Using risk factors to select children with fever for treatment

Based on the Baron data for children aged 3 to 24 months with a fever with no local symptoms, we can make the following theoretical calculations. When selecting for treatment of children with a body temperature of 40 ° C and higher, it will be carried out in a smaller number of patients and only 17 children per one child with latent bacteremia will not be shown this therapy. An insignificant number of patients with bacteremia will be missed (none of the 9 in this series).

If leukocytosis of 15×109 / l and more is added to this condition, an even smaller number of patients will be treated. Only 4 patients will not be indicated for one patient with bacteremia.

However, one of 8 patients with bacteremia (12.5%) will be missed. Meanwhile, when using such indicators as 10,000 polymorphonuclear neutrophils or 500 segmented (ring) neutrophils as the borderline level, 25 and 50% of patients with bacteremia will be missed, respectively. Theoretical calculations based on data from a Teele study on children in the first 24 months of life with fever without local symptoms show that using criteria such as a temperature of 39 ° C and higher and leukocytosis of 15×109 / l and more will lead to unreasonable treatment held in 8 children per child with bacteremia. At the same time, very few patients with bacteremia will be missed.

The choice of borderline levels for the three main risk factors (age, magnitude, fever, leukocytosis) is controversial and remains at the discretion of each doctor. The principle, however, is clear. The more stringent borderline is used, the smaller will be the number of patients who have undergone unreasonable treatment, but the greater the number of missed patients with bacteremia will be. Conversely, the more uncertain the borderline is, the fewer patients with bacteremia will be missed, but more patients will receive treatment without indications.

Different authors have different boundary levels of risk factors. Hamrick suggested the following: age younger than 36 months, body temperature above 40 ° C and leukocytosis more than 15×109 / l. In his opinion, children who “look more sick than usual” should also be considered a risk group for the development of bacteremia, and it is difficult to argue with this statement. A child with a fever stops playing, he has pathological eye symptoms. These manifestations correlate with a general risk of developing serious illnesses. Although in children with fever without local symptoms, their significance was not specifically evaluated. The potential value for the prediction of possible latent bacteremia of such non-permanent symptoms as rejection of the game, anxiety, or lethargy has not yet been established.

For the time being we must say that their appearance should cause us anxiety, and the absence should not reassure.

Teele described the child from the risk group as follows: age from 6 to 24 months, body temperature 39 ° C and higher, leukocytosis more than 15×109 / l. According to the author, the criteria proposed by Hamrick are more acceptable: age up to 36 months, body temperature 40 ° C and leukocytosis 15×109 / l.

Risk factors for latent bacteremia in children with fever with no local symptoms:
– Age less than 36 months
– Body temperature more than 40 ° С (especially more than 41 ° С)
– Leukocytosis more than 15×109 / l (especially more than 20×109 / l) – ESR more than 30 mm / h
– The presence of toxic granulation, vacuolation of polymorphonuclear leukocytes, thrombocytopenia
– Previous chronic disease (for example, sickle cell anemia, immunodeficiency, asplenia, treatment with corticosteroids)
– Clinical signs, such as failure to play, anxiety, lethargy, poor appetite, sleep disturbance
– Contact with N. meningiditis infection or N. influenzae – Febrile seizures

local_offerevent_note February 25, 2019

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