Because of the relatively greater risk for bacteremic illness and lack of sensitivity of the clinical examination, the febrile or ill-appearing neonate, regardless of temperature, should be comprehensively evaluated for SBI via a sepsis workup. This should include complete blood count, urinalysis, cerebrospinal fluid (CSF) cell count, Gram stain, evaluation of protein and glucose levels, and culture and sensitivities of the urine (suprapubic or catheterized), blood, and CSF. Respiratory symptoms or signs are indications for chest x-ray. The differential diagnosis for septic-appearing neonates includes congenital cardiac disease, metabolic disease, nonaccidental trauma, and bowel obstruction.
Infants 30 to 90 days of age are optimally evaluated via a low-risk versus high-risk stratification that combines both clinical and routine laboratory assessments 22
(Table 118-3). Low-risk infants are those who were born at full term, have no underlying medical problems, and have not previously been treated with antibiotics. On physical examination, these young infants must have a well appearance with no identified focus of possible bacterial infection to specifically include otitis media, skin, soft tissue, joint, or bone infection. To be considered low risk, these young infants must additionally have negative laboratory screening tests. These are defined as white blood count of 5000 to 15,000/pL with less than 1500 bands/pL, urinalysis revealing less than 10 white blood cells per high-power field (WBCs/hpf) and negative for leukocyte esterase and nitrite, and, when diarrhea is present, stool smear with less than 5 WBCs/hpf. Cultures of the blood and urine (suprapubic or catheterized) should be performed. Stool should be cultured if diarrhea is bloody or WBCs are present as above. A chest x-ray is indicated only if there are significant respiratory findings such as severe cough, tachypnea, grunting respirations, or rales. 23 Lumbar puncture should be performed routinely in febrile infants less than 60 days of age and strongly considered for those 60 to 90 days because of limited sensitivity of the clinical assessment at these ages for the detection of meningitis. Febrile infants aged 30 to 90 days who meet low-risk criteria have less than a 1 percent risk of bacteremia and less than a 2 percent risk of SBI. In contrast, young infants categorized as high risk are reported to have a 2 to 10 percent risk of bacteremia and 10 to 15 percent risk of SBI, with ill appearance weighing heavily toward the higher respective risks.24 Infants 30 to 90 days of age considered high risk by either clinical or laboratory parameters should have a complete evaluation for sepsis as for neonates.
TABLE 118-3 Low-Risk Criteria for Febrile Infants 30-90 Days of Age
The laboratory assessment of children 3 to 36 months of age and older should be individualized based on the overall appearance of the child, clues from the history and physical examination, and a knowledge of the incidence of bacteremia and SBI in this age group. Most importantly, an ill-appearing febrile child, regardless of age, should be stabilized and comprehensively evaluated for sepsis as just described. In contrast, a well-appearing febrile infant should have laboratory evaluation based on clinically identified risk factors for SBI with bacteremia. The reader is referred to subsequent chapters for a discussion of the laboratory evaluation for specific focal bacterial infections in children. Blood culture is of limited utility in the outpatient management of radiographically identified pneumonia but should be considered in those patients ill enough to warrant admission. 4 Similarly, blood cultures are indicated in febrile children aged 6 months or less who have UTI or those with clinical features of pyelonephritis indicating admission. 5 Blood cultures are also appropriate for febrile pediatric patients with presumed bacterial enteritis, facial cellulitis, septic arthritis, and osteomyelitis. All febrile patients who are immune-compromised, such as with sickle cell anemia and HIV, should also have blood cultures obtained (Table 118-4.). The identification of a clearly recognizable viral syndrome such as bronchiolitis renders the yield of laboratory testing for bacteremic disease negligible.25
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