Published online December 1, 2006
PEDIATRICS
Vol. 118
No. 6
December 2006, pp.
2604a-2605
(doi:10.1542/peds.2006-2658)
High Fever: In Reply.
Barbara W. Trautner, MD
Department of Internal Medicine,
Section of Infectious Diseases
Charles G. Macias, MD, MPH
A. Chantal Caviness, MD, MPH
Department of Pediatrics,
Section of Emergency Medicine,
Baylor College of Medicine,
Houston, TX 77030
Dr DiTraglia's letter raises some important issues with regard to the use of antibiotics and the utility of complete blood counts in evaluating children with hyperpyrexia. It should be emphasized that our study on febrile children was restricted to a cohort of children with hyperpyrexia.1 Subanalyses were limited by virtue of the small sample size.
In our cohort, 19 of 103 subjects had an underlying chronic illness; thus, to our knowledge, 84 subjects were previously healthy. Of the 19 children with underlying disease, 7 (37%) were diagnosed with a serious bacterial illness (SBI). Also, of the 20 children who were diagnosed with an SBI, 7 (35%) had an underlying illness. The presence of a preexisting chronic condition in the child may have affected the physician's decision whether to treat with antibiotics. In addition, given the paucity of literature on risk of SBI concurrent with each specific underlying condition, we cannot offer a definitive standard for when antibiotics should be given to highly febrile children with underlying medical illnesses.
However, Table 5 in our article highlights the appreciable risk of SBI in patients with hyperpyrexia among children without underlying risk factors. Although underlying conditions provided an odds ratio for bacterial illness of 3.19 (95% confidence interval: 1.06–9.61), the prevalence of SBI in children without underlying illness was 15.5% (95% confidence interval: 7.8%–23.2%).1 As pertains to isolated bacteremia, which is the only one of the illnesses not detected by chest radiograph, urinalysis, or lumbar puncture, there were 5 children who were bacteremic. Three of these children had no other concurrent illness or underlying chronic condition and, thus, would not have had other laboratory work warranting treatment.
As regards the specific question regarding the outcome of the 3 children with SBI who were not initially treated with antibiotics, 2 returned to the emergency department and were treated as outpatients, whereas the child with polycystic kidney disease returned and was admitted to the hospital. We cannot draw generalizable conclusions from such a small subgroup of children.
Our contention that white blood cell (WBC) counts were not particularly useful in distinguishing those at high risk for bacterial infection stems from the 45% of children with bacterial illness for which the WBC count was <15 000 cells per µL. This risk is greater than that expected from children who did not meet high-risk criteria (WBC counts ranging from 5000 to 15 000 cells per µL).2 We did not collect data on all the Rochester parameters and, thus, are unable to apply these criteria to our cohort. It is important to note that this study was neither designed nor powered to make definitive conclusions about the utility of complete blood counts in children with hyperpyrexia. We are only able to report the functioning of these laboratory results in our particular cohort. The utility of WBC counts and subsequent management of febrile children in general do remain controversial, particularly after the introduction of conjugate pneumococcal vaccine.3 This study, however, does not address that question outside of the scope of children with hyperpyrexia. Moreover, some studies based on cost and quality-adjusted life expectancy have suggested that observation alone would be the best treatment option,4 whereas some practitioners include the parental preferences in the decision.5 Therefore, despite the lack of utility of WBC counts in our population of hyperpyrexic children, no conclusion can be made about their utility in the management of all febrile children or even in children with hyperpyrexia.
We concur with the contention that there is no substitute for the thorough and cogent evaluation of any child at risk for serious bacterial infection. Instead, we bring attention to the high risk of SBI among children with hyperpyrexia, and we urge consideration for the use of antibiotics among this high-risk group when specific etiologies cannot be ruled out. Undoubtedly, future studies will continue to fine-tune diagnostic and management strategies for febrile children in the era of conjugate pneumococcal vaccine.
REFERENCES
- Trautner BW, Caviness AC, Gerlacher GR, Demmler G, Macias CG. Prospective evaluation of the risk of serious bacterial infection in children who present to the emergency department with hyperpyrexia (temperature of 106°F or higher). Pediatrics. 2006;118:34–40[Abstract/Free Full Text]
- Baraff JL, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever and without source [published correction appears in Ann Emerg Med. 1993;22:1490]. Ann Emerg Med. 1993;22:1198
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- 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. Clin Pediatr Emerg Med. 2004;5:13
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- Lee GM, Fleisher GR, Harper MB. Management of febrile children in the age of the conjugate pneumococcal vaccine: a cost-effectiveness analysis. Pediatrics. 2001;108:835
–844[Abstract/Free Full Text]
- Madsen KA, Bennett JE, Downs SM. The role of parental preferences in the management of fever without source among 3- to 36-month-old children: a decision analysis.
Pediatrics. 2006;117:1067–1076[Abstract/Free Full Text]
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