Bacteremia Medication: Antibiotic Agents, Antipyretic Agents

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Bacteremia Medication: Antibiotic Agents, Antipyretic Agents

Medication Summary



See Medical Care.

Antibiotic Agents



Class Summary



Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Amoxicillin (Amoxil, Biomox, Trimox)



Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.

Ampicillin (Marcillin, Omnipen, Polycillin, Principen, Totacillin)



Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication PO. Until recently, the HACEK bacteria were uniformly susceptible to ampicillin. Recently, however, beta-lactamase–producing strains of HACEK have been identified.

Ceftriaxone (Rocephin)



Third-generation cephalosporin with broad-spectrum gram-negative activity, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Cefotaxime (Claforan)



For septicemia and treatment of gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.

Gentamicin (Garamycin, I-Gent, Jenamicin)



Aminoglycoside antibiotic used for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Consider if penicillins or other less-toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM.

Vancomycin (Vancocin, Vancoled, Lyphocin)



Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or who have not responded to penicillins and cephalosporins or who have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.

To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients diagnosed with renal impairment.

Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.

Nafcillin (Unipen, Nafcil, Nallpen)



Initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections.

Initially use parenteral therapy in severe infections. Change to PO therapy as condition warrants.

Because of thrombophlebitis, particularly in children or elderly patients, administer parenterally only for short term (1-2 d); change to PO route as clinically indicated.

Meropenem (Merrem)



Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Has slightly increased activity against gram-negative organisms and slightly decreased activity against staphylococci and streptococci compared to imipenem.

Imipenem and cilastatin (Primaxin)



For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated because of potential for toxicity.

Cefepime (Maxipime)



Fourth-generation cephalosporin with good gram-negative coverage. Similar to third-generation cephalosporins but has better gram-positive coverage.

Antipyretic Agents



Class Summary



Inhibits central synthesis and release of prostaglandins that mediate the effect of endogenous pyrogens in the hypothalamus; thus, promotes the return of the set-point temperature to normal.

Ibuprofen (Advil, Excedrin IB, Ibuprin, Motrin)



One of the few NSAIDs indicated for reduction of fever.

Acetaminophen (Aspirin Free Anacin, Feverall, Tempra, Tylenol)



Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.

Follow-up



Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP Assistant Professor of Pediatrics, Co-Director of Antimicrobial Stewardship, Medical Director, Division of Pediatric Infectious Diseases and Immunology, Connecticut Children's Medical Center

Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics

Disclosure: Received research grant from: Cubist Pharmaceuticals, Durata Therapeutics, and Biota Pharmaceutical<br/>Received income in an amount equal to or greater than $250 from: HealthyCT insurance<br/>Medico legal consulting for: Various.

Coauthor(s)

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received consulting fee from sanofi pasteur for independent contractor; Received honoraria from medimmune for review panel membership; Received grant/research funds from glaxo smith kline for independent contractor.

Brian J Holland, MD Assistant Professor of Pediatrics, Pediatric Cardiology, University of Louisville School of Medicine

Brian J Holland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Cardiology

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Mark R Schleiss, MD Minnesota American Legion and Auxiliary Heart Research Foundation Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Pediatric Research

