Febrile child

July 2000Volume 2, Number 7

Revised Edition

Author

Michael S. Kramer, MDDepartments of Pediatrics and of Epidemiologyand Biostatistics, McGill University Faculty ofMedicine, Montreal, Quebec. Dr. Kramer is aDistinguished Scientist of the Medical ResearchCouncil of Canada.

Peer Reviewers

Steven G. Rothrock, MD, FACEP, FAAPAssociate Professor of Emergency Medicine,University of Florida; Orlando Regional MedicalCenter; Medical Director of Orange CountyEmergency Medical Service, Orlando, FL.

Andy Jagoda, MD, FACEPAssociate Professor of Emergency Medicine, MountSinai School of Medicine, New York, NY.

CME Objectives

Upon completing this article, you should be able to:1. explain important aspects of the history and physical

exam in children with fever;2. list indications for diagnostic tests in febrile children,

including CBC, lumbar puncture, chest x-ray,urinalysis, and urine culture;

3. describe the risks and indicators of occultbacteremia; and

4. discuss the evidence concerning empiric antibiotictreatment in febrile children.

Date of original release: July 1, 2000.Date of most recent review: March 13, 2001.

See “Physician CME Information” on back page.

EMERGENCY MEDICINE PRACTICEA N E V I D E N C E - B A S E D A P P R O A C H T O E M E R G E N C Y M E D I C I N E

Editor-in-Chief

Stephen A. Colucciello, MD, FACEP,Director of Clinical Services,Department of EmergencyMedicine, Carolinas MedicalCenter, Charlotte, NC; AssociateClinical Professor, Department ofEmergency Medicine, Universityof North Carolina at Chapel Hill,Chapel Hill, NC.

Associate Editor

Andy Jagoda, MD, FACEP,Associate Professor ofEmergency Medicine, MountSinai School of Medicine,New York, NY.

Editorial Board

Judith C. Brillman, MD, ResidencyDirector, Associate Professor,

Department of EmergencyMedicine, The University ofNew Mexico Health SciencesCenter School of Medicine,Albuquerque, NM.

W. Richard Bukata, MD, AssistantClinical Professor, EmergencyMedicine, Los Angeles County/USCMedical Center, Los Angeles, CA;Medical Director, EmergencyDepartment, San Gabriel ValleyMedical Center, San Gabriel, CA.

Francis M. Fesmire, MD, FACEP,Director, Chest Pain—StrokeCenter, Erlanger Medical Center;Assistant Professor of Medicine,UT College of Medicine,Chattanooga, TN.

Michael J. Gerardi, MD, FACEP,Clinical Assistant Professor,Medicine, University of Medicineand Dentistry of New Jersey;Director, Pediatric EmergencyMedicine, Children’s MedicalCenter, Atlantic Health System;

Chair, Pediatric EmergencyMedicine Committee, ACEP.

Michael A. Gibbs, MD, FACEP,Residency Program Director;Medical Director, MedCenter Air,Department of EmergencyMedicine, Carolinas MedicalCenter; Associate Professor ofEmergency Medicine, Universityof North Carolina at Chapel Hill,Charlotte, NC.

Gregory L. Henry, MD, FACEP,CEO, Medical Practice RiskAssessment, Inc., Ann Arbor,MI; Clinical Professor, Departmentof Emergency Medicine,University of Michigan MedicalSchool, Ann Arbor, MI; President,American Physicians AssuranceSociety, Ltd., Bridgetown,Barbados, West Indies; PastPresident, ACEP.

Jerome R. Hoffman, MA, MD, FACEP,Professor of Medicine/Emergency Medicine, UCLA

School of Medicine; AttendingPhysician, UCLA EmergencyMedicine Center;Co-Director, The DoctoringProgram, UCLA School ofMedicine, Los Angeles, CA.

John A. Marx, MD, Chair and Chief,Department of EmergencyMedicine, Carolinas MedicalCenter, Charlotte, NC; ClinicalProfessor, Department ofEmergency Medicine, Universityof North Carolina at Chapel Hill,Chapel Hill, NC.

Michael S. Radeos, MD, FACEP,Attending Physician inEmergency Medicine, LincolnHospital, Bronx, NY; ResearchFellow in Emergency Medicine,Massachusetts General Hospital,Boston, MA; Research Fellow inRespiratory Epidemiology,Channing Lab, Boston, MA.

Steven G. Rothrock, MD, FACEP,FAAP, Associate Professor of

Emergency Medicine, Universityof Florida; Orlando RegionalMedical Center; Medical Directorof Orange County EmergencyMedical Service, Orlando, FL.

Alfred Sacchetti, MD, FACEP,Research Director, Our Lady ofLourdes Medical Center, Camden,NJ; Assistant Clinical Professorof Emergency Medicine,Thomas Jefferson University,Philadelphia, PA.

Corey M. Slovis, MD, FACP, FACEP,Department of EmergencyMedicine, Vanderbilt UniversityHospital, Nashville, TN.

Mark Smith, MD, Chairman,Department of EmergencyMedicine, Washington HospitalCenter, Washington, DC.

Thomas E. Terndrup, MD, Professorand Chair, Department ofEmergency Medicine, Universityof Alabama at Birmingham,Birmingham, AL.

The Young Febrile Child:Evidence-Based DiagnosticAnd Therapeutic Strategies

FEVER is one of the most common reasons why young children arebrought to the emergency department (ED).1-3 Many parents (and

some physicians) are frightened by fever; they often exaggerate itsdangers and are overly aggressive in its treatment.4-6 In the early weeksand months of a child’s life, such level of concern may be appropriate.Not only is fever less common at that age, but it is also more likely to beassociated with a serious bacterial infection, such as meningitis orsepsis.7,8 After about 2 or 3 months, fever becomes both more frequentand less ominous. But until the child is about 2 to 3 months of age, thefindings on physical examination are insufficiently sensitive and specificto permit confident exclusion of a serious bacterial infection, particularlywhen the temperature is high (≥39˚C per rectum).9,10

This issue of Emergency Medicine Practice will concentrate on the 3- to36-month-old previously well child without a serious chronic illness(e.g., sickle cell disease, congenital heart disease, severe neuromusculardisease, etc.) who presents with a documented (at home or in the ED)fever, as defined by a rectal temperature of 38.0˚C or greater (or axillarytemperature ≥ 37.0˚C).

A careful history and physical examination will usually succeed inidentifying children with either an obvious bacterial focus or characteris-tic viral infection. The problem is how to manage the young febrile childwithout a clearly identifiable source. This clinical setting is fraught withcontroversy, complexity, and uncertainty. Many different clinical out-comes are possible, and even the most seasoned clinician cannot knowwhich will occur in a particular child. Researchers disagree on even themost fundamental issues regarding the need for diagnostic tests.

Emergency Medicine Practice 2 July 2000

When confronted with the febrile child, thepractitioner must make a series of decisions:

1. Should one or more diagnostic tests beobtained—and if so, which ones, and inwhat sequence?

2. If the diagnostic tests fail to reveal a bacterialinfection, should empiric (“expectant”) antibiotictreatment be prescribed?

3. If the choice is to treat with an antibiotic, should itbe given orally or parenterally (usually intramus-cular ceftriaxone)?

4. What follow-up should be arranged?

These questions apply to both the office-basedpractitioner and the emergency physician. However,two main differences between these settings lead tosubstantial disparity in diagnostic and therapeuticmanagement.11-15 First, diagnostic tests can be easilyobtained in the ED, whereas most office-based practi-tioners must send their patients to private or hospital-based laboratories for these tests. The second differ-ence is that office-based practitioners are often familiarwith both the child and his or her family. This familiar-ity helps establish the pertinence of specific signs andsymptoms and ensures adequate follow-up. The office-based practitioner can more easily adapt the intensityof diagnostic testing to the personalities and values ofthe child and family.

Nonetheless, the similarities in these two settingsexceed their differences. The diagnostic informationcontributed by testing should be identical in the twosettings. The potential for either benefit from anaccurate test or harm from a misleading result remainsthe same.

Over the past 10 or 20 years, there has been adistinct shift in the “climate” toward more aggressivemanagement of the young febrile child. As summa-rized in “practice guidelines” developed by expertsin the field of pediatrics, emergency medicine,and infectious disease, this more aggressiveclimate includes increased diagnostic testing,more frequent treatment, and more invasive (i.e.,parenteral rather than oral) treatment of such chil-dren.16,17 Yet is this shift justified? Are outcomesbetter with more aggressive testing and liberalizeduse of antibiotics, or does this strategy merely increasecosts, ED length of stay, and discomfort for childrenand their parents?

This issue of Emergency Medicine Practice willreview the evidence concerning the epidemiology andetiology of fever in young children, discuss thediagnostic value of specific items from the history andphysical examination, and the pros and cons of theindividual diagnostic tests. We also examine the risksand benefits of empiric oral and parenteral antibiotics,and the importance of follow-up. Finally, based on thisevidence, we propose a management algorithm for this

complex and common clinical problem.

Epidemiology And Etiology

Parents frequently bring their young children to see aphysician because of fever. Two-thirds of all childrensee a physician for a febrile illness during the first twoyears of life.18 From the ED perspective, as many asone-third of pediatric visits involve fever; the majorityof these visits occur in children between 3 and 36months of age.1,2

Febrile illnesses in young children can be dividedinto four broad categories:

1. clinically identifiable viral infections;2. clinically evident bacterial infections;3. other infectious illnesses (presumably viral); and4. occult bacterial infections.

In a small number of children, fever may be due tomalignancy, parasite infections, collagen vascular orother inflammatory diseases (such as Kawasaki’sdisease), drug effects, or other unusual causes.

Clinically identifiable viral infections includevaricella, measles, herpes simplex gingivostomatitis,croup, herpangina, and hand-foot-and-mouth disease.With the exception of viral croup, characteristicrashes define most of these infections. Other exan-thems, often maculopapular, are usually secondaryto viral infection, allergic reactions, heat rashes, orlocal irritation. Roseola becomes clearly identifiableonly in retrospect (i.e., after the fever resolves), asthe rash is not present at the time the child presentswith fever.

Clinically evident bacterial infections are thosethat can be readily diagnosed from the history andphysical examination alone. They include most cases ofotitis media and many cases of pneumonia, meningitis,septic arthritis/osteomyelitis, lymphadenitis, anddysentery-like bacterial enteritis.

The third category comprises nonspecific viralinfections, although in most cases, no virus is identi-fied. These infections are manifested as upper respira-tory infection (URI), bronchiolitis/asthma, viralgastroenteritis, mixed respiratory and gastrointestinalinfections, fever accompanied by rash, and fever only.Malaria, other parasitic diseases, and rare fungalinfections can sometimes resemble these nonspecificviral infections.

The final category, occult bacterial infections,includes bacteremia, the vast majority of children withUTI, and clinically “silent” cases of pneumonia,meningitis, septic arthritis/osteomyelitis, bacterialenteritis, and sinusitis. Pelvic or abdominal abscessesare considerably more rare. It is this fourth categorythat poses the greatest challenge for diagnostic andtherapeutic management. Because the infections are“occult,” they cannot be diagnosed with confidence

3 Emergency Medicine PracticeJuly 2000

based on the history and physical examinationalone. In the child with a fever and no source,the physician should consider the possibility ofa urinary tract infection. UTI is a common andimportant clinical problem in infants and youngchildren, with a prevalence of 5.3% among febrileinfants seen in the ED. As many as 17% of whitefemale infants with a rectal temperature of 39˚C ormore may have UTIs.19

Occult BacteremiaSome children with fever and no source evident onhistory and physical examination may have a detect-able source on diagnostic testing, such as urinalysis orchest radiography. Others do not, and the “source” offever is a blood infection—occult bacteremia.

Perhaps 1%-3% of non-toxic children with a feverof 39˚C (102.5˚F) or greater and no source will havebacteria in their blood, based on culture results. In onerecent study of over 9,000 children, the incidence ofoccult bacteremia (including children with otitismedia) was 1.6%, with no cases of H. influenzae type b(Hib).20 Although bacteremia due to Hib has decreasedsince the widespread use of the Hib conjugate vaccine,this decrease does not explain the lower prevalence ofoccult bacteremia in more recent studies. Of the 2%-3%of children with occult bacteremia, approximately 3%of these will go on to develop a serious bacterialinfection such as pneumonia, osteomyelitis, or menin-gitis. Thus, the calculation goes: 0.03 x 0.03 = 0.0009—in other words, one child in a thousand who looksclinically well with a fever of 102.5˚F and no focus ofinfection will go on to develop a serious bacterialillness over the next several days.

How do we prevent or detect this at an early

stage? How much should we spend and how manywell children should get blood cultures and receiveparenteral antibiotics to deal with this dilemma?Read on.

