Antibiotic Administration to Treat Possible Occult Bacteremia in Febrile Children

Abstract

We performed a prospective, randomized, placebo-controlled, double-blind clinical trial of antibiotic administration to treat possible occult bacteremia in febrile children. A total of 955 children aged 3 to 36 months with temperatures greater than or equal to 39.0 degrees C and no focal bacterial infection were enrolled at the emergency departments of two children's hospitals from January 1982 until July 1984. Blood samples for culture were obtained, and the children were randomly assigned to receive either oral amoxicillin or placebo and were restudied approximately 48 hours after enrollment. Data were also collected on 228 children who could not be randomly assigned. Twenty-seven of the randomly assigned children (2.8 percent) had bacteremic infections with pathogenic organisms (Streptococcus pneumoniae, Haemophilus influenzae, and salmonella). There were no differences in the incidence of major infectious morbidity associated with bacteremia between the antibiotic and placebo groups--2 of 19 patients (10.5 percent) in the antibiotic group and 1 of 8 (12.5 percent) in the placebo group--although the power for this comparison was low. Antibiotics reduced fever (P less than 0.005) and improved the clinical appearance (P = 0.07) in the children with bacteremia but not in those without bacteremia. Although there were no statistically significant differences in the incidence of side effects, diarrhea tended to occur more often in the patients treated with amoxicillin (15 vs. 11 percent, P less than 0.10). We conclude that our data do not support the routine use of standard oral doses of amoxicillin in febrile children who do not have evidence of focal bacterial disease.

Evaluation of the incidence of occult bacteremia among children with fever of unknown origin

“…In 1987, Jaffe et al [13] evaluated children between the ages of 3 and 36 months and discovered a 2.87% rate of bacteremia and an important presence of type-b H. influenzae. In 1993, Bass et al also evaluated children between 3 and 36 months and discovered occult bacteremia in 11.5% of the patients, with 10% having infection by type-b H. influenzae [14].…”

Antibiotic prescribing for upper respiratory tract infection: The importance of diagnostic uncertainty

“…This may be due to diagnostic uncertainty and resultant concern about missing an evolving or occult invasive bacterial infection. 16,17 There is often no way to definitively differentiate a bacterial from a viral infection. Diagnostics aids such as rapid streptococcal antigen testing for pharyngitis 26 or clinical criteria for the diagnosis of occult bacteremia 27 are underused, and physicians rely on clinical judgment, which may be inaccurate.…”

“…16,17 Parental pressure for an antibiotic was selected because it is one of the most frequently cited factors by physicians in antibiotic overuse in children. 7,9,[20][21][22] …”

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

“…Therefore, the reported rate of SBI was 0.08% (95% CI, 0.03%-0.17%; 6/7485). [9][10][11][12] Although the total number of patients who developed SBI was 8, 2 were from the no treatment group. 12 In a meta-analysis, Bulloch and colleagues 14 reported that the use of either oral antibiotics or intramuscular ceftriaxone did trend toward a reduced risk of serious infection; however, neither reached statistical significance (odds ratio [OR], 0.60; 95% CI, 0.10-3.49; and OR, 0.38; 95% CI, 0.12-1.17, respectively).…”