients with cultures positive for pathogenic bacteria were reevaluated
and serious adverse outcomes were documented.
RESULTS: The prevalence of occult bacteremia was
1.9% (95% confidence interval: 1.5%-2.3%). Streptococcus pneumoniae accounted
for 82.9% of all pathogens and H influenzae was not a causative organism in
this cohort. The mean time to positive culture was significantly shorter for
pathogens compared with contaminants (14.9 hours vs 31.1 hours). A culture that
was positive in </=18 hours was 13.0 (6.3-26. 6) times more likely to
contain a pathogen than a contaminant. The average time from positive culture
notification to reevaluation in the ED was 10.6 hours and over half of the
patients recalled to the ED for positive cultures were admitted to the
hospital. Of patients with occult pneumococcal bacteremia, 95.7% had resolution
of their bacteremia without the use of parenteral antibiotics. Two patients had
serious adverse outcomes. The rate of meningitis or death was. 03%
(.004%-.12%). The contamination rate of blood cultures was 2.1% (1.7%-2.5%).
Most (85%) of these patients were reevaluated in the ED and more than one third
were admitted to the hospital before full identification of the organism.
CONCLUSIONS: Prevalence of occult bacteremia in the
post-HIB vaccine era is lower than previously reported. S pneumoniae is the
most common causative organism and resolves without parenteral antibiotics in
the vast majority of cases. Continuously monitoring blood culture systems allow
for early identification and can aid in differentiating contaminated from true
pathogenic cultures by time to positive culture. Serious adverse outcome is an
uncommon result of occult bacteremia. Updated epidemiology and microbiologic
technology may impact the evaluation and treatment of children at risk for
occult bacteremia.
RISK OF SERIOUS BACTERIAL INFECTION IN CHILDREN WITH FEVER
WITHOUT A SOURCE IN THE POST-HAEMOPHILUS INFLUENZAE ERA WHEN ANTIBIOTICS ARE
RESERVED FOR CULTURE-PROVEN BACTEREMIA.
Bandyopadhyay S, et al. Arch Pediatr Adolesc Med
2002 May;156(5):512-7.
OBJECTIVE: To determine the rate of serious
bacterial infection in children aged 2 to 36 months with fever without a source
in the post-Haemophilus influenzae era, when antibiotic therapy is reserved
until blood culture results turn positive.
DESIGN AND SETTING: Retrospective review of
emergency department, urgent care center, and hospital medical records from an
urban children's hospital.
PARTICIPANTS: Eligible participants were identified
from hospital medical record and microbiology laboratory databases. Immunocompetent
individuals aged 2 to 36 months with fever without a source were eligible for
enrollment. Exclusion criteria were temperature less than 39.0 degrees C,
identifiable focus of infection, current or recent antibiotic use, and hospital
admission.
INTERVENTIONS AND OUTCOME MEASURES: Enrolled
participants were assigned to group 1 (blood culture obtained) or group 2 (no
blood culture) and did not receive empiric antibiotic treatment in the
emergency department, in the urgent care center, or for home use. Demographic
and outcome data were collected on all enrolled patients. RESULTS: During the
study, 9241 febrile children were identified; 2641 (29%) met the enrollment
criteria. Blood cultures (group 1) were performed on 1202 patients (46%), and
37 (3%) had culture-proven occult bacteremia (95% confidence interval,
2.2%-4.2%). Streptococcus pneumoniae was the most prevalent organism (84%). The
mean +/- SD time for reporting a positive blood culture finding was 17.5 +/-
8.5 hours. Two patients (0.08%; 95% confidence interval, 0.009%-0.27%)
developed serious bacterial infection, and both recovered completely.
CONCLUSION: Reserving antibiotic therapy for
culture-proven occult bacteremia was not associated with increased risk of
developing serious bacterial infection compared with previously published data.
COMMENTS: For a good article on approaching the
pediatric patient with fever, see Evaluation Styles For Well-Appearing
Febrile Children: Are You A "Risk-Minimizer" Or A
"Test-Minimizer"? by Green, SM, et al, Ann Emerg Med
33(2):211, February 1999.