History

Age is a valuable piece of diagnostic information, evenwithin the restricted group of 3 to 36 months. Inparticular, children under 12 months are at consider-ably higher risk of UTI and meningitis than are olderchildren,21-23 while those over 2 years of age are athigher risk of sinusitis.24 Occult bacteremia is lesscommon in children under 6 months of age due toprotective maternal antibodies and in those over 24months old due to acquired immunity.25

Race and gender have important differentialdiagnostic value for UTI, with whites22 and fe-males22,26,27 at higher risk. Among males (especiallythose < 6 months), the risk is much higher amonguncircumcised than among circumcised males.22,28-31

Although duration of fever has been infrequentlystudied, it is somewhat diagnostic. Ask the parentswhether the fever has occurred daily since onsetor whether the fever course was characterized byone or more afebrile days. The latter history usuallymeans a second febrile (usually viral) illness ratherthan a continuation of the first. Clinical experienceand limited studies suggest that a child (not takingantibiotics) who remains febrile for five or moredays, as documented by daily thermometry, isvery unlikely to have an occult meningitis oroccult bacteremia.32

Prolonged fever generally indicates a viral illnessor an occult bacterial process such as pneumonia, UTI,

Practical Antibiotic PearlsKeep the good stuff on hand.

• Stock the most important parenteral antibiotics in the ED

(ceftriaxone or cefotaxime).

Set limits.

• If the child is toxic, tell the nurse, “If antibiotics are not

infusing in 15 minutes, come and get me. Pull me out of a

code, if necessary!”

Get a dive watch.

• For those of you who do not SCUBA dive, a bezel is

ratcheted outer dial with numbers that keeps track of

elapsed time. Every time you have a child with suspected

meningitis or meningococcemia, set the bezel for 15

minutes—your personal antibiotic deadline. When 15

minutes passes, check to be sure the antibiotics are

already running.

Don’t overdo it.

• No antibiotics or testing is needed in child under 2 with

exudative tonsillitis. They are all viral.

Go to the bone.

• A febrile moribund child who needs antibiotics

cannot wait 40 minutes for the IV team to start a line.

If an IV cannot be started within several minutes,

consider an intramuscular or even intraosseous dose

of antibiotics.


bartonellosis, tuberculosis, or sinusitis.33-35 Moreover,the largest prospective study of occult bacteremiafound that 3- to 36-month-old children with tempera-tures of 39˚C or greater who had a fever for less thanone day were significantly more likely to be bacteremiccompared to those with a fever duration of one day ormore (3.8% vs 2.4%).32

The symptoms accompanying the currentillness are of obvious diagnostic value. Runny nose,sneezing, and cough are frequent with upper respira-tory tract infection (URI). Isolated cough, especiallyif accompanied by high fever and recurrent vomiting,increases the likelihood of an occult pneumonia.36,37

(Of course, the vast majority of children with coughand fever have a viral illness.) The combination ofvomiting and diarrhea suggests the diagnosis of viralgastroenteritis. Bloody or purulent diarrhea suggestsbacterial enteritis. Irritability, excessive sleepiness, andother changes in mental status are nonspecific but mayincrease the risk of occult bacterial meningitis,9

although one study found no such increase.38 The truesignificance of a child pulling at his or her ears is notknown. Some pediatric experts suggest that it does notsuggest otitis media, any more than playing with theirtoes means osteomyelitis of the feet.151

Contrary to conventional wisdom, a historyof reduced appetite and/or activity is not helpfulin developing a differential diagnosis. The sameinflammatory cytokines (IL-1b, IL-6, and tumornecrosis factor) responsible for prostaglandin Erelease in the hypothalamus and the developmentof fever also lead to hypothalamic-mediated anorexiaand weakness.39,40

Sometimes the absence of certain symptoms may behelpful. Some authorities have found that the lack ofrespiratory or gastrointestinal symptoms in febrileinfants increases the probability of UTI. However,clinicians must realize that signs and symptoms arepoor discriminators of UTI.

Ask whether the child has already seen a physicianfor this illness. Many parents may not volunteer thefact that they brought their child to a different ED orphysician for the same illness earlier in the week. Theymight be afraid of looking like they are “doctor-shopping” and need to be directly questioned in asympathetic, nonjudgmental manner. Those physi-cians’ diagnostic impressions and treatments can oftenprovide useful information.

Ask specifically whether the child has beentaking antibiotics, as the child may already be on aprescribed or non-prescribed antibiotic. Non-pre-scribed antibiotics may be left over from a previousillness or prescribed for someone else in the family.In one study, nearly 20% of children up to the age of2 brought to the ED because of a presumed infectionhad antibiotics in their urine. This was despite the factthat 80% of their parents did not admit to administer-

ing antibiotics.41 In another study, urine assays werepositive for antibacterial activity in 16.5% of thepatients who presented to a pediatric ED, and again,only half of the parents admitted giving their childrenthese medications.42

Whether or not a febrile child is already takingantibiotics may affect the results of any cultures thatare collected. Furthermore, it may have importantimplications when it comes to deciding either thenecessity for or interpretation of a lumbar puncture.

History of day care attendance and the presence ofother close infectious contacts is often valuable. Closecontact with other known cases of URI, gastroenteritis,or febrile illnesses with rash makes it far more likelythat the child with compatible symptoms suffers froma similar infection. Travel history can be helpful insuggesting or ruling out malaria, other parasiticdiseases, and bacterial enteritis.

Determine whether the child has any significantpast medical history. Prior UTI significantly increasesthe likelihood of UTI as the cause of fever in thecurrent illness,22 especially if the child has documentedvesicoureteral reflux, abnormal urodynamics, orurinary obstruction. Similarly, a past history of lobarpneumonia or right middle lobe collapse in a knownasthmatic should alert the clinician to the possibility ofa recurrence, even in the absence of suggestive signsand symptoms.

During the history, ask the parents about the birth,especially regarding prematurity and intubation, asthese may be associated with later pulmonary ortracheal infections. Determine whether the child is atrisk for immunodeficiency from sickle cell, HIV, orother acquired or congenital syndromes. The unvacci-nated child is at higher risk for a wide variety ofinfectious diseases, such as varicella, measles, andHaemophilus influenzae.

Physical Examination

A careful physical examination is essential to identifychildren who appear “toxic,” those with alteredmental status or meningeal signs, and those withclinically recognizable bacterial or viral infections.The following features of the physical examinationmerit particular attention.

The temperature at presentation is of diagnosticvalue, even if an antipyretic has been given shortlybefore the visit to the office or ED. High fevers(≥ 39˚C) are associated with a higher risk of occultbacterial infection, though the vast majority ofhigh fevers still have a viral etiology.22,26,43 Veryhigh fevers may be significant. In one small study,more than half of all children with rectal temperaturegreater than 41.1˚C (106˚F) had serious disease. Inthese children, the peripheral blood studies didnot correlate reliably with the final diagnosis or


need for admission.44

The height of the fever correlates loosely with thepresence of occult pneumococcal bacteremia. Occultbacteremia is only found in 1.0%-1.8% of those withtemperatures of 39.0-39.9˚C, 2.0%-3.2% at 40.0-40.9˚C,and 2.8-4.4% with temperatures of 41˚C or greater.20

For reasons that remain unclear, these rates of occultbacteremia are much lower than the rates reported inearlier studies. They are expected to drop precipitouslyonce immunization with conjugate pneumococcalvaccine becomes routine.

The response of a fever to acetaminophen or otherantipyretics was once thought to have diagnosticimplications. This myth may be responsible for theoutdated practice of keeping a child in the ED to see ifthe temperature comes down. In reality, reduction oftemperature in response to acetaminophen or otherantipyretics does not reduce the likelihood of an occultbacterial infection.45-49 Children with serious bacterialillnesses may defervesce with antipyretics, whilechildren with minor viral illnesses may remain febriledespite adequate doses.

While some EDs use tympanic thermometry toevaluate the presence of fever in children, numerousstudies question the reliability of such devices.50-53 If itis important to determine whether a child has a fever, arectal temperature is the most reliable method in theED. If however, a tympanic, forehead, oral, or axillarymeasurement demonstrates an elevated temperature,the child does have a fever. The converse is not

necessarily true.Changes in heart rate, blood pressure, shaking,

chills, and skin flushing or pallor are probably morerelated to the magnitude and direction (increasing ordecreasing) of fever than to its cause.

General appearance is one of the most importantfactors used to assess febrile infants and children. Ascoring system (the Yale Observation Scale score—seeTable 1) developed in 1982 found that children whoappeared well (score 6-10) had a less than 3% probabil-ity of harboring serious illness, while those who weremoderately ill (11-15) had a 23% illness rate, and thosewith scores greater than 15 had a 93% probability ofharboring a serious illness.54 For well-appearing febrileinfants and children with a temperature of 39˚C orgreater, the lowest possible Yale score carries a 2.5%probability of bacteremia, while a score of 8-9 and 10or higher carry a 4.7% and 5.7% risk of occult bacter-emia, respectively.55

Children with meningitis have a significantlyhigher Yale observation score (median, 18-19) com-pared to febrile children without meningitis (mean, 8-9). While administration of acetaminophen generallyimproves the appearance of febrile children withoutserious illness, those with meningitis do not improveupon defervescence.47

Because of the importance of how ill a childappears, some emergency physicians believe that theircar keys are a more important diagnostic instrument inthe evaluation of a child than any other piece of

Table 1. Yale Observation Scale.

Normal Moderate impairment Severe impairmentObser vation it em (1 point each item) (3 points each item) (5 points each item)

Qualit y of cr y Strong or none Whimper or sob Weak or moaning, high- pitched,or hardly responds

Parental Cries briefly or no cry Cries off and on Persistent cry with little responsestimula tion and content

State variation Stays awake or Eyes close briefly, then wakes No arousal and falls asleepawakens quickly or awakens with prolonged

stimulation

Color Pink Pale extremities or acrocyanosis Pale, cyanotic, mottled, or ashen

Hydration Skin/eyes normal and Mouth dry Skin doughy or tented and/ormoist membranes sunken eyes

Response t o Smiles or alerts Brief smiles or alerts No smile, anxious, dull, no alertingsocial o vertures

The total of these items corresponds as follows:Appears well (score, 6-10)

Moderately ill (score, 11-15)Toxic appearing (score, >15)


medical equipment—including the stethoscope orotoscope. The well infant will visually track keys,the toddler will grab for them, and the older childshould play catch with them. (In the case of a Saabor Lexus, the febrile teen may try to take them.) Theinability to elicit play or smile in the febrile childnecessitates serial examinations, diagnostic testing,or both.

Head, Eyes, Ears, Nose, And ThroatIn addition to the smile, the head, eyes, ears, nose, andthroat (HEENT) examination provides important cluesto the child’s condition. In younger children, a bulgingfontanelle in a toxic-appearing child means meningitisuntil proven otherwise. Suppleness of the neck andmental status should be carefully evaluated as clues topossible meningitis in children of all ages. Importantly,the sensitivity of neck stiffness (nuchal rigidity) fordiagnosing bacterial meningitis rises from 27% forinfants 0-6 months old, to 71% at 7-12 months, 87% at13-18 months, and greater than 95% for infants olderthan 18 months.56

Injection of the conjunctiva is usually seenwith viral illnesses and possibly Kawasaki’s disease.Red conjunctivae, lips, tongue, palms, and solesare useful in diagnosing Kawasaki’s disease,especially in the presence of enlarged cervicalnodes and prolonged (≥ 5 days) fever. (See Table 2.)The combination of conjunctivitis and a red throatsuggests the diagnosis of pharyngeal-conjunctivalfever, a common viral illness. Copious rhinorrheaoften accompanies a URI, while unilateral purulentnasal discharge should prompt a search for a nasalforeign body. Careful inspection of the tympanicmembranes is essential in diagnosing otitis media,which usually (but not always) develops on a back-ground of or preceding to a respiratory infection.Any crying child can have a red ear, and the use ofpneumatic otoscopy is more accurate for otitis mediathan inspection alone.57

Examination of the throat and mouth is especiallyrevealing. The presence of ulcerations on the lips,tongue, or mucosa essentially confirms the diagnosisof a viral infection, usually herpetic. One of theparents will usually offer that the child has been

drooling or not eating. Exudative tonsillitis in youngfebrile children is almost always viral. In one study,children under 2 years old with pharyngitis had a nogreater incidence of group A Streptococcus than asymp-tomatic controls.58

The chest examination should include a measure-ment of the respiratory rate and an assessment ofrespiratory distress. Respiratory signs suggestive ofpneumonia include rales, rhonchi, wheezing, retrac-tions, grunting, nasal flaring, or focally decreasedbreath sounds.59 Tachypnea has the highest positiveand negative predictive value for abnormalities onchest x-ray.60 In children without asthma, a respiratoryrate of 50/min or greater, or chest in-drawing, areexcellent predictors of pneumonia, while auscultationand percussion are 90% sensitive.60

Close examination of the skin is useful in diagnos-ing meningococcemia and typical (but nonspecific)maculopapular viral eruptions. Look for the classiclesions of varicella (“dew drop on a rose petal”),which in early stages may be limited to a few unas-suming vesicles.