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association



Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

References

  1. Kuppermann N. Occult bacteremia in young febrile children. Pediatr Clin North Am. 1999 Dec. 46(6):1073-109. [Medline].
  2. Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med. 2000 Dec. 36(6):602-14. [Medline].
  3. Nigrovic LE, Malley R. Evaluation of the febrile child 3 to 36 months old in the era of pneumococcal conjugate vaccine: focus on occult bacteremia. Clinical Pediatric Emergency Medicine. 2004. 5.
  4. Spraycar M, ed. Stedman's Medical Dictionary. 26th ed. Baltimore, Md: Lippincott Williams & Wilkins; 1995.
  5. [Guideline] Kramer MS, Shapiro ED. Management of the young febrile child: a commentary on recent practice guidelines. Pediatrics. 1997 Jul. 100(1):128-34. [Medline].
  6. Harper MB, Fleisher GR. Occult bacteremia in the 3-month-old to 3-year-old age group. Pediatr Ann. 1993 Aug. 22(8):484, 487-93. [Medline].
  7. Lorin MI. Introduction and overview. Semin Pediatr Infect Dis. 1993. 4:2-3.
  8. Swindell SL, Chetham MM. Occult bacteremia. Fever without localizing signs: the problem of occult bacteremia. Semin Pediatr Infect Dis. 1993. 4:24-29.
  9. McCarthy PL. Fever. Pediatr Rev. 1998 Dec. 19(12):401-7; quiz 408. [Medline].
  10. [Guideline] Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med. 1993 Jul. 22(7):1198-210. [Medline].
  11. Baraff LJ. Management of infants and children 3 to 36 months of age with fever without source. Pediatr Ann. 1993 Aug. 22(8):497-8, 501-4. [Medline].
  12. Bass JW, Steele RW, Wittler RR, et al. Antimicrobial treatment of occult bacteremia: a multicenter cooperative study. Pediatr Infect Dis J. 1993 Jun. 12(6):466-73. [Medline].
  13. Chase M, Klasco RS, Joyce NR, Donnino MW, Wolfe RE, Shapiro NI. Predictors of bacteremia in emergency department patients with suspected infection. Am J Emerg Med. 2012 May 23. [Medline].
  14. Baker MD. Evaluation and management of infants with fever. Pediatr Clin North Am. 1999 Dec. 46(6):1061-72. [Medline].
  15. Jaskiewicz JA, McCarthy CA. Evaluation and management of the febrile infant 60 days of age or younger. Pediatr Ann. 1993 Aug. 22(8):477-80, 482-3. [Medline].
  16. Baraff LJ, Oslund SA, Schriger DL, et al. Probability of bacterial infections in febrile infants less than three months of age: a meta-analysis. Pediatr Infect Dis J. 1992 Apr. 11(4):257-64. [Medline].
  17. Biondi E, Evans R, Mischler M, Bendel-Stenzel M, Horstmann S, Lee V, et al. Epidemiology of bacteremia in febrile infants in the United States. Pediatrics. 2013 Dec. 132(6):990-6. [Medline].
  18. Kadish HA, Loveridge B, Tobey J, et al. Applying outpatient protocols in febrile infants 1-28 days of age: can the threshold be lowered?. Clin Pediatr (Phila). 2000 Feb. 39(2):81-8. [Medline].
  19. Baskin MN. The prevalence of serious bacterial infections by age in febrile infants during the first 3 months of life. Pediatr Ann. 1993 Aug. 22(8):462-6. [Medline].
  20. Baraff LJ, Oslund S, Prather M. Effect of antibiotic therapy and etiologic microorganism on the risk of bacterial meningitis in children with occult bacteremia. Pediatrics. 1993 Jul. 92(1):140-3. [Medline].
  21. Jones RG, Bass JW. Febrile children with no focus of infection: a survey of their management by primary care physicians. Pediatr Infect Dis J. 1993 Mar. 12(3):179-83. [Medline].
  22. Alpern ER, Alessandrini EA, McGowan KL, et al. Serotype prevalence of occult pneumococcal bacteremia. Pediatrics. 2001 Aug. 108(2):E23. [Medline].
  23. Lee GM, Harper MB. Risk of bacteremia for febrile young children in the post-Haemophilus influenzae type b era. Arch Pediatr Adolesc Med. 1998 Jul. 152(7):624-8. [Medline].
