Published online December 1, 2006
PEDIATRICS Vol. 118 No. 6 December 2006, pp. 2605-2606 (doi:10.1542/peds.2006-2622)

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Gunasekera, H. Articles by Cheng, N. Search for Related Content PubMed PubMed Citation Articles by Gunasekera, H. Articles by Cheng, N. Related Collections Infectious Disease & Immunity Related AAP Red Book topics: Group A Streptococcal Infections Social Bookmarking                         What's this?

LETTER TO THE EDITOR

Febrile Confusion: Do the Hyperpyrexia Study Conclusions Fit?

Hasantha Gunasekera, MIPH
Institute for Child Health Research,
Children's Hospital at Westmead,
Westmead 2145, New South Wales, Australia

Patrick Patradoon-Ho, FRACP
Department of Paediatrics,
Blacktown/Mt Druitt Health,
Mt Druitt 2770, New South Wales, Australia

Nicholas Cheng, FRACP
Vice President,
Paediatric Emergency Medicine,
Society of Australia and New Zealand,
Emergency Department,
Children’s Hospital at Westmead,
Westmead 2145, New South Wales, Australia

To the Editor.—

We read with interest the recent prospective study by Trautner et al,¹ who examined the outcomes of children presenting with hyperpyrexia (106°F). However, we question the authors' conclusion that "children with hyperpyrexia are at equally high risk for serious bacterial infection and for viral illness." This conclusion was based on the identification of bacterial pathogens in 19 of 103 children, viral pathogens in 21 of 103 children, and both bacterial and viral pathogens in 1 child. This assumes that the remaining 62 of 103 children can be ignored or distributed equally into the bacterial and viral groups. In our experience, febrile children with negative cultures and clear chest radiographs are more likely to have clinical courses consistent with viral illness regardless of whether a specific virus is identified. This in no way undermines the authors' crucial message that antibiotics should be considered for all children with hyperpyrexia.

The next issue is that there are 2 examples of misclassification of serious bacterial infection (SBI). Pneumonia should be included as an SBI given that, globally, it is a leading cause of childhood morbidity² and mortality.³ If we include lobar pneumonia as an SBI (acknowledging the subjectivity of chest radiograph interpretation), then 36 (35.0%) of 103 children with hyperpyrexia had SBI rather than 20 (19.4% [not 18.4% as published]) of 103. We cannot determine how this influences the analysis of predictors. Nonetheless, we can correct for the surprising conclusion that "diarrhea itself was associated with an increased risk" of SBI.¹ This association was based on a very small sample of children with diarrhea (17 of 103). An ascertainment bias results from the fact that bacterial stool cultures were only performed on children with "significant diarrhea" (n = 13), and stool pathogens were included in the SBI classification. In fact, the true association here was between diarrhea and dysentery, not diarrhea and SBI. If we exclude the case of Shigella dysentery and reanalyze the data, then 6 of 17 children with diarrhea and 13 of 86 without diarrhea had SBI, and diarrhea is not a significant predictor.

Our final concern is that one quarter of the patients with SBI had underlying conditions, including muscular dystrophy, sickle cell anemia, and polycystic kidney disease, and 2 patients with unspecified conditions had central venous lines. We would have been interested in a subanalysis excluding these patients. We postulate that SBI risk and SBI predictors would be significantly different in patients with and without underlying conditions.

REFERENCES

1. 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]
2. Shoham Y, Dagan R, Givon-Lavi N, et al. Community-acquired pneumonia in children: quantifying the burden on patients and their families including decrease in quality of life. Pediatrics. 2005;115:1213–1219[Abstract/Free Full Text]
3. World Health Organization. World health report 2005: make every mother and child count. Available at: www.who.int/whr/2005/en. Accessed September 5, 2006

---

PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

CiteULike    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Gunasekera, H. Articles by Cheng, N. Search for Related Content PubMed PubMed Citation Articles by Gunasekera, H. Articles by Cheng, N. Related Collections Infectious Disease & Immunity Related AAP Red Book topics: Group A Streptococcal Infections Social Bookmarking                         What's this?