Petechiae are especially important. A toxic childwith fever and petechiae is a medical emergencyand requires emergent antibiotics. However, thevast majority of febrile children with petechiae donot have serious disease. In one study, less than 2%of such children had bacteremia or clinical sepsis;all bacteremic children appeared ill.61 Macularpurpura occurring anywhere on the body withfever should be presumed to be meningococcaluntil proven otherwise.

Petechiae confined to the face, neck, and chestabove the nipple line is not infrequent in children withcough. In another study, no febrile child with petechiaelimited to above the nipple line had invasive disease.62

Of course, meningitis or sepsis should be considered inany ill-appearing child regardless of rash.

Finally, for children who are willing and able towalk, the gait should be examined; a limp increases thediagnosis likelihood of bone or joint infection in thelower extremities.

Laboratory Testing

The history and physical examination are high-yield,cost-effective, and essentially painless. The samecannot always be said of diagnostic tests. Whencontemplating whether or not to obtain one or morelaboratory tests, the clinician must consider not onlytheir differential diagnostic value (the “pros”), butalso their potential for harm and their financial costs(the “cons”).

The positive and negative predictive value of testsare of more practical concern to the clinician than themathematical standards of sensitivity and specificity.The positive and negative predictive value depends on

Table 2. Criteria For Kawasaki’s Disease.

• Fever for at least five days

• Bilateral conjunctival injection (painless, no exudate)

• Mucous membrane changes (pharyngitis, red fissured or

cracked lips)

• Edema or erythema of palms or soles

• Rash (polymorphous and truncal)

• Cervical adenopathy with at least node > 1.5 cm


the pretest likelihood of disease (an estimate of whichis best made based on the prevalence of the disease, inconjunction with the history and physical examina-tion). With low pretest probability, a particular diag-nostic test may yield false positives, suggesting adisease the child does not have. With a high pretestprobability, a false-negative test may steer the clinicianaway from the correct diagnosis.

The physician should have a testing strategy anddecide before a test is ordered whether it is likely tochange what he or she plans to do for the child. In oneinteresting study, 75% of pediatric emergency physi-cians ordered a CBC in the evaluation of a febrile (>39˚C) child without a source. However, the majority ofthese physicians did not use the information to guidemanagement in any way.63 If a test will not affect whatyou do, consider skipping the test.

The type and number of tests ordered on a febrilechild may be more a matter of style than science.64

Some physicians may be risk-minimizers (somesay test maximizers) by nature, while others aretest-minimizers (hopefully not risk-maximizers).The literature cannot definitively say which approachis ultimately better for the child—only which ismore expensive.

Test ordering correlates with many factorsthat have nothing to do with the patient. Physicianswith 10 or more years of experience order fewertests on febrile children, unless they are accompaniedby a physician-in-training (particularly duringJuly).65 Even the location of the examining roomhas an impact. The same physician seeing a febrilechild in the Fast Track tends to order fewer testswhen compared to seeing them in a room locatedelsewhere in the same ED. These findings are notexplained by differences in patient ages, vital signs,

or demographics.66

The most common tests obtained in the ED mayinclude the CBC and differential, the erythrocytesedimentation rate (ESR) or C-reactive protein (CRP),urinalysis, and chest radiograph. Physicians mayalso order cultures of the throat, urine, blood, orstool. Emergency Medicine Practice argues that thesingle most important test in the febrile child remainsthe lumbar puncture.

The CBC, ESR, And CRPIndicationsThe indications for measuring these inflammatorymarkers remain unclear. Some physicians use thesetests to determine which children should have a bloodculture drawn; others use the results to guide theadministration of empiric antibiotics. Others do both.However, the utility of these tests in the managementof the febrile child is hotly debated.

ProsIt has repeatedly been shown that a high white bloodcell count (≥ 15,000/mm3) occurs two or three timesmore frequently in children with bacterial infectionsthan in those with viral infections.27,43,67-69 An elevatedESR or CRP70-73 contributes independent diagnosticinformation above the total white count; the evidenceconcerning the independent contribution of an el-evated “band” (unsegmented neutrophil) count isless clear.27,68

ConsDespite the more frequent occurrence of high whitecounts in children with occult bacterial infections, thetest has too low a specificity (~75%) and sensitivity(~60%); that is, it is associated with many false posi-

Table 3. Summary Of The American Academy Of Pediatrics Practice Parameter Regarding The Diagnosis Of The InitialUrinary Tract Infection In Febrile Infants And Young Children.

1.Consider UTI in young children 2 months to 2 years of age

with unexplained fever.

2.In young children 2 months to 2 years of age with

unexplained fever, assess the degree of toxicity, dehydra-

tion, and ability to retain oral intake.

3.If the child is ill enough to require immediate antibiotics,

obtain a urine specimen by SPA or transurethral bladder

catheterization—not by urine collected in a bag.

4.If the young child with unexplained fever does not

require immediate antibiotics, there are two options:

• Option 1: Obtain and culture a urine specimen collected

by SPA or transurethral bladder catheterization.

• Option 2: Perform a urinalysis on a urine specimen

obtained by the most convenient means (including a

bagged specimen). If this suggests a UTI, collect a urine

specimen for culture using SPA or catheterization; if

urinalysis does not suggest a UTI, the physician does

not need to give antibiotics. However, a negative

urinalysis does not rule out a UTI.

5.The diagnosis of a UTI requires a urine culture.

Adapted from: Anonymous. Practice parameter: the diagnosis,treatment, and evaluation of the initial urinary tract infection infebrile infants and young children. American Academy of Pediatrics.Committee on Quality Improvement. Subcommittee on Urinary TractInfection. Pediatrics 1999;103(4 Pt 1):843-852.


tives and false negatives, respectively. In addition, thetest is painful, even if obtained by fingerprick ratherthan venipuncture. The CBC and (especially the ESRand CRP) entail considerable waiting time by thechild and family before the results are obtained andknown to the physician.74,75 While children with anelevated WBC count (≥15,000 cells/mm3) have aslightly greater chance of being bacteremic thanthose without an elevated WBC, this test is insensitiveand poorly specific. WBC counts at or above the15,000/mm3 threshold fail to identify 14%-21% ofbacteremic children.20,25

Moreover, the CBC is useless at distinguishingbetween occult bacteremia due to Neisseria meningitidisbacteremia and viral illnesses.76 Perhaps mostimportantly, the majority of children with bacterialmeningitis will have a leukocyte count less than

15,000/cc.77,78 African-American children with meningi-tis are even less likely to have an elevation of theperipheral leukocyte count than white children.79

Although the CBC on its own should never be used todetermine the need for a lumbar puncture, in a childwhose findings on history or physical examination arenot reassuring, a high WBC count will sometimes tipthe balance in favor of performing a lumbar puncture.

The ordering of a CBC may increase costs withoutproviding a benefit to the child. One survey asked 294pediatric, family, general, and emergency physiciansabout how they would manage a febrile infant without afocal source of infection. Physicians were randomlyassigned to receive a case scenario with either a normalor an elevated WBC. The knowledge of an elevated WBCincreased the likelihood of additional test ordering (anddoubled the attendant costs) but did not otherwise

Cost-Effective Strategies For Managing The Febrile Child1. No “shotgunning.”

The emergency physician can be a medical “sniper” instead of

a “shotgunner.” Zero in on your target with the history and

physical. Perform an LP or arthrocentesis when indicated.

One positive lumbar puncture is worth more than a thousand

“positive” CRPs, ESRs, or CBCs. Some consider performing

these “inflammatory” tests as akin to blasting into the bushes

in a vague hope of hitting some unseen, rapidly moving

target. One recent ED study on febrile children examined the

positive predictive values and likelihood ratios of laboratory

tests. They could not accurately predict either serious

bacterial disease or culture positivity.147 The findings

supported greater reliance on clinical impression and less on

laboratory values.

Risk Management Caveat: Some laboratory tests are very

important. These include urine cultures or dipstick

urinalysis in the appropriate clinical situation. Analysis of

the CSF and synovial fluid is of extreme importance in the

toxic child or in those suspected of having a septic joint.

2. Use dipstick urinalysis versus microscopy in febrile

child.

A clean-voided bag urine specimen is inadequate for

culture because of an unacceptably high contamination

rate.84 It is probably sufficient for urinalysis, however. A

dipstick urinalysis positive for leukocytes or nitrites is

essentially as sensitive as a urine Gram’s stain (88% vs

93%). It is much faster and less expensive. In addition,

urine dipstick is more sensitive for UTI than pyuria found

on microscopy.82

If the dipstick is positive for leukocytes or nitrites, a

specimen should be obtained by catheterization or

suprapubic aspiration (SPA) and sent for culture.

Risk Management Caveat: Evidence suggests that

pyelonephritis that remains untreated for five or more

days is more likely to lead to renal scarring (and its

potential sequelae).88 (However, most lower-tract UTIs, if

left untreated, appear to resolve spontaneously.148)

Obtain a urine culture in the high-risk child who has a

fever and no source—that is, young white females,

uncircumcised males, if the child is ill enough to receive

empiric antibiotics, or has a history of prior UTI.

3. Limit the workup of febrile seizures.

Children with febrile seizures have no greater incidence of

bacteremia than febrile children who do not seize. An

extensive evaluation involving CBC, electrolytes, calcium,

magnesium, CT, EEG, and LP is not necessary. If the child

has a source of infection, simply treat it. If the child has no

obvious source, consider urine culture in males under 6

months or females under 2 years old. Blood cultures may

be helpful if follow up is problematic.

Risk Management Caveat: Do a good history and physical

exam. Determine that the child truly had a simple febrile

seizure. They should be between the ages of 6 months

and 6 years with a single, generalized (not focal) seizure

lasting less than 10 minutes. They should not have had aContinued on page 9


influence the management plan for most physicians(although some physicians chose a more aggressivestrategy based on an elevated white count alone).80

Like any other diagnostic test, tests of inflamma-tory markers, such as CBC, ESR, or CRP, should beobtained only if some decision (further testing, hospi-tal admission, antibiotic, or other treatment) will beaffected by the result. This obviously sensible dictum isignored more often for the CBC than for any other testobtained in febrile children.

UrinalysisIndicationsAlthough some authors have argued for the clinicalutility of urine odor, urinary frequency, dysuria, andother symptoms for diagnosis of UTI,21 empirical datais limited or non-existent. Few practitioners find them

to be useful in children in the age group under discus-sion. Owing to the insensitivity of the physical exami-nation to detect UTI in febrile infants and youngchildren, it is advisable to obtain a urinalysis for girlsand uncircumcised boys less than 2 years of age withfever and no source. (See also Table 3 on page 7.)

ProsThe presence of pyuria by dipstick leukocyte esteraseor by microscopic examination has a sensitivity ofapproximately 80-85% and a similar specificity.81,82 Thenitrite test provides better specificity but a much lowersensitivity.81,82 The dipstick, in particular, is easy toperform. A Gram’s stain on an un-spun urine sample ismore than 95% accurate at detecting UTI, althoughperformance is operator- and site-dependent. Theavailable evidence is insufficient to make any conclu-

prolonged postictal state. Most importantly, the child

should be interactive and not toxic upon examination.

They should not have neurologic abnormalities or

meningeal signs.

4. Limit blood cultures.

Besides the discomfort of the test, knowledge that the

child who is found to have been bacteremic at the initial

visit and who remains febrile for 24-48 hours often leads

to additional diagnostic tests (repeat blood culture, LP),

admission, and parenteral antibiotic therapy. For the vast

majority of children who have already cleared their

bacteremia spontaneously or will subsequently do so,

these additional interventions are unnecessary.

Risk Management Caveat: Blood cultures should always

be obtained in a child with fever and purpura, or with

petechiae below the nipple line, and before initiating

antibiotic treatment for suspected bacteremia,

meningitis, septic arthritis, or osteomyelitis.

5. Limit chest radiographs.

Restrict chest radiographs to children with suggestive

symptoms and signs (especially tachypnea and rales) or

prolonged (≥ 5 days) fever with cough. Although “positive”

chest films are sometimes seen in children without

respiratory symptoms, it is unknown whether this

occurs more commonly than in well, afebrile children or

whether antibiotics are useful or necessary to “treat” the

detected infiltrates.

Cost-Effective Strategies For Managing The Febrile Child (continued)

Risk Management Caveat: Chest radiographs may be

under-used in children with prolonged fever and

persistent cough whose chest examination shows no

tachypnea, rales, or other adventitial sounds.

6. Order a single-view chest film.

There is no need to obtain both a posterior-anterior and

lateral chest film in the child suspected of pneumonia.

The study may be safely limited to a single posterior-

anterior (PA) view.149 Besides the cost of the additional

film, routinely including a lateral view doubles the

radiation exposure.

Risk Management Caveat: The lateral film may be

helpful in patients with an unclear or non-diagnostic

PA view, or when there is suspicion of cardiac or

malignant disease.150

7. Limit the use of broad-spectrum parenteral

antibiotics.