  24. Lee GM, Fleisher GR, Harper MB. Management of febrile children in the age of the conjugate pneumococcal vaccine: a cost-effectiveness analysis. Pediatrics. 2001 Oct. 108(4):835-44. [Medline].
  25. Greenhow TL, Hung YY, Herz AM. Changing epidemiology of bacteremia in infants aged 1 week to 3 months. Pediatrics. 2012 Mar. 129(3):e590-6. [Medline].
  26. Steele RW. Fever with bacteremia: a disappearing classic. Consultant for Pediatr. 2013. 12:19-23.
  27. Black SB, Shinefield HR, Hansen J, et al. Postlicensure evaluation of the effectiveness of seven valent pneumococcal conjugate vaccine. Pediatr Infect Dis J. 2001 Dec. 20(12):1105-7. [Medline].
  28. Kaplan SL, Mason EO Jr, Wald E, et al. Six year multicenter surveillance of invasive pneumococcal infections in children. Pediatr Infect Dis J. 2002 Feb. 21(2):141-7. [Medline].
  29. Giebink GS. The prevention of pneumococcal disease in children. N Engl J Med. 2001 Oct 18. 345(16):1177-83. [Medline].
  30. Kupperman N, Malley R, Inkelis SH, et al. Clinical and hematologic features do not reliably identify children with unsuspected meningococcal disease. Pediatrics. 1999. 103:E20.
  31. Harper MB, Bachur R, Fleisher GR. Effect of antibiotic therapy on the outcome of outpatients with unsuspected bacteremia. Pediatr Infect Dis J. 1995 Sep. 14(9):760-7. [Medline].
  32. Chancey RJ, Jhaveri R. Fever without localizing signs in children: a review in the post-Hib and postpneumococcal era. Minerva Pediatr. 2009 Oct. 61(5):489-501. [Medline].
  33. Bauchner H, Pelton SI. Management of the young febrile child: a continuing controversy. Pediatrics. 1997 Jul. 100(1):137-8. [Medline].
  34. Fleisher GR, Rosenberg N, Vinci R, et al. Intramuscular versus oral antibiotic therapy for the prevention of meningitis and other bacterial sequelae in young, febrile children at risk for occult bacteremia. J Pediatr. 1994 Apr. 124(4):504-12. [Medline].
  35. Strait RT, Kelly KJ, Kurup VP. Tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6 levels in febrile, young children with and without occult bacteremia. Pediatrics. 1999 Dec. 104(6):1321-6. [Medline].
  36. Dirnberger DR. Outpatient management of infants 28-60 days of age with fever without a source in a military setting. AAP Uniformed Services Section. 1996.
  37. Zuckerbraun NS, Zomorrodi A, Pitetti RD. Occurrence of serious bacterial infection in infants aged 60 days or younger with an apparent life-threatening event. Pediatr Emerg Care. 2009 Jan. 25(1):19-25. [Medline].
  38. Levine OS, Farley M, Harrison LH, et al. Risk factors for invasive pneumococcal disease in children: a population-based case-control study in North America. Pediatrics. 1999 Mar. 103(3):E28. [Medline].
  39. Bass JW, Wittler RR, Weisse ME. Social smile and occult bacteremia. Pediatr Infect Dis J. 1996 Jun. 15(6):541. [Medline].
  40. Bonadio WA. Defining fever and other aspects of body temperature in infants and children. Pediatr Ann. 1993 Aug. 22(8):467-8, 470-3. [Medline].
  41. [Guideline] Baraff LJ, Schriger DL, Bass JW, et al. Management of the young febrile child. Commentary on practice guidelines. Pediatrics. 1997 Jul. 100(1):134-6. [Medline].
  42. Mandl KD, Stack AM, Fleisher GR. Incidence of bacteremia in infants and children with fever and petechiae. J Pediatr. 1997 Sep. 131(3):398-404. [Medline].
  43. Greenes DS, Harper MB. Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatr Infect Dis J. 1999 Mar. 18(3):258-61. [Medline].
  44. Bass JW, Vincent JM, Demers DM. Oral antibiotic therapy for suspected occult bacteremia. J Pediatr. 1994 Dec. 125(6 Pt 1):1015-6. [Medline].
  45. Hsu K, Pelton S, Karumuri S, et al. Population-based surveillance for childhood invasive pneumococcal disease in the era of conjugate vaccine. Pediatr Infect Dis J. 2005 Jan. 24(1):17-23. [Medline].
