Risk of Serious Bacterial Infection in Young Febrile Infants With Respiratory Syncytial Virus Infections
* Departments of Pediatrics and Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center, New York, New York
Departments of Pediatrics and Division of Emergency Medicine, The Children’s Hospital of New York Presbyterian, New York, New York
Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
|| Department of Pediatrics, University of Pennsylvania School of Medicine, Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
¶ Department of Pediatrics, Division of Emergency Medicine, Long Island Jewish Hospital-Schneider’s Children’s Hospital, New Hyde Park, New York
# Departments of Pediatrics and Emergency Medicine, New York Hospital-Medical Center of Queens, New York, New York
** Departments of Pediatrics and Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
Department of Radiology, New York University School of Medicine/Bellevue Hospital Center, New York, New York
Division of Emergency Medicine, Department of Internal Medicine and the Department of Pediatrics, University of California, Davis School of Medicine, Davis, California
Background. The evaluation of young febrile infants is controversial, in part because it is unclear whether clinical evidence of a viral infection significantly reduces the risk of serious bacterial infections (SBIs). Specifically, it remains unclear whether the risk of SBI is altered in a meaningful way in the presence of respiratory syncytial virus (RSV) infections.
Objective. The objective of this study was to determine the risk of SBI in young febrile infants who are infected with RSV compared with those without RSV infections.
Methods. We conducted a 3-year multicenter, prospective, cross-sectional study. All febrile (
38°C) infants who were 
60 days of age and presented to any of 8 pediatric emergency departments from October through March 1998–2001 were eligible. General clinical appearance was evaluated using the Yale Observational Scale. We determined RSV status by antigen testing of nasopharyngeal secretions. We defined bronchiolitis as either wheezing alone or chest retractions in association with an upper respiratory infection. We evaluated infants with blood, urine, cerebrospinal fluid, and stool cultures. Urinary tract infection (UTI) was defined by single pathogen growth of 5 x 104 cfu/mL, or 104 cfu/mL in association with a positive urinalysis in a catheterized specimen, or 103 cfu/mL in a suprapubic aspirate. Bacteremia, bacterial meningitis, and bacterial enteritis were defined by growth of a known bacterial pathogen. SBI was defined as any of the above-mentioned 4 bacterial infections.
Results. We enrolled 1248 patients, including 269 (22%) with RSV infections. The overall SBI status could be determined in 1169 (94%) of the 1248 patients, and the rate of SBIs was 11.4% (133 of 1169; 95% confidence interval [CI]: 9.6%–13.3%). The rate of SBIs in the RSV-positive infants was 7.0% (17 of 244; 95% CI: 4.1%–10.9%) compared with 12.5% (116 of 925; 95% CI: 10.5%–14.8%) in the RSV-negative infants (risk difference: 5.5%; 95% CI: 1.7%–9.4%). The rate of UTI in the RSV-positive infants was 5.4% (14 of 261; 95% CI: 3.0%–8.8%) compared with 10.1% (98 of 966; 95% CI: 8.3%–12.2%) in the RSV-negative infants (risk difference: 4.7%; 95% CI: 1.4%–8.1%). The RSV-positive infants had a lower rate of bacteremia than the RSV-negative infants (1.1% vs 2.3%; risk difference: 1.2%; 95% CI: –0.4% to 2.7%). No RSV-positive infant had bacterial meningitis (0 of 251; 95% CI: 0%–1.2%); however, the differences between the 2 groups with regard to bacteremia and bacterial meningitis did not achieve statistical significance.
Conclusions. Febrile infants who are 60 days of age and have RSV infections are at significantly lower risk of SBI than febrile infants without RSV infection. Nevertheless, the rate of SBIs, particularly as a result of UTI, remains appreciable in febrile RSV-positive infants.
Key Words: fever • infant • RSV • serious bacterial infection • bronchiolitis • bacteremia • urinary tract infection
Abbreviations: SBI, serious bacterial infection • UTI, urinary tract infection • RSV, respiratory syncytial virus • ED, emergency department • CSF, cerebrospinal fluid • UA, urinalysis • CXR, chest radiograph • URI, upper respiratory tract infection • WBC, white blood cell • CI, confidence interval • RR, relative risk
Received for publication Aug 11, 2003; Accepted Jan 9, 2004.
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