Other than a high rate of defervescence at follow-up,

broad-spectrum parenteral antibiotics have no proven

benefit over narrow-spectrum oral agents like amoxicillin.

Moreover, broad-spectrum agents increase selection

pressures favoring antibiotic-resistant organisms, both in

the patient and in the community.

Risk Management Caveat: Any child who appears ill

enough to require hospital admission probably merits

parenteral therapy, after a blood culture and LP have

been obtained.


sive statements about the sensitivity and specificity ofclean-voided bag vs. catheter or suprapubic aspiration(SPA) specimens in regards to simple urinalysis. Howthe specimen is obtained, however, has importantimplications for culture. Bag specimens are probablyadequate for assessment of pyuria or nitrite.

ConsThe waiting time can be considerable for a bag urinespecimen, because it may take several hours before thechild spontaneously voids.74,75 The microscopic exami-nation often entails additional waiting time if the urinesample is sent to a hospital laboratory and does notsubstantially improve the sensitivity or specificity overthe dipstick alone.82,83 In addition, an abnormal urinaly-sis by bag specimen requires follow-up with a urineculture from a second specimen obtained by catheter-ization or SPA to reduce the risk contamination.84

Moderate degrees of pyuria can occur in febrilechildren even in the absence of a UTI.85

Urine CultureIndicationsA urine culture should always be obtained in a childwith a urinalysis positive for significant pyuria,nitrites, leukocyte esterase, or bacteria. A urine cultureshould also be obtained in a child admitted for treat-ment with antibiotics because of suspicion of bacter-emia or generalized sepsis.

ProsA positive urine culture based on a catheterizedor SPA specimen is diagnostic of UTI, althoughthere is a small risk of contamination with eithermethod. Prompt diagnosis of UTI via the urine cultureresults in earlier treatment and reduced risk of renalscarring (if treatment is initiated within 4 days ofonset).88 Proper ED evaluation can also lead to earlydiagnosis and surgical treatment of a renal anomalyand may reduce the long-term risks of hypertensionand end-stage renal disease.89,90 The most commonbenefit of early diagnosis, however, is the earlierrelief of symptoms.

ConsCulture of a bag specimen is highly likely to becontaminated, which can lead to unnecessary follow-up, treatment, radiologic investigation, and evenhospital admission.84 A catheter or SPA specimen,however, involves discomfort or even pain for thechild.75 Moreover, the results are not obtained for atleast 24-48 hours, and microbial sensitivities often takea day or so longer. There is a slight risk of introducinginfection through a catheter or needle,91,92 and bothprocedures are associated with (rare) risk of trauma tothe urethra and/or bladder.93,94

Chest RadiographIndicationsBecause cough and fever alone do not mandate a chestx-ray, physical examination should direct the search forpediatric pneumonia.

In 1997, a panel of experts in pediatrics,infectious disease, and microbiology concluded thatthe absence of respiratory distress, tachypnea (usingWorld Health Organization criteria: rate > 60/min forneonate, > 50/min for 1-12 months, and > 40/min for1-5 years), rales, and diminished breath soundsaccurately excluded pneumonia.95 However, a morerecent prospective validation trial found that thesecriteria only detected 45% of pneumonia cases inchildren under age 5.96 However, this being said, thevast majority of all pneumonias in children are viralrather than bacterial.

Indications for chest x-ray in febrile children olderthan 3 months include:

• Respirations ≥ 50/min 3-12 months• Respirations ≥ 40/min 12 months to 5 years• Nasal flaring• Retractions• Grunting• Diminished breath sounds• Rales

One recent study suggested that chestradiography should be routine in young childrenwith a temperature of 39˚C or greater with unex-plained leukocytosis (WBC count ≥ 20,000/mm3)despite the absence of respiratory findings.97 Thisinvestigation however, contrasts with the results ofmultiple other studies.59,60 This study also had severalimportant sources of bias, including the fact that theindications for obtaining (or not obtaining) a CBCwere not studied; residents rather than attendingphysicians performed the majority (56%) of clinicalassessments; and radiologists were not blinded tothe clinical information.

ProsA chest radiograph is very sensitive to pneumonia.Prompt diagnosis can lead to earlier institution oftreatment and, hence, earlier relief of symptoms. Inaddition, the procedure is usually well tolerated bychildren and their parents.75

ConsChest radiographs have many false positives and arecharacterized by poor inter-observer agreement, evenamong radiologic experts.98-100 Moreover, in the agegroup under consideration, most infiltrates, even largeand asymmetrical ones, are more likely to be of viralthan bacterial etiology.98,101 Finally, the test is moder-ately expensive.


Blood CultureIndicationsThe indications for blood cultures in febrile childrenremain unclear. In children with a known source ofinfection, such as pneumonia, pyelonephritis, orcellulitis, blood cultures rarely change management.One study included nearly a thousand children withpneumonia. Blood cultures were drawn in 44% of casesand were positive in less than 3%. All of these childrenwere started on appropriate antibiotics before cultureresults were available.102 In the case of pyelonephritis,urine cultures provide the best source of informationregarding the pathogen. In a study of children andadults with pyelonephritis, blood cultures had noimpact on clinical management; only one patient(0.2%) grew a pathogenic organism not found in theurine (which was susceptible to the current antibi-otic).103 In our post-H. influenzae era, blood cultures arenot cost-effective in the child admitted to the hospitalwith cellulitis.104 Despite these statistics showing littleto no impact on management, blood cultures arefrequently drawn in children hospitalized for aninfectious disease.

The utility of blood cultures in a child withpresumed occult bacteremia is even more unclear, asshown in the subsequent text.

ProsA positive blood culture for a known pathogenis highly specific and reasonably sensitive forbacteremia, although bacteremia may be intermittent(thus leading to occasional false-negative bloodcultures).98 The major advantage of the blood cultureis that diagnosis of bacteremia before the onsetof meningitis or other serious complications cantheoretically prevent such complications (see thesubsequent section titled “Empiric AntibioticTherapy”). Increasing the volume of blood inoculatedinto culture bottles (9.5 mL rather than 2 mL) improvesthe detection of bacteremia in pediatric patientsand spares the patients the cost and pain of anadditional venipuncture.105

ConsThe blood culture usually requires 24-36 hours toobtain a result, and most cases of bacterial meningitishave often already developed by that time. Pneumo-coccal bacteremia is often transient. If the temperaturepersists at the time that the blood culture returnspositive, such knowledge usually results in arepeat physician visit and (often) an unnecessaryhospitalization and parenteral antibiotic treatment.106,107

The hospitalization and treatment are usually unneces-sary, because pneumococcal bacteremia generallyclears spontaneously by the time the child is re-evaluated or would do so subsequently even inabsence of treatment.106-111

Blood cultures entail considerable expense, andthe negative impact of false-positive cultures issignificant. Over 20% of positive pediatric bloodcultures may be false positives. This leads to increasedcosts, unnecessary hospitalizations, excessive antibiotictherapy, and additional testing.112 Contaminantsleading to false positive cultures add an additional$642 per true pathogen recovered and this should beconsidered when determining the cost/benefit of bloodcultures in children.113

Stool CultureIndicationsMost diarrheal infections are due to viral pathogens,and most bacterial causes of diarrhea in childrendo not require antibiotic treatment (in the case of E.coli 0157:H7, antibiotics may be deleterious). Forthis reason, bacterial cultures of the stool may bemore important for reasons of public health andcontrolling outbreaks rather than individual patientcare. In one study of children less than 1 year old withdiarrhea, a number of clinical factors predicted abacterial etiology:

1. History of blood in the stool (best individualpredictor; sensitivity 39%, specificity 88%).

2. Temperature greater than 39˚C (sensitivity 34%,specificity 85%)

3. 10 or more stools in 24 hours (sensitivity 28%,specificity 85%).114

Children who meet any two of these criteria are athighest risk for bacterial enteritis; however, theisolated finding of visible blood in the stool willprompt a stool culture in many EDs.

ProsStool culture has high sensitivity and specificity forbacterial enteropathogens. For certain pathogens (e.g.,Shigella, Campylobacter), a positive culture should leadto prompt treatment and, perhaps, the earlier relief ofsymptoms. Successful treatment also reduces the riskof spread to uninfected contacts. Finally, the test isreasonably noninvasive and inexpensive.

ConsThe results of the culture are usually not available for24-72 hours. More importantly, the pathogen cultured(e.g., Salmonella, pathogenic E. coli) often does notrequire or benefit from treatment.

Lumbar PunctureIndicationsThe lumbar puncture is arguably the most importanttest in the evaluation of the febrile child. The childwith no source of infection who appears toxic despitetemperature reduction will need a lumbar puncture.

Continued on page 14


Clinical Pathway: Management Of The Young Febrile Child

This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon apatient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants each subscriberlimited copying privileges for educational distribution within your facility or program. Commercial distri-bution to promote any product or service is strictly prohibited.

Toxic appearance, altered mentalstatus, or meningeal signs?

Evident bacterial source? Treat source

Evident viral source?

Duration?

CBC, blood culture, UA, urine culture, and LP;admit and treat →

Yes

→Yes

Symptomatic treatment →Yes

→ No

→ No

→ No

→

→

Four days or less Five days or more

Go to top of next pageHistory of reflux,obstruction,or prior UTI?

UA Catheter, urine culture,and treat

→No

Symptoms and signs?

Yes →

Positive →

→

Negative

→

→

→

Tachypnea or rales Gastrointestinal Other

Chest x-ray

→

→ Positive

→

Negative

Treat

Blood or pus in stool?

→

→

Yes

→

No

Stool culture

→ Positive

→

Negative

Treat ifappropriate

Sex, circumcision?

→

→

→

UA

Positive

→Negative

Catheter,urineculture,and treat

Circumcisedboy

Girl or uncircum-cised boy

Symptomatic treatment; no further tests

→

Follow up in 48-72 hours

→

→

→


Clinical Pathway:Management Of The Young Febrile Child (continued)

Duration of fever: five days or more

Cough, tachypnea, or rales?

→

Chest x-ray →Yes

No

→

→

UA

Positive

→Negative

Catheter,urine culture,

and treat

Negative Positive→ →

→

Treat

→

CBCand blood

culture

→

Diarrhea? Stool culture →Yes

→ No

Symptomatic treatment; no further tests

→

Follow up in 48-72 hours

→

This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon apatient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants each subscriberlimited copying privileges for educational distribution within your facility or program. Commercial distri-bution to promote any product or service is strictly prohibited.


Even the child with an obvious source of infection mayneed a lumbar puncture if they appear toxic or have astiff neck. As many as one-third of children withbacterial meningitis have a concurrent infection suchas pneumonia, otitis media, or orbital cellulitis.115

Routine lumbar puncture is not necessary in thechild with a simple febrile seizure who is not toxic andhas no meningeal signs.116,117

Prior use of antibiotics can affect the clinicalpresentation of meningitis and perhaps require a lowerthreshold for lumbar puncture. In one study, pretreatedchildren had lower temperatures, fewer alterations inmental status, and a longer duration of symptomsbefore diagnosis. The authors also found that childrenwith meningitis who are on antibiotics at the time ofdiagnosis also have more frequent vomiting, moreconcurrent ear, nose, and throat infections, andphysician visits in the week before detection of menin-gitis than children not on antibiotics. In this study,there was no difference in incidence of upper respira-tory symptoms, seizures, nuchal rigidity, Kerning’sand Brudzinski’ s signs, focal neurologic signs, mortal-ity, and length of hospitalization between groups.118

ProsLumbar puncture has extremely high sensitivity andspecificity for the diagnosis of bacterial, as well asviral, meningitis. For bacterial meningitis, earlierdiagnosis and prompt treatment should, at leasttheoretically, result in improved prognosis withreduced risk of death or major morbidity, although onestudy calls this into question.119

ConsThe lumbar puncture is frightening to children andtheir parents, even with adequate local anesthesia, andis associated with moderate pain and discomfort. It cantheoretically result in introducing of meningealinfection through the spinal needle used in the proce-dure, but the risk of such a complication appears to beextremely remote.38

Some children may be too ill to undergo alumbar puncture. The moribund child may sufferrespiratory failure or cerebral herniation during theprocedure. One study suggests that antibiotics shouldbe given and the lumbar puncture deferred until thepatient stabilizes if the child has decerebrate ordecorticate posturing, focal neurological signs, or noresponse to pain.120

Empiric Antibiotic Therapy

Perhaps no aspect of the management of the youngfebrile child has been more controversial the use ofempiric (“expectant”) antibiotic therapy in childrenwithout a documented bacterial infection. Both

observational studies and randomized trials haveexamined the efficacy of empiric antibiotic treatment inreducing the risk of subsequent meningitis and otherinfectious complications.