  46. Black S, Shinefield H, Baxter R, et al. Postlicensure surveillance for pneumococcal invasive disease after use of heptavalent pneumococcal conjugate vaccine in Northern California Kaiser Permanente. Pediatr Infect Dis J. 2004 Jun. 23(6):485-9. [Medline].
  47. Black S, Shinefield H, Baxter R, et al. Impact of the use of heptavalent pneumococcal conjugate vaccine on disease epidemiology in children and adults. Vaccine. 2006 Apr 12. 24 Suppl 2:S2-79-80. [Medline].
  48. Singleton RJ, Hennessy TW, Bulkow LR, et al. Invasive pneumococcal disease caused by nonvaccine serotypes among alaska native children with high levels of 7-valent pneumococcal conjugate vaccine coverage. JAMA. 2007 Apr 25. 297(16):1784-92. [Medline].
  49. Pelton SI, Huot H, Finkelstein JA, et al. Emergence of 19A as virulent and multidrug resistant Pneumococcus in Massachusetts following universal immunization of infants with pneumococcal conjugate vaccine. Pediatr Infect Dis J. 2007 Jun. 26(6):468-72. [Medline].
  50. Hicks LA, Harrison LH, Flannery B, et al. Incidence of pneumococcal disease due to non-pneumococcal conjugate vaccine (PCV7) serotypes in the United States during the era of widespread PCV7 vaccination, 1998-2004. J Infect Dis. 2007 Nov 1. 196(9):1346-54. [Medline].
  51. Fernandez Lopez A, Luaces Cubells C, Garcia Garcia JJ, et al. Procalcitonin in pediatric emergency departments for the early diagnosis of invasive bacterial infections in febrile infants: results of a multicenter study and utility of a rapid qualitative test for this marker. Pediatr Infect Dis J. 2003 Oct. 22(10):895-903. [Medline].
  52. Pulliam PN, Attia MW, Cronan KM. C-reactive protein in febrile children 1 to 36 months of age with clinically undetectable serious bacterial infection. Pediatrics. 2001 Dec. 108(6):1275-9. [Medline].
  53. Lacour AG, Gervaix A, Zamora SA, et al. Procalcitonin, IL-6, IL-8, IL-1 receptor antagonist and C-reactive protein as identificators of serious bacterial infections in children with fever without localising signs. Eur J Pediatr. 2001 Feb. 160(2):95-100. [Medline].
  54. Isaacman DJ, Burke BL. Utility of the serum C-reactive protein for detection of occult bacterial infection in children. Arch Pediatr Adolesc Med. 2002 Sep. 156(9):905-9. [Medline].
  55. Wack RP, Demers DM, Bass JW. Immature neutrophils in the peripheral blood smear of children with viral infections. Pediatr Infect Dis J. 1994 Mar. 13(3):228-30. [Medline].
  56. Gendrel D, Raymond J, Coste J, et al. Comparison of procalcitonin with C-reactive protein, interleukin 6 and interferon-alpha for differentiation of bacterial vs. viral infections. Pediatr Infect Dis J. 1999 Oct. 18(10):875-81. [Medline].
  57. Jaye DL, Waites KB. Clinical applications of C-reactive protein in pediatrics. Pediatr Infect Dis J. 1997 Aug. 16(8):735-46; quiz 746-7. [Medline].
  58. Gendrel D, Bohuon C. Procalcitonin as a marker of bacterial infection. Pediatr Infect Dis J. 2000 Aug. 19(8):679-87; quiz 688. [Medline].
  59. Mariscalco MM. Is plasma procalcitonin ready for prime time in the pediatric intensive care unit?. Pediatr Crit Care Med. 2003 Jan. 4(1):118-9. [Medline].
  60. Leclerc F, Cremer R, Noizet O. Procalcitonin as a diagnostic and prognostic biomarker of sepsis in critically ill children. Pediatr Crit Care Med. 2003 Apr. 4(2):264-6. [Medline].
  61. Gendrel D, Raymond J, Assicot M, et al. Measurement of procalcitonin levels in children with bacterial or viral meningitis. Clin Infect Dis. 1997 Jun. 24(6):1240-2. [Medline].
  62. Bachur RG, Harper MB. Predictive model for serious bacterial infections among infants younger than 3 months of age. Pediatrics. 2001 Aug. 108(2):311-6. [Medline].
  63. Herr SM, Wald ER, Pitetti RD, et al. Enhanced urinalysis improves identification of febrile infants ages 60 days and younger at low risk for serious bacterial illness. Pediatrics. 2001 Oct. 108(4):866-71. [Medline].
