Fever without source as the first manifestation of SARS-CoV-2 infection in infants less than 90 days old.

Abstract

Fever without source (FWS) in infants is a frequent cause of consultation at the emergency department and the emergence of SARS-CoV-2 could affect the approach to those infants. The aim of this study is to define the clinical characteristics and rates of bacterial coinfections of infants < 90 days with FWS as the first manifestation of SARS-CoV-2 infection. This is a cross-sectional study of infants under 90 days of age with FWS and positive SARS-CoV2 PCR in nasopharyngeal swab/aspirate, attended at the emergency departments of 49 Spanish hospitals (EPICO-AEP cohort) from March 1st to June 26th, 2020. Three hundred and thirty-three children with COVID-19 were included in EPICO-AEP. A total of 67/336 (20%) were infants less than 90 days old, and 27/67(40%) presented with FWS. Blood cultures were performed in 24/27(89%) and were negative in all but one (4%) who presented a Streptococcus mitis bacteremia. Urine culture was performed in 26/27(97%) children and was negative in all, except in two (7%) patients. Lumbar puncture was performed in 6/27(22%) cases, with no growth of bacteria. Two children had bacterial coinfections: 1 had UTI and bacteremia, and 1 had UTI. C-reactive was protein over 20 mg/L in two children (one with bacterial coinfection), and procalcitonin was normal in all. One child was admitted to the Pediatric Intensive Care Unit because of apnea episodes. No patients died. Conclusion: FWS was frequent in infants under 90 days of age with SARS-CoV-2 infection. Standardized markers to rule out bacterial infections remain useful in this population, and the outcome is generally good.

SARS-CoV-2 Among Infants <90 Days of Age Admitted for Serious Bacterial Infection Evaluation

“…Overall illness among infants with SARS-CoV-2 infection in this study was mild to moderate, consistent with the severity of disease in this age group previously reported. 26,28 A minority of infants with SARS-CoV-2 required respiratory support or ICU admission, consistent with the reported literature, 8,9,12,13,19,[28][29][30]32 although this may be confounded by our observed higher prevalence of comorbidities among infants without SARS-CoV-2 compared to infants with SARS-CoV-2. The median hospital LOS for SARS-CoV-2 positive infants in this study was shorter than previously reported 10,30 and all infants with SARS-CoV-2 survived to discharge, consistent with good outcomes reported across other studies.…”

“…However in this study, isolated fever was the most common presentation of SARS-CoV-2, with a higher percentage of infants in this study presenting with isolated fever compared to the 40% reported in another study of infants. 28 A lower proportion of infants with SARS-CoV-2 in this study had dermatological, respiratory, or gastrointestinal symptoms noted at admission compared with other pediatric and young infant studies. 5, 9-14, 20, 26, 27, 29-32 The mean age of all infants with SARS-CoV-2 infection in our study was higher than that of SARS-CoV-2 negative infants, but in line with mean or median ages (16-39 days) reported in other studies of infants undergoing SBI evaluation.…”

“…Case reports and series have identified concomitant urinary tract infections and bacteremia among young infants with COVID-19. 9,13,[26][27][28] We found lower rates of positive urine and CSF cultures in infants with SARS-CoV-2 compared to those without SARS-CoV-2, but no difference in blood culture positivity rates. Given the potentially severe consequences of untreated bacterial infections, we recommend clinicians continue to assess young febrile infants for bacterial infections, regardless of SARS-CoV-2 status.…”

“…5, 9-14, 20, 26, 27, 29-32 The mean age of all infants with SARS-CoV-2 infection in our study was higher than that of SARS-CoV-2 negative infants, but in line with mean or median ages (16-39 days) reported in other studies of infants undergoing SBI evaluation. 9,12,26,28,30 While this could reflect longer exposure to the extrauterine environment and more opportunities for viral transmission, inclusion of asymptomatic newborns exposed to maternal infections may have decreased the average age of SARS-CoV-2 negative infants, which may explain why this age difference was not observed in the febrile subgroup. The lower age among infants without SARS-CoV-2 infection may confound the differences in hemoglobin observed between all infants with and without SARS-CoV-2, since hemoglobin may be elevated shortly after birth and no hemoglobin differences were observed between SARS-CoV-2 positive and negative infants in the older, febrile subgroup.…”

SARS-COV-2 Infection in Children in Emergency Departments in Spain

“…Of note, among urine cultures performed on patients less than 3 months of age, 10.3% were positive. This result is consistent with the study by Blázquez-Gamero et al, 28 who found a prevalence of 10,20,29,30 Although it would be expected that coinfection rates with influenza or RSV would be higher during the winter months when outbreaks of both viruses mostly occur, low levels of RSV and influenza activity were detected in Europe during the 2020/2021 season; public health measures implemented to reduce transmission of coronavirus disease and ecological niche competition were factors proposed as possible explanations. 31,32 According with previous reviews, 15,16 symptomatic treatment alone was used in most cases, particularly in children managed as outpatients, whereas less than 1% of patients were given antiviral agents or hydroxychloroquine at the ED.…”