The observational studies consistently report thatchildren with bacteremia at the initial visit who weretreated with antibiotics developed fewer “new” foci ofinfection than did bacteremic children who did notreceive antibiotics.38,111,121-127 One meta-analysisuncritically pooled data from observational studiesand randomized trials and reported a significantlyreduced risk of bacterial meningitis in bacteremicchildren treated with antibiotics at the initial visit.128

But these studies are inherently biased toward findinga beneficial effect of treatment, because treatment wasnot assigned randomly. In particular, the studies werecarried out primarily at academic tertiary-care EDs andwalk-in clinics. The vast majority of these children whoreceived antibiotics at the initial visit were those whohad identified foci of bacterial infection, such aspneumonia or otitis media. Because they already had afocus of infection, treated children with focal bacterialinfection were obviously at much lower risk fordeveloping a new focus of infection. For the untreatedchildren, some were likely to have unrecognizedpneumonia, otitis media, or UTI. Because these fociwere recognized only at follow-up, they were classifiedas “new” foci; the children were not initially treatedwith antibiotics and were therefore at risk for meningi-tis and other serious complications. The pneumonia orthe UTI may have not been recognized because therequisite diagnostic test (chest radiograph or urinalysisand urine culture) was not obtained. Otitis media isnotoriously difficult to diagnose and may have escapeddetection at the initial visit, particularly when thetympanic membrane was difficult to visualize or whenerythematous membranes were seen in a crying child.

Randomized control trials (RCTs) of course aremore likely to yield a scientifically valid answer to thequestion of whether empiric antibiotic treatment iseffective. Four such trials108-110,129 have been published;two108,129 compared oral antibiotics vs placebo (one ofthese129 gave an initial dose of intramuscularbenzathine penicillin), while the two others109,110

compared intramuscular ceftriaxone vs oral antibiotics(amoxicillin or amoxicillin/potassium clavulanate).Unfortunately, all four trials had substantial method-ological problems. All four limited their statisticalanalyses to children (around 3% of the total) who laterproved to have had bacteremia at the time they wereenrolled. When the results are expressed in terms of allchildren randomized (the correct analysis for anyrandomized trial), no significant benefit was seen inreduction in risk of subsequent bacterial meningitis. Thepresence or absence of bacteremia cannot be ascer-tained at the time of the initial visit when the physicianmust decide whether or not to treat, and thus the

Continued from page 11


analysis should not be restricted to bacteremic chil-dren. Such an analysis of course ignores the outcomesin the 97% of children without bacteremia who wererandomized and treated. Moreover, the majority ofcases with bacterial meningitis that occurred in thesetrials were due to Haemophilus influenzae type b (Hib),which has been virtually eliminated since the introduc-tion of conjugate Hib vaccines.127,130,131 Finally, a meta-analysis of occult S. pneumoniae bacteremia found thatthe development of meningitis was rare (< 3% of allbacteremic children) and that there was no significantdecrease in the progression to meningitis in children

treated with antibiotics.132,133 Even if cases of meningitiscould be prevented, the authors of this meta-analysisfound that more than 2,500 febrile infants andchildren would have to be cultured and treated(causing 200-500 side effects) to theoretically preventone case of meningitis.132,133

The only outcome analyzed in these trials thatappears to be a genuine benefit of empiric antibiotictreatment is more rapid defervescence. The shorterduration of fever in children treated empirically isprobably explained by the presence of unrecognized

Excuses That Don’t Work In CourtMost of these excuses have a common theme. If you are sued

regarding the febrile child, it will most likely be for one of two

reasons—failure to diagnose meningitis or meningococcemia,

or failure to administer timely antibiotics.

1. “It was the nurse’s fault!”

So you say it was the nurse’s fault that the antibiotics were

not given until the child began posturing. A jury will have

to decide that. But if you had set your bezel and checked

back with her, you would have discovered she had trouble

starting the IV, getting the antibiotics from the pharmacy,

and had “lots of other patients to take care of.”

2. “I never even thought to get a urine test. Her urine did

not smell, and mom said she was urinating normally.”

Urine infections are an important cause of pediatric fever.

Clinical findings are not helpful. Do the test.

3. “Sickle cell?! The mom never told me her child had sickle

cell! I would have given antibiotics and admitted him if I

had known.”

Sometimes you just have to ask. Children with immune

suppression require extra care and more aggressive

management strategies. Ask, “Does your child have any

medical problems? Have they ever been in a hospital after

they were born?” Amazingly, parents do not always

volunteer important information.

4. “I thought it was a viral exanthem. I never saw a case of

meningococcemia before.”

That’s no excuse. Physicians are expected to recognize the

fastest and deadliest of pediatric diseases. When examining

a febrile child with a rash, check to see (and document)

whether the rash will blanch. You can even take a glass slide

and press down on the skin to get a real-time view of the

blanching process in equivocal cases. A petechial rash,

especially below the nipple line, or in an ill-appearing child

means instant antibiotics. (Plus, children with Henoch-

Schonlein purpura will not be adversely affected by one

dose of ceftriaxone.)

5. “I know he looked sick, but he really didn’t have clear-cut

meningeal signs. I thought I would just continue the

amoxicillin his pediatrician started three days before.”

Children with partially treated meningitis may not have

classic findings. If a child remains febrile for several days on

antibiotics, has no obvious focus, and looks somewhat ill, he

or she may need a lumbar puncture.

6. “But she had otitis media! It even showed up on

the autopsy.”

One-third of children with meningitis have a concurrent

extra-meningeal infection. Toxic children, especially those

with meningeal signs, need a lumbar puncture despite the

presence of otitis media.

7. “When I saw the child had a stiff neck, I called the

pediatrician. He came in and did the lumbar puncture, and

after we got the results, we gave the antibiotics. I haven’t

done an LP on a child in years.”

In litigation, it is not the issue of “if” antibiotics but “when.”

Some textbooks suggest that antibiotics should be given

within 30 minutes after meningitis becomes a reasonable

suspicion. The plaintiff’s bar has guidelines for antibiotic

administration as well. Their general rule is that antibiotics

should always be given at least 30 minutes before they

actually were.

There is no need to defer antibiotics if the lumbar

puncture will be delayed. Cultures will be positive for hours

after administration; pleocytosis and antigens, for days.

Continued on page 17


Tool 1. Sample Discharge Instructions For The Child With Fever.

Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce thisEmergency Medicine Practice tool for institutional use.

Return to the Emergency Department if your child:• Becomes more fussy or won’t stop crying• Gets too sleepy or drowsy• Gets a stiff neck• Won’t stop vomiting• Gets a new rash• Has a seizure• Gets any other new or worsening symptom(s) that concerns you

Follow-up

See Dr. ______________________________ within ____________________________

Call ________________________________ for appointment

Return here for a recheck in _____________________________________________

What to do:• If your child is prescribed an antibiotic, be sure to finish all of the antibiotic. Do not stop the

medicine, even if your child is feeling better. Taking all of the antibiotic will help keep theinfection from returning.

• Give your child acetaminophen (Tylenol) or ibuprofen (Children’s Advil/Motrin) for feveror pain.

• Do not give aspirin.• Do not sponge your child with alcohol

Acetaminophen Dosing

Infant Drops Children’s Elixir Children’s Tablets Junior-StrengthAge (Weight) (80 mg/0.8 mL) (160 mg/5 mL) (80 mg/tablet (160 mg/caplet)

0-3 months (6-11 lbs.) 1/2 dropper (0.4 mL) — — —

4-11 months (12-17 lbs.) 1 dropper (0.8 mL) 1/2 tsp. — —

12-23 months (18-23 lbs.) 1.5 droppers (1.2 mL) 3/4 tsp. — —

2-3 years (24-35 lbs.) 2 droppers (1.6 mL) 1 tsp. 2 tablets —

4-5 years (36-47 lbs.) — 1.5 tsp. 3 tablets —

6-8 years (48-59 lbs) — 2 tsp. 4 tablets 2 caplets

9-10 years (60-71 lbs.) — 2.5 tsp. 5 tablets 2.5 caplets

11 years (72-95 lbs.) — 3 tsp. 6 tablets 3 caplets

12-14 years (96 lbs. and up) — — — 4 caplets

Remember that the emergency department is open 24 hours a day, every day, and we are alwaysglad to see you.


focal bacterial infection (e.g., pneumonia or otitismedia) at the initial visit. Given the concern overselection for resistant organisms with the use ofbroad-spectrum antibiotics,134-138 this questionablebenefit does not justify empiric treatment for thelarge number of young febrile children who havefever but no source.

The question of empiric treatment raises anotherimportant question: Why are CBCs and blood culturesalong with parenteral antibiotics justified in childrenwithout a focus of bacterial infection but not in febrilechildren with identifiable foci such as otitis media orpneumonia? Children with the latter conditions havepositive blood cultures at least as often as childrenwithout such a focus.124,125,139-141 Few even attempt todefend this “double standard.”

Antibiotic AddictionSome parents expect (insist upon) antibiotics if theirchild has a fever and routinely pressure the physicianfor a prescription.142 Many shameless physiciansprescribe antibiotics for viral infections and are stillable to sleep at night. Over 40% prescribe antibioticsfor the common cold.143

Yet some physicians still have enough lingeringself-respect to be embarrassed by such practices. Sothey have another solution to the dilemma of antibioticaddiction—otitis media, the physician’s friend.Who’s to say the ear isn’t a little bit red? When thesource of fever remains unclear, the physician canbypass all of the controversy regarding CBCs andblood cultures, write “otitis media” on the chart, andhand mom a script for amoxicillin. Case closed. (Notthat readers of Emergency Medicine Practice have everdone such a thing!)

However, it is more scientific, honest, and honor-able to search for a real focus of infection, including aUTI in the child with a high fever and an equivocal ear.If there is no indication for antibiotics, explain this tothe parent. Some EDs supply parents with a pre-printed handout entitled “Why Your Child Did NotReceive Antibiotics.”

The Importance Of Follow-Up

The conscientious practitioner relies heavily on follow-up. The development of new signs or symptoms willalter the diagnostic probabilities. The clinical trajectoryis key to management; is the child getting better orgetting worse? Most importantly, does the child whowas only mildly ill now have signs compatible withmeningitis? Finally, follow-up is valuable in assessingthe parents’ ability to cope with a child who remainsfebrile or has other persistent symptoms.

Emergency physicians often bemoan the lack offollow-up care, especially for the poor, the “doctor-

less,” the uninsured, and for the patients seen onFriday night. This is silly. The emergency physician hasaccess to an excellent follow-up system—the ED. If indoubt, bring febrile children back for a recheck.Parents deemed reliable can return if their childbecomes worse; those parents whose clinical skillsseem lacking can return for a mandatory recheck thenext day. Telephone contact with the parent is anotheralternative. Some EDs maintain a callback log. Physi-cians write the name and phone number of the patientthey wish to be contacted, and a designated nurse willmake the follow-up call the next day. Recognize,however, that in one-third of cases where children aredischarged from the ED, their guardians cannot bereached by telephone over the next 72 hours.144

Summary

The Clinical Pathway on pages 12 and 13 depicts analgorithm based on the principles discussed in thisarticle. The clinician should first screen out childrenwhose condition mandates specific management. Theseinclude children with a toxic appearance despite feverreduction, altered mental status, meningeal signs,petechiae below the nipple line, or purpura. Thesechildren require a more extensive diagnostic work-up,empiric antibiotic treatment, and admission to hospi-tal. Altered mental status or meningeal signs, evenin the absence of overt toxicity, mandate the perfor-mance of a lumbar puncture.

Clinically evident bacterial infectionsrequire appropriate antibiotic therapy, whereasidentifiable viral infections may benefit from symp-tomatic treatment (e.g., antipyretics, topical or sys-temic antipruritics).

The history should focus on the duration of fever.Determine whether it is continuous vs. intermittent.The symptoms associated with the fever are oftenhelpful in increasing or decreasing the diagnostic valueof specific diagnostic tests (e.g., a chest radiograph in achild with a high fever and persistent cough, or a stoolculture in a child with bloody or purulent diarrhea).Gender, circumcision status, and prior history of UTIare useful for deciding to perform a urinalysis.

Physical examination is most helpful in elicitingmeningeal signs and respiratory signs suggestiveof pneumonia (rales, tubular breath sounds, tachyp-nea). The latter suggest the need for a chest radio-graph. Wheezing, reduced, or asymmetrical airentry, and/or retractions may prompt a trial ofinhaled bronchodilators.

The decision to draw blood for a CBC or bloodcultures in a febrile child who has a fever of more than102.5˚F and no source does not represent the standardof care. Clinicians routinely ignore practice parametersthat suggest such an approach.12,14,145 Most parents feelthat the “blood test”-based strategy is generally too

Continued from page 15


aggressive and prefer fewer painful tests and proce-dures, shorter stays in the ED, and reduced costs.146

They are glad to return for reevaluation if the child’scondition deteriorates.

