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Fever Caused By Occult Infections In The 3-To-36-Month-Old Child

July 2007

Fever is a common presenting complaint among pediatric patients, accounting for approximately 20% of emergency department (ED) visits by children.1,2 Hence, management of the febrile child is a challenge faced by emergency physicians on a daily basis. Despite the fact that the vast majority of children with fever have self-limited viral illnesses,3 there is a finite number who may harbor serious bacterial illnesses (SBIs), and, in many cases, these patients are clinically indistinguishable from the rest. The emergency physician's challenge is to identify and treat those children who have SBIs while avoiding overtreatment with antibiotics of those without SBIs, thereby limiting the propagation of antimicrobial resistance. Making this distinction is particularly difficult early in the course of a febrile illness. In addition, this decision process is often conducted in the setting of a family with "fever phobia." Many myths regarding fever exist among the general public, and these misconceptions are often reinforced by the mixed messages that we in the medical community provide. Assessing the risk of SBI to an individual patient, selectively making reasonable diagnostic and therapeutic interventions, and simultaneously reassuring and educating families regarding appropriate concern for fever can make what appears to be a routine common complaint an important and challenging encounter.

Some instances of fever in children require simple decision making. When a child with fever has an evident source of infection, such as acute otitis media or acute gastroenteritis, decisions are relatively straightforward: treat the source and manage the patient's condition appropriately. In the case of the febrile patient with an underlying medical condition (such as sickle-cell disease) or indwelling hardware (such as a central venous catheter), diagnostic investigations and empiric therapy are usually protocoldriven. These circumstances place the patient at greater risk for SBI, and more aggressive management is apropos. This conservative approach extends to the youngest infants (less than 2-3 months of age), who have yet to develop a fully competent immune response. Finally, any patient who appears "toxic" demands a comprehensive search for the source of fever and empiric broad-spectrum antibiotic coverage until the clinical picture clears. This is true whether the patient is 45 days or 45 years of age.

Like the child in our vignette, however, it is the febrile pediatric patient without a readily identifiable source of infection, an unremarkable medical history, and a nontoxic appearance who can be the most challenging. What is this patient's risk of SBI? Are there laboratory tests that can guide us in pinpointing those at risk? Who should receive antibiotics? And what is an appropriate disposition and followup plan for these patients?
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