  64. Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics. 2004 Jun. 113(6):1728-34. [Medline].
  65. Krief WI, Levine DA, Platt SL, et al. Influenza virus infection and the risk of serious bacterial infections in young febrile infants. Pediatrics. 2009 Jul. 124(1):30-9. [Medline].
  66. Bachur R, Perry H, Harper MB. Occult pneumonias: empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med. 1999 Feb. 33(2):166-73. [Medline].
  67. Walson PD, Galletta G, Chomilo F, et al. Comparison of multidose ibuprofen and acetaminophen therapy in febrile children. Am J Dis Child. 1992 May. 146(5):626-32. [Medline].
  68. Avner JR, Crain EF, Shelov SP. The febrile infant less than 10 days of age in the emergency department. Semin Pediatr Infect Dis. 1993. 4:18-23.
  69. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med. 1993 Nov 11. 329(20):1437-41. [Medline].
  70. Baskin MN, O'Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr. 1992 Jan. 120(1):22-7. [Medline].
  71. Dagan R, Powell KR, Hall CB, et al. Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. J Pediatr. 1985 Dec. 107(6):855-60. [Medline].
  72. Friedland IR. Comparison of the response to antimicrobial therapy of penicillin-resistant and penicillin-susceptible pneumococcal disease. Pediatr Infect Dis J. 1995 Oct. 14(10):885-90. [Medline].
  73. Rothrock SG, Harper MB, Green SM, et al. Do oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia? A meta-analysis. Pediatrics. 1997 Mar. 99(3):438-44. [Medline].
  74. Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003.
  75. Nilsson P, Laurell MH. Carriage of penicillin-resistant Streptococcus pneumoniae by children in day-care centers during an intervention program in Malmo, Sweden. Pediatr Infect Dis J. 2001 Dec. 20(12):1144-9. [Medline].
  76. Arditi M, Mason EO Jr, Bradley JS, et al. Three-year multicenter surveillance of pneumococcal meningitis in children: clinical characteristics, and outcome related to penicillin susceptibility and dexamethasone use. Pediatrics. 1998 Nov. 102(5):1087-97. [Medline].
  77. Tamma PD, Turnbull AE, Harris AD, Milstone AM, Hsu AJ, Cosgrove SE. Less Is More: Combination Antibiotic Therapy for the Treatment of Gram-Negative Bacteremia in Pediatric Patients. JAMA Pediatr. 2013 Aug 5. [Medline].
  78. Irwin AD, Drew RJ, Marshall P, Nguyen K, Hoyle E, Macfarlane KA, et al. Etiology of childhood bacteremia and timely antibiotics administration in the emergency department. Pediatrics. 2015 Apr. 135 (4):635-42. [Medline].
  79. Phillips D. Changing Etiology of Bacteremia in Kids Poses New Challenges. Medscape Medical News. Available at http://www.medscape.com/viewarticle/841079. March 09, 2015; Accessed: June 23, 2015.
  80. Isaacman DJ, Kaminer K, Veligeti H, et al. Comparative practice patterns of emergency medicine physicians and pediatric emergency medicine physicians managing fever in young children. Pediatrics. 2001 Aug. 108(2):354-8. [Medline].
  81. Obaro SK, Adegbola RA, Banya WA, et al. Carriage of pneumococci after pneumococcal vaccination. Lancet. 1996 Jul 27. 348(9022):271-2. [Medline].
  82. Advisory Committee for Immunization Practices. Draft ACIP recommendations for PCV13 vaccination schedule. Available at http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct09/11-2-PCV13.pdf. Accessed: 12/14/09.
  83. DeAngelis C, Joffe A, Wilson M, et al. Iatrogenic risks and financial costs of hospitalizing febrile infants. Am J Dis Child. 1983 Dec. 137(12):1146-9. [Medline].
  84. Busko M. Bacteremia appears to increase 30-day risk of MI or stroke. Heartwire. February 17, 2014. [Full Text].
  85. Dalager-Pedersen M, Sogaard M, Schonheyder HC, Nielsen H, Wernich Thomsen R. Risk for myocardial infarction and stroke after community-acquired bacteremia: a 20-year population-based cohort study. Circulation. 2014 Feb 12. [Medline].