Future research may well suggest changes in eitherdiagnostic or therapeutic management. In particular,new rapid diagnostic tests may lead to early detectionand treatment of occult bacterial infections. Theintroduction of conjugate pneumococcal vaccinesshould reduce the febrile child’s risk of occult pneumo-coccal bacteremia and of meningitis caused by Pneumo-coccus. Furthermore, if this vaccine proves more than95% effective, the incidence of bacterial pneumoniawill fall from approximately 20% of all pneumonia ininfants less than 2-3 years old to less than 2%-3% of allpneumonia at this age. In the meantime, the proposedalgorithm should help both office- and ED-basedclinicians to identify those infants and young childrenwho require diagnostic testing, to avoid unproven andpotentially harmful treatments, and to ensure adequatefollow-up of children whose fever persists.

After this issue of Emergency Medicine Practice,you may never perform another CBC in a febrile childand still deliver stellar care—as long as you stickenough needles in the L 2-3 interspace and ensureadequate follow-up. ▲

Acknowledgements

Drs. David McGillivray and Martin Pusic providedvaluable comments and suggestions on a previousversion of this manuscript.

References

Evidence-based medicine requires a critical appraisalof the literature based upon study methodology andnumber of subjects. Not all references are equallyrobust. The findings of a large, prospective, random-ized, and blinded trial should carry more weight than acase report.

To help the reader judge the strength of eachreference, pertinent information about the study, suchas the type of study and the number of patients in thestudy, will be included in bold type following thereference, where available. In addition, the mostinformative references cited in the paper, as deter-mined by the authors, will be noted by an asterisk (*)next to the number of the reference.

1. Wright PF, Thompson J, McKee KT, et al. Patterns ofillness in the highly febrile young child: epidemiologic,clinical and laboratory correlates. Pediatrics 1981;67:694-700. (Comparative; 301 episodes in 375 infants andyoung children)

2. Eskerud JR, Laerum E, Fagerthun H, et al. Fever ingeneral practice: I. Frequency and diagnoses. Fam Pract1992;263-269. (Physician survey; 1610 episodes)

3. Finkelstein JA, Christiansen CL, Platt R. Fever in

pediatric primary care: occurrence, management, andoutcomes. Pediatrics 2000;105:260-266. (Retrospective,cohort; 20,585 children)

4. Schmitt BD. Fever phobia: misconceptions of parentsabout fevers. Am J Dis Child 1980;134:176-181. (Survey;81 parents)

5. Kramer MS, Naimark L, Leduc DG. Parental fever phobiaand its correlates. Pediatrics 1985;75:1110-1113. (Survey;202 parents)

6. May A, Bauchner H. Fever phobia: the pediatrician’scontribution. Pediatrics 1992;90:851-854. (Physicianquestionnaire; 172 responses)

7. Klein JO, Schlesinger PC, Karasic RB. Management of thefebrile infant three months of age or younger. PediatrInfect Dis J 1984;3:75-79.

*8. Baraff LJ, Lee SI. Fever without source: management ofchildren 3 to 36 months of age. Pediatr Infect Dis J1992;11:146-51. (Review)

*9. Long SS. Approach to the febrile patient with no obviousfocus of infection. Pediatr Rev 1984;5:305-315.

10. McCarthy P. Management of the febrile infant. Pediatrics1992;89:1251-1253.

11. Nazarian LF. Perspective: the office-based pediatricpractice. In: The Febrile Infant and Occult Bacteremia.Report of the Nineteenth Ross Roundtable on CriticalApproaches to Common Pediatric Problems; Columbus,OH: Ross Laboratories; 1988:40-47.

12. Young PC. The management of febrile infants byprimary-care pediatricians in Utah: comparison withpublished practice guidelines. Pediatrics 1995;95:623-627.(Comparative, physicians survey; 94 respondents)

13. Yamamoto LG, Boychuk RB. Emergency departmentversus office setting and physician/patient kinshipeffects in the diagnostic and therapeutic choices offebrile children at risk for occult bacteremia. Hawaii MedJ 1997;56:209-214. (Physician survey; 138 respodents)

14. Wittler RR, Cain KK, Bass JW. A survey about manage-ment of febrile children without source by primary carephysicians. Pediatr Infect Dis J 1998;271-279. (Compara-tive, physician survey; 1600 physicians)

15. Nelson DG, Leake J, Bradley J, et al. Evaluation of febrilechildren with petechial rashes: is there consensus amongpediatricians? Pediatr Infect Dis J 1998;17:1135-1140.(Comparative, physician survey; 416 respndents)

*16. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guidelinefor the management of infants and children 0 to 36months of age with fever without source. Pediatrics1993;92:1-12. (Meta-analysis)

17. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guidelinefor the management of infants and children 0 to 36months of age with fever without source. Agency forHealth Care Policy and Research. Ann Emerg Med1993;22:1198-1210. (Meta-analysis)

18. Soman M. Characteristics and management of febrileyoung children seen in a university family practice. JFam Pract 1985;21:117-122. (Follow-up study, cohortretrospective; 311 children)

*19. Hoberman A. Wald ER. Urinary tract infections in youngfebrile children. Pediatr Infect Dis J 1997;16(1):11-17.(Review)

*20. Lee GM, Harper MB. Risk of bacteremia for febrilechildren in the post-Haemophilus influenzae type bera.Arch Pediatr Adolesc Med 1998;152:624-628. (Prospec-


tive; 1911 children)21. Randolph MF, Morris KE, Gould EB. The first urinary

tract infection in the female infant. Prevalence, recur-rence, and prognosis: a 10-year study in private practice.J Pediatr 1975;86:342-348. (Follow-up study; 800 femaleinfants)

*22. Shaw KN, Gorelick M, McGowan KL, et al. Prevalence ofurinary tract infection in febrile young children in theemergency department. Pediatrics 1998;102:16. (Cross-sectional prevalence survey; 2411 children)

23. Schuchat A, Robinson K, Wenger JD, et al. Bacterialmeningitis in the United States in 1995. Active Surveil-lance Team. N Engl J Med 1997;337:970-976. (Populationsurveillance; total population more than 10,000,000)

24. Wald ER, Milmoe GJ, Bowen AD, et al. Acute maxillarysinusitis in children. N Engl J Med 1981;304:749-754. (23children)

*25. Kuppermann N, Fleisher GR, Jaffe DM. Predictors ofoccult pneumococcal bacteremia in young febrilechildren. Ann Emerg Med 1998;31:679-687. (Prospective;6579 patients)

26. Hoberman A, Han-Pu C, Keller DM, et al. Prevalence ofurinary tract infection in febrile infants. J Pediatr1993;123:17-23. (Comparative, follow-up study; 945febrile infants, 50 diagnosed with UTI)

*27. Kramer MS, Tange SM, Mills EL, et al. Role of thecomplete blood count in detecting occult focal bacterialinfection in the young febrile child. J Clin Epidemiol1993;46:349-357. (Prospective; 2492 children)

29. Ginsburg CM, McCracken GH. Urinary tract infections inyoung infants. Pediatrics 1982;69:409-412. (100 infants)

29. Wiswell TE, Smith FR, Bass JW. Decreased incidence ofurinary tract infections in circumcised male infants.Pediatrics 1985;75:901-903.

30. Wiswell TE, Hachey WE. Urinary tract infections and theuncircumcised state: an update. Clin Pediatr 1993;32:130-134. (Meta-analysis; 209,399 infants)

31. Craig JC, Knight JF, Sureshkumar P, et al. Effect ofcircumcision on incidence of urinary tract infection inpreschool boys. J Pediatr 1996;128:23-27. (Case-control;886 boys)

*32. Teach SJ, Fleisher GR. Duration of fever and its relation-ship to bacteremia in febrile outpatients three to 36months old. The Occult Bacteremia Study Group. PediatrEmerg Care 1997; 317-319. (Prospective cohort; 6680children)

33. Chantada G, Casak S, Plata JD, et al. Children with feverof unknown origin in Argentina: an analysis of 113 cases.Pediatr Infect Dis J 1994;13:260-263. (Retrospective; 113cases)

34. Lebeda MD, Haller JR, Graham SM, et al. Evaluation ofmaxillary sinus aspiration in patients with fever ofunknown origin. Laryngoscope 1995;195:683-685. (Retro-spective; 51 sinus aspirations in 34 patients)

35. Jacobs RF, Schutze GE. Bartonella henselae as a cause ofprolonged fever and fever of unknown origin inchildren. Clin Infect Dis 1998;26:80-84. (Prospective; 146children)

36. Leventhal JM. Clinical predictors of pneumonia as aguide to ordering chest roentgenograms. Clin Pediatr1982;21:730-734. (Prospective; 136 children)

37. Zukin DD, Hoffman JR, Cleveland RH, et al. Correlationof pulmonary signs and symptoms with chest radio-

graphs in the pediatric age group. Ann Emerg Med1986;15:792-796. (Prospective; 125 children)

38. Shapiro EG, Aaron NH, Wald ER, et al. Risk factors fordevelopment of bacterial meningitis among childrenwith occult bacteremia. J Pediatr 1986;109:15-19. (Com-parative; 310 patients)

39. Moltz H. Fever: causes and consequences. NeurosciBiobehav Rev 1993;17:237-269. (Review)

40. Saper CB, Breder CD. The neurologic basis of fever. NEngl J Med 1994;330:1880-1886. (Review)

41. Cunningham DG, Challapalli M, O’Keefe JP, et al.Unprescribed use of antibiotics in common childhoodinfections. J Pediatr 1983;103(5):747-749. (Prospective,observational; 763 children)

42. Barnett ED, Pelton SI, Vinci RJ, et al. Reported use ofantimicrobial agents in children attending a pediatricemergency department. Pediatr Infect Dis J1991;10(12):949-950. (Prospective observational study;79 children aged one month to six years)

43. McCarthy PL, Jekel JF, Dolan TF. Temperature greaterthan or equal to 40˚C in children less than 24 months ofage: a prospective study. Pediatrics 1977;59:663-668.(Prospective; 330 children)

44. Press S, Fawcett NP. Association of temperature greaterthan 41.1 degrees C (106 degrees F) with serious illness.Clin Pediatr 1985;24(1):21-25. (Prospective, observa-tional; 15 children)

45. Torrey SB, Henretig F, Fleisher G, et al. Temperatureresponse to antipyretic therapy in children: relationshipto occult bacteremia. Am J Emerg Med 1985;3:190-192.(Prospective; 255 patients)

46. Weisse ME, Miller G, Brien JH. Fever response toacetaminophen in viral vs bacterial infections. PediatrInfect Dis 1987;6:1091-1094. (Comparative; 100 children)

47. Baker MD, Fosarelli PD, Carpenter RO. Childhood fever:correlation of diagnosis with temperature response toacetaminophen. Pediatrics 1987;80:315-318. (Prospective;1559 children)

48. Bonadio WA, Bellomo T, Brady W, et al. Correlatingchanges in body temperature with infectious outcome infebrile children who receive acetaminophen. Clin Pediatr1993;32:343-346. (Retrospective; 140 children)

*49. Mazur LJ, Kozinetz CA. Diagnostic tests for occultbacteremia: temperature response to acetaminophenversus WBC count. Am J Emerg Med 1994;12:403-406.(Comparative, cohort; 484 children)

50. Wilshaw R, Beckstrand R, Waid D, et al. A comparison ofthe use of tympanic, axillary, and rectal thermometers ininfants. J Pediatr Nurs 1999;14(2):88-93.

51. Weiss ME, Sitzer V, Clarke M, et al. A comparison oftemperature measurements using three ear thermom-eters. Appl Nurs Res 1998;11(4):158-166.

52. Doezema D, Lunt M, Tandberg D. Cerumen occlusionlowers infrared tympanic membrane temperaturemeasurement. Acad Emerg Med 1995;2(1):17-19. (Random-ized, controlled)

*53. Modell JG, Katholi CR, Kumaramangalam SM, et al.Unreliability of the infrared tympanic thermometer inclinical practice: a comparative study with oral mercuryand oral electronic thermometers [see comments]. So MedJ 1998;91(7):649-654. (Controlled)

*54. McCarthy PL, Sharpe MR, Spiezel SZ, et al. Observationscales to identify serious illness in febrile children.


