Interventions for a child with a high-risk fever

Knowledge of risk factors allows the doctor to identify a group of patients at high risk. What follows from this? What are necessary events? A rational algorithm for the clinical management of children with a fever without infection is presented in the figure. This algorithm is arbitrary in a certain sense and represents only a general guide. They should not use, excluding other clinical data, or consider it as the only way to manage the patient.

Apparently, blood culture should be performed in all children at risk. This allows the physician to more accurately select children for re-examination and makes it possible to select a very small group of patients for hospitalization and intensive care – only those who initially had bacteremia and who had fever by the time they received a positive blood culture. These questions will be discussed in the next article on the site.

It is advisable that patients from the high-risk group should begin to be treated with antibiotics, without waiting for the result of blood seeding. Marshall argued that “treating such children before obtaining the results of a bacteremia test can be effective.”

Teele wrote: “… we believe that treatment even before confirmation of bacteremia is justified in children between the ages of 6 and 24 months with a temperature of 39 ° C and a leukocyte count of 15×109 / l. He recommended the use of ampicillin, not penicillin. According to the author, the treatment of patients at high risk on an outpatient basis leads to a significant reduction in the incidence of persistent bacteremia and pyogenic complications, especially meningitis; He agrees that such therapy is reasonable.

It should be noted that not all doctors agree with this clinical approach. In 1977, Bratton wrote: “Our data do not allow us to recommend or deny the benefits of preventive antibiotic therapy in children with a fever without an infection.” The remaining two authors of this article (Teele and Klein) later, in 1979, wrote that such preventive therapy was indicated. Todd in 1978 In his letter to the journal editor, he suggested that treating children with fever with antibiotics without laboratory testing is the cheapest and most successful way to solve this problem.

According to Surpure, the performance of relevant laboratory studies is shown only “in some cases in accordance with clinical data.” Both authors examined the problem of fever in children in general and did not specifically focus on children with fever without local symptoms.

In deciding which children should be treated before ~ ​​obtaining the results of the first blood seeding, in addition to determining the magnitude of fever and leukocytosis, other laboratory and clinical research methods may be useful. Thus, there is a correlation between increased ESR and bacteremia or other bacterial diseases. The addition of leukocytosis of 15×109 / l and more to the ESR value of 30 mm / h and higher on the condition “or — or” leads to an increase in sensitivity, but to a decrease in specificity.

The use of increased ESR as an independent indicator in addition to leukocytosis leads to an increase in specificity, but at the cost of reduced sensitivity. The author believes that there is no need to determine the ESR during the examination of all children with fever without local symptoms, although this should be done for individual children.

The value of other laboratory indicators as an accurate threshold criterion is limited. These include: toxic granulation, vacuolation of polymorphonuclear leukocytes and a pronounced increase in the total number of non-segmented (ring forms) neutrophils (more than 500) or the total number of polymorphonuclear leukocytes (more than 10,000). Thrombocytopenia should also cause suspected bacteremia or sepsis.

In some chronic diseases, there is undoubtedly an increased risk of developing bacteremia. These include sickle cell anemia, immunodeficiency states, asplenia. Patients receiving corticosteroids are also at high risk. An increased likelihood of developing a serious infectious disease, including bacteremia and meningitis, exists in young children and in those who have recently been in contact with N. meningiditis or H. influenzae infection.

It is considered that children with febrile convulsions in combination with fever of unknown origin have an increased risk of bacteremia. However, according to McCarthy, the incidence of bacteremia in children with febrile convulsions is very low. If from all observations presented by him exclude 4 cases of septic meningitis, then among 150 patients with fever and convulsions there are only 2 cases of bacteremia (1.3% frequency) and none of the 23 patients with fever without local symptoms.

In conclusion, it should be noted that it depends on the socio-economic conditions of the patient whether he can come to the doctor’s office for re-examination. This should be taken into account when deciding on a laboratory examination and / or treatment of a child with a fever, although these factors do not affect the risk of developing bacteremia. That is, the doctor should resort to an immediate examination or treatment of a sick child, if there is no certainty of his return visit.

local_offerevent_note February 27, 2019

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