EVALUATION OF THE INFANT WITH FEVER WITHOUT SOURCE: AN EVIDENCE BASED APPROACH

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The infant with fever is a common presenting problem in most emergency departments (EDs). Most of these children have benign, self-limited illnesses. A few will have infections which, if untreated, could have serious sequelae. Although some of these infections are obvious on examination, some younger infants will have only vague or nonspecific signs and symptoms of illness that could be overlooked or misinterpreted. A missed diagnosis of sepsis or meningitis is a common source of malpractice suits in emergency medicine.88 Of less concern than the ill-appearing infant with an obvious source of bacterial infection, for whom the management is often clear, is the infant who looks well but may be at risk for occult infection. Because of this uncertainty, many infants under the age of 2 or 3 months receive a full diagnostic work-up for sepsis, including blood, urine, and spinal fluid cultures, and many infants are hospitalized and given empiric treatment with antibiotics pending negative culture results.102 At present, there is a great deal of controversy over the best clinical strategy in this group of infants at high risk for serious bacterial infections.

The diagnosis and management of the well-appearing infant with fever without source (FWS) has been a source of intense study and debate over the last 20 years. The intensity of that debate is reflected in the simultaneous publication of guidelines for the management of the child with fever without source in 1993 in both Pediatrics16 and Annals of Emergency Medicine. Although this article codified much of the preceding research, it was largely an experts' consensus document and not a critical appraisal of the scope of the research on the subject. Although many of its recommendations have been universally accepted, many issues still remain unclear, and significant debate continues.15, 17, 19, 23, 91, 102, 145

Recent estimates suggest that serious illness in all febrile children may be rare, but in a given infant presenting on a given day, is there a way to determine what that infant's risk is? A detailed history and physical examination is insufficient to identify children at risk because some may “look” well at first. Furthermore, no single laboratory test has been found to be 100% sensitive or specific in predicting the presence of serious infection. Numerous combinations of tests have been proposed and tested. A rational approach to the child with FWS must take into account the prevalence of this entity in the pediatric population, the risks associated with febrile illnesses, and the ability of standard diagnostic measures to evaluate risk of serious underlying disease in a given child. Clinicians must understand the pretest probability of disease, the characteristics (sensitivity, specificity, etc.) of the test(s) used, and the resulting posterior (or post-test) probability of disease.60 Along those lines, this article provides

  • 1

    An assessment of the prevalence of FWS in infants from birth to age 3 months

  • 2

    An evaluation of the utility of the history and physical examination

  • 3

    A critical evaluation of the utility of laboratory and radiographic tests commonly used in the evaluation of these infants

Section snippets

DEFINITIONS

FWS is understood to mean fever with no apparent focus of infection after a careful history and physical examination have been performed. Occult bacteremia (OB) is the presence of a pathogenic bacterial species in the blood culture from a child not suspected of having a bacterial infection based on history, physical examination, and screening laboratory tests, including chest x-ray, lumbar puncture, and urinalysis. Serious bacterial illness (SBI) generally has included bacteremia, bacterial

METHODS

MEDLINE databases from 1966 to 1997 were searched using the category * fever (*meaning “explode” fever) modified to include English language articles, limited to age groups neonates up to and including children 2 to 5 years old. Additional searches were performed using other categories (e.g., * bacteremia, urinalysis, and spinal puncture) similarly modified to ensure completeness as needed. Articles were selected with preference given to clinical trials or cohort studies dealing with the

GENERAL EPIDEMIOLOGY

Physician visits for fever are very common in the first few years of life. In one family practice–based series,128 21% of office visits for infants under the age of 6 months involved a temperature over 37.8°C. In other series, the incidence of pediatric clinic visits for fever was reported as ranging from 6.5% of patients having temperatures over 38°C75 to 12%,27 to as high as 33% of sick visits, with 19% having temperatures ≥39.4°C.154, 170 In a review of all children presenting to an urban

History

Evaluation of the febrile infant should begin with a detailed history relevant to infectious diseases in children, including a history of the present illness that considers birth history and maternal infection risks, recent immunizations, sick contacts, travel and immigration (e.g., recent immigration from a malaria-endemic region), recent serious illness, level of activity, “fussiness” or irritability, feeding habits, vomiting, bowel habits (e.g., diarrhea), an assessment of hydration status

CONCLUSIONS AND RECOMMENDATIONS

No single aspect of the history and physical examination of the febrile infant will reliably identify an infant at increased risk for SBI; however, the combination of a “low-risk” history, “well” appearance, and certain normal laboratory test results can reliably identify most infants who do not have SBI. This assertion has several ramifications for both current and future practice. Routine hospitalization with empiric antibiotic therapy in all febrile infants has a significant risk of

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