Pediatrics 1982;70:802-809. (Regression analysis)*55. Teach SJ, Fleisher GR. Efficacy of an observation scale in

detecting bacteremia in febrile young children three to 36months of age, treated as outpatients. Occult BacteremiaStudy Group. J Pediatr 1995;126:877-881. (Prospective,multicenter, randomized, interventional; 6611 patients)

56. Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinicalpredictors of bacterial versus aspetic meningitis inchildhood. Ann Emerg Med 1992;21:910-914. (Prospective;172 children)

57. Pichichero ME. Acute otitis media: Part I. Improvingdiagnostic accuracy [see comments]. Am Fam Phys2000;61(7):2051-2056. (Review; 23 references)

58. Woods WA, Carter CT, Schlager TA. Detection of group Astreptococci in children under 3 years of age withpharyngitis. Pediatr Emerg Care 1999;15(5):338-340.(Prospective, observational; 230 children)

59. Patterson RJ, Bisset GS, Kirks DR, e tal. Chest radio-graphs in the evaluation of the febrile infant. AJR Am JRoent 1990;155:833. (Retrospective, 105 infants; prospec-tive, 121 infants)

60. Harari M, Shann F, Spooner V, et al. Clinical signs ofpneumonia in children. Lancet 1991;334:928-930. (Pro-spective; 185 children)

*61. Mandl KD, Stack AM, Fleisher GR. Incidence of bacter-emia in infants and children with fever and petechiae. JPediatr 1997;131(3):398-404. (Prospective, observational;411 children with fever and petechiae)

62. Baker RC, Seguin JH, Leslie N, et al. Fever and petechiaein children. Pediatrics 1989;84(6):1051-1055. (Prospective,observational; 190 children)

63. Ros SP, Herman BE, Beissel TJ. Occult bacteremia: isthere a standard of care? Pediatr Emerg Care1994;10(5):264-267. (Physician questionnaire; 306respondents)

*64. Green SM, Rothrock SG. Evaluation styles for well-appearing febrile children: are you a “risk-minimizer” ora “test-minimizer”? Ann Emerg Med 1999;33(2):211-214.(Editorial)

*65. McGillivray DL, Roberts-Brauer R, Kramer MS. Diagnos-tic test ordering in the evaluation of febrile children.Physician and environmental factors. Am J Dis Child1993;147(8):870-874. (Prospective; 6191 visits)

66. Hampers LC, Cha S, Gutglass DJ, et al. Fast track and thepediatric emergency department: resource utilizationand patients outcomes. Acad Emerg Med 1999;6(11):1153-1159. (Prospective, comparative, cohort; 1036 patients)

67. Stein RC. The white blood cell count in fevers ofunknown origin. Am J Dis Child 1972;124:60-63.

68. Todd JK. Childhood infections: diagnostic value ofperipheral white blood cell and differential cell counts.Am J Dis Child 1974;127:810-816. (Retrospective)

69. Jaffe DM, Fleisher GR. Temperature and total whiteblood cell count as indicators of bacteremia. Pediatrics1991;87:670-674. (955 children)

70. McCarthy PL, Jekel JF, Dolan TF. Comparison of acute-phase reactants in pediatric patients with fever. Pediatrics1978;62:716-720. (Comparative)

71. Bennish M, Beem MO, Ormiste V. C-reactive protein andzeta sedimentation ratio as indicators of bacteremia inpediatric patients. J Pediatr 1984;104:729-732.

72. Baker RC, Tiller T, Bausher JC, et al. Severity of diseasecorrelated with fever reduction in febrile infants.

Pediatrics 1989;83:1016-1019. (Prospective; 154 children)73. Berger RM, Berger MY, van Steensel-Moll HA, Dzoljic-

Danilovic G, et al. A predictive model to estimate the riskof serious bacterial infections in febrile infants. Eur JPediatr 1996;155:468-473. (Regression analysis; 138infants)

74. Liptak GS, Super DM, Baker N, et al. An analysis ofwaiting times in a pediatric emergency department. ClinPediatr 1985;24:202-209. (Observational; 216 children)

*75. Kramer MS, Etezadi-Amoli J, Ciampi A, et al. Parents’versus physicians’ values for clinical outcomes in youngfebrile children. Pediatrics 1994;93:697-702. (Cross-sectional; 100 parents of well children aged 3 to 24months, 61 parents of febrile children aged 3 to 24months, and 56 attending staff physicians)

*76. Kupperman N, Malley R, Inkelis SH, et al. Clinical andhematologic features do not reliably identify childrenwith unsuspected meningococcal disease. Pediatrics1999;103:e20. (Retrospective; 6514 children)

77. Kline MW, Smith EO, Kaplan SL, et al. Effects ofcausative organism and presence or absence of meningi-tis on white blood cell counts in children with bacter-emia. J Emerg Med 1988;6(1):33-35. (Comparative; 182patients)

78. Lembo RM, Marchant CD. Acute phase reactants and riskof bacterial meningitis among febrile infants andchildren. Ann Emerg Med 1991;20(1):36-40. (Prospective;160 patients)

79. Sadowitz PD, Oski FA. Differences in polymorpho-nuclear cell counts between healthy white and blackinfants: response to meningitis. Pediatrics 1983;72(3):405-407. (Comparative; 100 patients)

80. Kikano GE, Stange KC, Flocke SA, et al. Effect of thewhite blood count on the clinical management of thefebrile infant. J Fam Pract 1991;33(5):465-469. (Compara-tive, physician questionnaire; 294 respondents)

81. Hoberman A, Wald ER, Reynolds EA, et al. Pyuria andbacteriuria in urine specimens obtained by catheter fromyoung children with fever. J Pediatr 1994;124:513-519.(2181 urine specimens)

82. Gorelick MH, Shaw KN. Screening tests for urinary tractinfection in children: a meta-analysis. Pediatrics1999;104:1-7. (Meta-analysis)

83. Hoberman A, Wald ER, Hickey RW, et al. Oral versusinitial intravenous therapy for urinary tract infections inyoung febrile children. Pediatrics 1999;104:79-86.(Multicenter, randomized, controlled; 306 children)

84. Al-Orifi F, McGillivray D, Tange S, et al. Urine culturefrom bag specimens in young children: are the risks toohigh? J Pediatr (in press).

85. Turner GM, Coulthard MG. Fever can cause pyuria inchildren. BMJ 1995;311(7010):924.

86. Hoberman A, Wald ER, Reynolds EA, et al. Is urineculture necessary to rule out urinary tract infection inyoung febrile children? Pediatr Infect Dis J 1996;15:304-309. (4253 patients)

87. Gorelick MH, Shaw KN. Clinical decision rule to identifyfebrile young girls at risk for urinary tract infection. ArchPediatr Adolesc Med 2000;154(4):386-390. (Prospective,cohort; 1469 girls)

88. Smellie JM, Poulton A, Prescod NP. Retrospective studyof children with renal scarring associated with reflux andurinary infection. Br Med J 1994;308:1193-1196. (Retro-


spective; 52 children)89. Kramer MS, Tange SM, Drummond KN, et al. Urine

testing in young febrile children: a risk-benefit analysis. JPediatr 1994;125:6-13. (Decision analysis)

*90. American Academy of Pediatrics. Practice parameter: thediagnosis, treatment, and evaluation of the initialurinary tract infection in febrile infants and youngchildren. Pediatrics 1999;103:843-852. (Practice guideline)

91. Pollack C, Pollack E, Andrew M. Suprapubic bladderaspiration versus urethral catheterization in ill infants.Ann Emerg Med 1994;23:225-230. (Prospective, random-ized; 50 patients)

92. Lohr JA, Downs SM, Dudley S, et al. Hospital-acquiredurinary tract infections in the pediatric patient: aprospective study. Pediatr Infect Dis J 1994;13:8-12.(Prospective; 525 children)

93. Carlson D, Mowery B. Standards to prevent complica-tions of urinary catheterization in children: shoulds andshould-knots. J Soc Pediatr Nurs 1997;2:37-41. (Review)

94. Smith A, Adams L. Insertion of indwelling urethralcatheters in infants and children: a survey of currentnursing practice. Pediatr Nurs 1998;24:229-234. (Com-parative, nurse survey)

95. Jadavji T, Law B, Lebel MH, et al. A practical guide forthe diagnosis and treatment of pediatric pneumonia. CanMed Assoc J 1997;156 (suppl): S703-711. (Practiceguideline)

96. Fanelli JM, Rothrock SG, Green SM, et al. Do evidence-based guidelines predict pneumonia in young childrenpresenting to the ED? Acad Emerg Med 2000;7:403.

97. Bachur R, Perry H, Harper MB. Occult pneumonias:Empiric chest radiographs in febrile children withleukocytosis. Ann Emerg Med 1999;33:166-173. (Prospec-tive, cohort; 278 patients)

98. McCarthy PL, Spiesel SZ, Stashwick CA, et al. Radio-graphic findings and etiologic diagnosis in ambulatorychildhood pneumonias. Clin Pediatr 1981;20:686-691.(Comparative; 128 chest roentgenograms)

99. Kramer MS, Roberts-Bräuer R, Williams RL. Bias and“overcall” in interpreting chest radiographs in youngfebrile children. Pediatrics 1992;90:11-13. (Comparative;287 chest radiographs)

100. Davies HD, Wang E, Manson D, et al. Reliability of thechest radiograph in the diagnosis of lower respiratoryinfections in young children. Pediatr Infect Dis J1996;15:600-604. (Evaluation study; 40 chest radiograms)

101. Bettenay FAL, de Campo JF, McCrossin DB. Differentiat-ing bacterial from viral pneumonias in children. PediatrRadiol 1988;18:453-454. (58 children)

102. Hickey RW, Bowman MJ, Smith GA. Utility of bloodcultures in pediatric patients found to have pneumoniain the emergency department. Ann Emerg Med1996;27(6):721-725. (Retrospective; 939 children)

103. McMurray BR, Wrenn KD, Wright SW. Usefulness ofblood cultures in pyelonephritis. Am J Emerg Med1997;15(2):137-140. (Retrospective; 338 patients)

104. Sadow KB, Chamberlain JM. Blood cultures in theevaluation of children with cellulitis. Pediatrics1998;101(3):E4. (Retrospective; 381 patients)

*105. Isaacman DJ, Karasic RB, Reynolds EA, et al. Effect ofnumber of blood cultures and volume of blood ondetection of bacteremia in children. J Pediatr1996;128(2):190-195. (Prospective; 300 patients)

*106. Kramer MS, Lane DA, Mills EL. Should blood culturesbe obtained in the evaluation of young febrile childrenwithout evident focus of bacterial infection? A decisionanalysis of diagnostic management strategies. Pediatrics1989;84:18-27. (Comparative, evaluation study)

107. Kramer MS, Shapiro ED. Management of the youngfebrile child: a commentary on recent practice guidelines.Pediatrics 1997;100:128-134. (Review)

108. Jaffe DM, Tanz RR, Davis AT, et al. Antibiotic administra-tion to treat possible occult bacteremia in febrilechildren. N Engl J Med 1987;317:1175-1180. (Prospective,randomized, placebo-controlled, double-blind; 955children)

109. Bass JW, Steele RW, Wittler RR, et al. Antimicrobialtreatment of occult bacteremia: a multicenter cooperativestudy. Pediatr Infect Dis J 1993;12:466-473. (Prospective,multicenter; 519 patients)

110. Fleisher GR, Rosenberg N, Vinci R, et al. Intramuscularversus oral antibiotic therapy for the prevention ofmeningitis and other bacterial sequelae in young, febrilechildren at risk for occult bacteremia. J Pediatr1994;124:504-512. (Prospective, comparative; 6733patients)

*111.Bachur R, Harper MB. Reevaluation of outpatients withStreptococcus pneumoniae bacteremia. Pediatrics2000;105:502-509. (Retrospective; 548 episodes)

*112.Thuler LC, Jenicek M, Turgeon JP, et al. Impact of a falsepositive blood culture result on the management offebrile children. Pediatr Infect Dis J 1997;16(9):846-851.(Retrospective; 9959 blood cultures)

113. Segal GS, Chamberlain JM. Resource utilization andcontaminated blood cultures in children at risk for occultbacteremia. Arch Pediatr Adolesc Med 2000;154(5):469-473.(Retrospective; 8306 children)

114. Finkelstein JA, Schwartz JS, Torrey S, et al. Commonclinical features as predictors of bacterial diarrhea ininfants. Am J Emerg Med 1989;7(5):469-473. (1035 infants)

115. Akpede GO. Localized extracranial infections in childrenwith acute bacterial meningitis. J Trop Pediatr1994;40(4):231-234. (66 children)

116. Al-Eissa YA. Lumbar puncture in the clinical evaluationof children with seizures associated with fever. PediatrEmerg Care 1995;11(6):347-350. (Prospective; 200 chil-dren)

*117.Green SM, Rothrock SG, Clem KJ, et al. Can seizures bethe sole manifestation of meningitis in febrile children?Pediatrics 1993;92(4):527-534. (Retrospective; 503patients)

118. Rothrock SG, Green SM, Wren J, et al. Pediatric bacterialmeningitis: is prior antibiotic therapy associated with analtered clinical presentation? Ann Emerg Med1992;21(2):146-152. (Retrospective; 258 patients)

119. Kallio MJT, Kilpi T, Anttila M, et al. The effect of a recentprevious visit to a physician on outcome after childhoodbacterial meningitis. JAMA 1994;272:787-791. (Prospec-tive; 325 patients)

120. Rennick G, Shann F, de Campo J. Cerebral herniationduring bacterial meningitis in children. BMJ1993;306(6883):953-955. (Retrospective; 445 patients)

121. Marshall R, Teele DW, Klein JO. Unsuspected bacteremiadue to Haemophilus influenzae: outcome in children notinitially admitted to hospital. J Pediatr 1979;95:690-695.(94 episodes)


122. Teele DW, Marshall R, Klein JO. Unsuspected bacteremiain young children: a common and important problem.Pediatr Clin North Am 1979;26:773-784.