Application of low-risk criteria and approach for the febrile infant: A reasonable approach for treating febrile infants younger than 3 months who have a temperature of greater than 38°C.

Application of algorithms for children aged 3-36 months: A reasonable approach for treating infants and young children aged 3-36 months who have a temperature of at least 39.5°C.

  • Table 1. Age, Fever, and Bacterial Infection[40]
  • Table 2. Children Aged 3-36 Months - Fever and Occult Bacteremia[1, 2, 6, 8, 41]
  • Table 3. Causes of Occult Bacteremia in Neonates and Infants with a Temperature of 38°C or Higher[14, 15, 16, 18, 19]
  • Table 4. Causes of Occult Bacteremia and Changes Over Time in Children Aged 3-36 Months with FWS[1, 6, 10, 12, 20, 23, 31]
  • Table 5. Studies Evaluating the Established WBC More Than 15 per HPF Screen for Occult Bacteremia in FWS
  • Table 6. Recent Studies Reevaluating WBC Count as a Screen in FWS
  • Table 7. ANC as a Screen for Occult Bacteremia[1, 35]
  • Table 8. Studies Reevaluating CRP level as a Screen in FWS
  • Table 9. Recent Studies Evaluating PCT level as a Screen in FWS
  • Table 10. Effect of Illness Duration - PCT level as a Screen in FWS[51]
  • Table 11. Low-Risk Criteria for Infants Younger than 3 Months[10, 69, 70, 71]
  • Table 12. Occult Bacteremia - Relationship Between Outpatient Antibiotic Use and Complications[10, 11, 12, 31, 72]
  • Table 13. Pneumococcal Bacteremia - Relationship Between Outpatient Antibiotic Use and Complications[1, 2, 10, 11, 21, 24, 33, 41, 73]


Table 1. Age, Fever, and Bacterial Infection
AgeTemperature, Degrees CelsiusRate of Bacterial Infection, %
Neonates < 1 mo38-38.95
39-39.97.5
≥ 4018
Infants aged 1-2 mo38-38.93
39-39.95
≥ 4026

Table 2. Children Aged 3-36 Months - Fever and Occult Bacteremia
Temperature, Degrees CelsiusOccult Pneumococcal Bacteremia, %Positive Blood Culture, %Positive Blood Culture, %Occult Pneumococcal Bacteremia, %
≤ 39Very low1.61…
39-39.41.21.65…
39.5-39.72.52.85…
39.8-39.92.52.85…
40-40.23.23.7510-10.4
40.3-40.53.23.7510-10.4
40.5-40.94.43.81210-10.4
≥ 419.39.21210-10.4

Table 3. Causes of Occult Bacteremia in Neonates and Infants with a Temperature of 38°C or Higher
AgeOrganismPositive Blood Cultures, %
Neonates < 1 moGroup B Streptococcus73
Escherichia coli8
S pneumoniae3
Staphylococcus aureus3
Enterococcus species3
Enterobacter cloacae3
Infants aged 1-2 moGroup B Streptococcus31
E coli20
Salmonella species16
S pneumoniae10
H influenzae type b6
S aureus4
E cloacae4
Also, less frequently (< 1%), Listeria species, Klebsiella species, group A Streptococcus, Staphylococcus epidermis, Streptococcus viridans, and N meningitidis

Table 4. Causes of Occult Bacteremia and Changes Over Time in Children Aged 3-36 Months with FWS
Organism1975-1993, %1993, %1993-1996, %1990 to present, %
S pneumoniae83-86939289
H influenzae type b5-13200
N meningitidis1-3………
Salmonella species1-7………
Also, less frequently (< 1%), E coli, S aureus, Streptococcus pyogenes, group B Streptococcus, Moraxella species, Kingella species, Yersinia species, and Enterobacter species

Table 5. Studies Evaluating the Established WBC More Than 15 per HPF Screen for Occult Bacteremia in FWS
Study Cutoff NPV, % PPV, %
Kuppermann, 1999WBC >15996
Lee, 2001WBC >15995
Strait, 1999WBC >15986

Table 6. Recent Studies Reevaluating WBC Count as a Screen in FWS
Study Screening Goal Cutoff, per HPF NPV, % PPV, %
Fernandez Lopez, 2003Invasive bacterial infectionWBC >176969
Pulliam, 2001Serious bacterial infectionWBC >158930
Lacour, 2001Serious bacterial infectionWBC >158946
Isaacman, 2002Occult bacterial infectionWBC >179530
Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; dimercaptosuccinic acid (DMSA)–positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months

