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ARTICLES:
Barbara W. Trautner, A. Chantal Caviness, Gary R. Gerlacher, Gail Demmler, and Charles G. Macias
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] [Full text] [PDF]
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[Read P3R] Add a Grain of Salt to Antibiotics for High Fever
Kevin C. Osterhoudt   (8 August 2006)

Add a Grain of Salt to Antibiotics for High Fever 8 August 2006
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Kevin C. Osterhoudt,
Associate Professor of Pediatrics
The Children's Hospital of Philadelphia

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Re: Add a Grain of Salt to Antibiotics for High Fever

OsterhoudtK{at}email.chop.edu Kevin C. Osterhoudt

In ancient Rome, poisoning antidotes were sometimes written to be taken with a grain of salt (cum grano salis) – a practice which any evidence-based clinician would currently view with skepticism.

This study regarding serious bacterial infection among children with extremely high fever, by Dr. Barbara Trautner and colleagues, provides very useful epidemiologic data to guide health care providers caring for children with fever. Indeed, the noted lack of value of the white blood cell count or absolute neutrophil count in distinguishing serious bacterial infection in this patient population is thought-provoking. However, the recommendation to provide “antibiotics for all children with hyperpyrexia who do not have a confirmed viral illness” is not directly reached from the data, and must be recognized as personal opinion.

It was difficult to discern the frequency of “occult” serious bacterial infection from the data presented in the manuscript. That is, among fully immunized, non-septic-appearing, previously healthy children with normal urinalyses, normal chest radiography, and without occult blood in stools, what was the incidence of serious bacterial infection? As the presence or absence of “rhinorrhea” as documented by the study is quite subjective, it would also be helpful to know the incidence of occult serious bacterial infection among children in the midst of an obvious acute viral upper respiratory infection (as opposed to mild, subacute nasal congestion).

Before a scientific recommendation to administer empiric antibiotics can be made, the true incidence of occult serious bacterial infection must be provided. Additionally, the possibility of spontaneous clearance of bacteremia must be considered. And then, the risks of diagnosis and treatment must be considered. What is the false-positive blood culture rate? How does antibiotic therapy affect subsequent diagnostic evaluations, including subsequent lumbar puncture? What is the adverse event rate of expectant antibiotics within the individual (allergy, opportunistic enterocolitis, etc.), and what are the possible adverse implications on a population-based model? Until risk-benefit modeling is performed, the data presented should be incorporated into rational clinical decision making, but the advisement for expectant antibiotics should be taken with a grain of salt.

Conflict of Interest:

None declared