Culture-positive bacteremia/meningitis/septic arthritis/urinary tract infection (UTI); focal infiltrate on chest radiograph

Culture-positive bacteremia/meningitis/osteomyelitis; DMSA-positive pyelonephritis; lobar pneumonia

Culture-positive bacteremia/UTI; lobar pneumonia


Table 7. ANC as a Screen for Occult Bacteremia
ANCSensitivity, %Specificity, %PPV, %NPV, %
10,0007678899.2
>7,20082747.599.4

Table 8. Studies Reevaluating CRP level as a Screen in FWS
Study Screening Goal Cutoff NPV, % PPV, %
Lopez, 2003Invasive bacterial infection2.88169
Pulliam, 2001Serious bacterial infection598Not reported
Lacour, 2001Serious bacterial infection49651
Gendrel, 1999Invasive bacterial infection49734
Isaacman, 2002Occult bacterial infection4.49430
Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; DMSA-positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months

Culture-positive bacteremia/meningitis/septic arthritis/UTI; focal infiltrate on chest radiography

Culture-positive bacteremia/meningitis/osteomyelitis; DMSA-positive pyelonephritis; lobar pneumonia

Culture-positive bacteremia/sepsis/meningitis

Culture-positive bacteremia/UTI; lobar pneumonia


Table 9. Recent Studies Evaluating PCT level as a Screen in FWS
Study Screening Goal Cutoff NPV, % PPV, %
Lopez, 2003Invasive bacterial infection0.69091
Lacour, 2001Serious bacterial infection19755
Gendrel, 1999Invasive bacterial infection29952
Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; DMSA-positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months

Culture-positive bacteremia/meningitis/osteomyelitis; DMSA-positive pyelonephritis; lobar pneumonia

Culture-positive bacteremia/sepsis/meningitis


Table 10. Effect of Illness Duration - PCT level as a Screen in FWS
Illness Duration Screening Goal Optimal Cutoff NPV, % PPV, %
Any (< 12 h and >12 h)Invasive bacterial infection0.69091
< 12 hInvasive bacterial infection0.79097
*Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; DMSA-positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months

Table 11. Low-Risk Criteria for Infants Younger than 3 Months
CriterionPhiladelphiaBostonRochesterAAP 1993
Age1-2 mo1-2 mo0-3 mo1-3 mo
Temperature38.2°C≥38°C≥38°C≥38°C
AppearanceAIOS < 15WellAnyWell
HistoryImmuneNo antibiotics in the last 24 h;

No immunizations in the last 48 h

Previously healthyPreviously healthy
ExaminationNonfocalNonfocalNonfocalNonfocal
WBC count< 15,000/μL; band-to-neutrophil ratio

< 0.2

< 20,000/μL5-15,000/μL;

ABC < 1,000

5-15,000/μL;

ABC < 1,000

Urine assessment< 10 WBCs per HPF;

Negative for bacteria

< 10 WBCs per HPF;

Leukocyte esterase negative

< 10 WBCs per HPF< 5 WBCs per HPF
CSF assessment< 8 WBCs per HPF;

Negative for bacteria

< 10 WBCs per HPF< 10-20 WBCs per HPF…
Chest radiographyNo infiltrateWithin reference range, if obtainedWithin reference range, if obtained…
Stool culture< 5 WBCs per HPF…< 5 WBCs per HPF…
Acute illness observation score

Table 12. Occult Bacteremia - Relationship Between Outpatient Antibiotic Use and Complications
ComplicationNo Antibiotic Therapy, %Oral Antibiotic Therapy, %Intramuscular/Intravenous Antibiotic Therapy, %
Persistent bacteremia18-213.8-50-5
New focal infection135-6.65-7.7
Meningitis9-104.5-8.20.3-1

Table 13. Pneumococcal Bacteremia - Relationship Between Outpatient Antibiotic Use and Complications
ComplicationNo Antibiotic Therapy, %Any Antibiotic Therapy, %Oral Antibiotic Therapy, %Intramuscular/Intravenous Antibiotic Therapy, %
Persistent bacteremia7-171-1.52.5…
Focal infection/SBI9.7-103.3-4……
Meningitis2.7-60.4-10.4-1.50.4-1
Source...
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