123. Alario AJ, Nelson EW, Shapiro ED. Blood cultures in themanagement of febrile outpatients later found to havebacteremia. J Pediatr 1989;115:195-199. (Retrospective;482 episodes)

124. Woods ER, Merola JL, Bithoney WG, et al. Bacteremia inan ambulatory setting. Improved outcome in childrentreated with antibiotics. Am J Dis Child 1990;144:1195-1199. (414 patients)

125. Forman PM, Murphy TV. Reevaluation of the ambulatorypediatric patient whose blood culture is positive forHaemophilus influenzae type b. J Pediatr 1991 Apr;118(4 (Pt 1)):503-508. (Retrospective; 60 patients)

126. Korones DN, Marshall GS, Shapiro ED. Outcome ofchildren with occult bacteremia caused by Haemophilusinfluenzae type b. Pediatr Infect Dis J 1992;11:516-520.(Retrospective; 69 patients)

127. Harper MB, Bachur R, Fleisher GR. Effect of antibiotictherapy on the outcome of outpatients with unsuspectedbacteremia. Pediatr Infect Dis J 1995;14:760-767. (Retro-spective, comparative; 559 patients)

128. Baraff LJ, Oslund S, Prather M. Effect of antibiotictherapy and etiologic microorganism on the risk ofbacterial meningitis in children with occult bacteremia.Pediatrics 1993;92:140-143. (Bayesian meta-analysis)

129. Carroll WL, Farrell MK, Singer JI, et al. Treatment ofoccult bacteremia: a prospective randomized clinicaltrial. Pediatrics 1983;72:608-612. (Prospective, random-ized; 96 children)

130. Shapiro ED. Infections caused by Haemophilus influenzaetype b: the beginning of the end? JAMA 1993;269:264-266.

131. Centers for Disease Control. Progress toward eliminationof Haemophilus influenzae type b disease among infantsand children-United States, 1987-1993. MMWR1994;43:144-148.

*132. Rothrock SG, Green SM, Harper MB, et al. Parenteral vsoral antibiotics in the prevention of serious bacterialinfections in children with Streptococcus pneumoniaeoccult bacteremia: a meta-analysis. Acad Emerg Med 1998;5: 599-606. (Meta-analysis)

133. Rothrock SG, Harper MB, Green SM, et al. Do oralantibiotics prevent meningitis and serious bacterialinfections in children with occult pneumococcalbacteremia? A meta-analysis. Pediatrics 1997; 99:438-444.(Meta-analysis)

134. Riley LW, Cohen ML, Seals JE, et al. Importance of hostfactors in human salmonellosis caused by multiresistantstrains of Salmonella. J Infect Dis 1984;149:878-883. (542patients)

135. Molstad S, Arvidsson E, Eliasson I, et al. Production ofbetalactamase by respiratory tract bacteria in children:relationship to antibiotic use. Scand J Prim Health Care1992;10:16-20. (Comparative, 1133 children)

136. Tan TQ, Mason EO Jr, Kaplan SL. Penicillin-resistantsystemic pneumococcal infections in children: a retro-spective case-control study. Pediatrics 1993;92:761-767.(Retrospective, case-control; 43 children)

137. Kunin CM. Resistance to antimicrobial drugs-a world-wide calamity. Ann Intern Med 1993;118:557-561.(Review)

138. Lee LA, Puhr ND, Maloney EK, et al. Increase inantimicrobial-resistant Salmonella infections in theUnited States, 1989-1990. J Infect Dis 1994;170:128-134.(Prospective)

139. McGowan JE, Bratton L, Klein JO, et al. Bacteremia infebrile children seen in a “walk-in” pediatric clinic. NEngl J Med 1973;288:1309-1312. (Prospective)

140. Teele DW, Pelton SI, Grant MJA, et al. Bacteremia infebrile children under 2 years of age: results of culturesof blood of 600 consecutive febrile children seen in a“walk-in” clinic. J Pediatr 1975;87:227-230. (Prospective;600 children)

141. Schutzman SA, Petrycki S, Fleisher GR. Bacteremia withotitis media. Pediatrics 1991;87:48-53. (Retrospective;2982 children)

142. Bauchner H, Pelton SI, Klein JO. Parents, physicians, andantibiotic use Pediatrics 1999;103(2):395-401. (Physiciansurvey; 610 respondents)

143. Watson RL, Dowell SF, Jayaraman M, et al. Antimicrobialuse for pediatric upper respiratory infections: reportedpractice, actual practice, and parent beliefs Pediatrics1999;104(6):1251-1257. (Physician survey; 366 respon-dents)

144. Horne A, Ros SP. Telephone follow-up of patientsdischarged from the emergency department: howreliable? Pediatr Emerg Care 1995;11(3):173-175. (250 calls)

*145. Flores G, Lee M, Bauchner H, et al. Pediatricians’attitudes, beliefs, and practices regarding clinicalpractice guidelines: a national survey. Pediatrics2000;105(3 Pt 1):496-501. (Cross-sectional mail survey;627 respondents)

146. Oppenheim PI, Sotiropoulos G, Baraff LJ. Incorporatingpatient preferences into practice guidelines: managementof children with fever without source. Ann Emerg Med1994;24(5):836-841. (Survey)

147. Procop GW, Hartman JS, Sedor F. Laboratory tests inevaluation of acute febrile illness in pediatric emergencyroom patients. Am J Clin Pathol 1997;107(1):114-121.(Retrospective; 155 cases)

148. Newman TB, Bernzweig JA, Takayama JI, et al. Naturalhistory of urinary tract infections in febrile infants 0 to 3months old: inferences from the PROS Febrile InfantStudy. Pediatr Res 2000;47:213A.

149. Kennedy J, Dawson KP, Abbott GD. Should a lateralchest radiograph be routine in suspected pneumonia?Aust Paediatr J 1986;22:299. (414 children)

150. Lamme T, Nijhout M, Cadman D, et al. Value of thelateral radiologic view of the chest in children with acutepulmonary illness. Can Med Assoc J 1986;134:353.(Retrospective; 179 views)

151. Al Sacchetti, personal communication.

Physician CME Questions

1. Which of the following viral infections is notcharacterized by rash?a. Varicellab. Measlesc. Croupd. Herpes simplex gingivostomatitis


2. Sources of occult bacteremia include all of thefollowing except:a. Roseolab. UTIc. Pneumoniad. Septic arthritis/osteomyelitise. Meningitis

3. H. influenzae type b:a. has increased significantly in recent years.b. has virtually disappeared due to the wide-

spread use of the Hib vaccine.c. is frequently the cause of otitis media.d. occurs much more frequently in summer

than winter.

4. A higher risk of UTI occurs with all of thefollowing except:a. males under 6 months of age.b. females under 2 years.c. those with uretero-vesicle reflux.d. uncircumcised males.e. African-American children.

5. A history of reduced appetite and activity in thefebrile child:a. is not helpful in developing a differential

diagnosis.b. is suggestive of meningitis.c. increases the probability of UTI.d. is seen primarily in viral vs. bacterial

infections.

6. All of the following suggest meningitis in thefebrile child except:a. high Yale Observation Scale score.b. Kerning’s sign.c. Braham’s sign.d. bulging fontanelle.

7. Important historical considerations in the febrilechild up to 3 years old include:a. whether the child has seen another doctor in

the past week.b. whether the child has taken any prescribed or

non-prescribed antibiotics recently.c. travel history and day care attendance.d. prior infections, especially UTIs and

pneumonia.e. all of the above.

8. All of the following have important diagnosticimplications except:a. especially high fevers.b. general appearance.c. response to antipyretics.d. past medical history.

9. The Yale Observation Scale score:a. can be used to assess a child’s risk for

serious illness.b. is significantly higher in children with

meningitis.c. is based on the child’s cry, wakefulness,

color, hydration, and response to parentsand social overtures.

d. all of the above.

10. Which of the following most strongly suggestsotitis media?a. Decreased mobility of the tympanic

membraneb. Red earsc. A child who pulls or tugs at his or her earsd. Lack of other clinical diagnosis in the

febrile child

11. The diagnostic test least likely to lead to a clini-cally beneficial change in treatment strategy is:a. the CBC.b. lumbar puncture.c. urinalysis.d. chest x-ray.

12. The CBC:a. can distinguish between N. meningitidis

bacteremia and viral illness.b. shows a leukocyte count of more than

15,000/cc in the majority of children withbacterial meningitis.

c. can determine the need for lumbar puncture.d. is associated with high false-positive and

false-negative rates.

13. Urinalysis and urine culture:a. are less valuable than urine odor, urinary

frequency, and dysuria in establishing adiagnosis of UTI.

b. are generally recommended in femalesyounger than 2 years old and malesyounger than 6 months who have feverand no source.

c. are correlated with a very high false-positiverate for UTI.

d. result in many complications if obtainedby a catheter.

14. Indications for chest x-ray in febrile childrenolder than 3 months include all of thefollowing except:a. respirations of 50/min or higher.b. nasal flaring, retractions, and grunting.c. diminished breath sounds.d. rales.e. isolated cough.


Physician CME Information

This CME enduring material is sponsored by Mount Sinai School of Medicineand has been planned and implemented in accordance with the Essentialsand Standards of the Accreditation Council for Continuing MedicalEducation. Credit may be obtained by reading each issue and completingthe post-tests administered in December and June.Target A udienc e: This enduring material is designed for emergency

medicine physicians.Needs A ssessmen t: The need for this educational activity was determined

by a survey of medical staff, including the editorial board of this publica-tion; review of morbidity and mortality data from the CDC, AHA, NCHS,and ACEP; and evaluation of prior activities for emergency physicians.

Date of O riginal R elease: This issue of Emergency Medicine Practicewas published July 1, 2000. This activity is eligible for CME credit throughJuly 1, 2003. The latest review of this material was March 13, 2001.

Discussion of I nvestiga tional I nformation: As part of the newsletter,faculty may be presenting investigational information aboutpharmaceutical products that is outside Food and Drug Administrationapproved labeling. Information presented as part of this activity isintended solely as continuing medical education and is not intendedto promote off-label use of any pharmaceutical product. Disclosure ofOff-Label Usage: This issue of Emergency Medicine Practice discusses theuse of high-dose amoxicillin (80-100 mg/kg/day). While this dose is wellstudied and seems prudent in areas where penicillin-resistantpneumococci is endemic, this dosage is not FDA approved.

Facult y Disclosur e: In compliance with all ACCME Essentials, Standards,and Guidelines, all faculty for this CME activity were asked to complete afull disclosure statement. The information received is as follows: Dr.Rothrock owns Pfizer, Merck, and Johnson & Johnson stock, Dr. Jagoda ison the speaker’s bureau for Parke-Davis and Glaxo and receives researchfunding from Aitken Neuroscience Center, and Dr. Kramer reports nosignificant financial interest or other relationship with the manufacturer(s)of any commercial product(s) discussed in this educational presentation.

Accreditation: Mount Sinai School of Medicine is accredited by theAccreditation Council for Continuing Medical Education to sponsorcontinuing medical education for physicians.

Credit D esigna tion: Mount Sinai School of Medicine designates thiseducational activity for up to 4 hours of Category 1 credit toward theAMA Physician’s Recognition Award. Each physician should claim onlythose hours of credit actually spent in the educational activity. EmergencyMedicine Practice is approved by the American College of Emergency Phy-sicians for 48 hours of ACEP Category 1 credit (per annual subscription).

Earning C redit: Physicians with current and valid licenses in the UnitedStates, who read all CME articles during each Emergency Medicine Practicesix-month testing period, complete the CME Evaluation Form distributedwith the December and June issues, and return it according to thepublished instructions are eligible for up to 4 hours of Category 1 credittoward the AMA Physician’s Recognition Award (PRA) for each issue. Youmust complete both the post-test and CME Evaluation Form to receivecredit. Results will be kept confidential. CME certificates will be mailed toeach participant scoring higher than 70% at the end of the calendar year.

Class I• Always acceptable, safe• Definitely useful• Proven in both efficacy

and effectiveness• Must be used in the

intended manner forproper clinical indications

Level of Evidence:• One or more large

prospective studiesare present (withrare exceptions)

• Study results consistentlypositive and compelling

Class IIa• Safe, acceptable• Clinically useful• Considered treatments

of choiceLevel of Evidence:• Generally higher levels

of evidence• Results are consistently

positive

Class IIb• Safe, acceptable• Clinically useful• Considered optional or

alternative treatmentsLevel of Evidence:• Generally lower or

intermediate levelsof evidence

• Generally, but notconsistently, positive results

Class III:• Unacceptable• Not useful clinically• May be harmfulLevel of Evidence:• No positive high-level data• Some studies suggest or

confirm harm

Indeterminate• Continuing area of research• No recommendations until

further researchLevel of Evidence:• Evidence not available• Higher studies in progress• Results inconsistent,

contradictory• Results not compelling

Adapted from: The EmergencyCardiovascular Care Committeesof the American Heart Associationand representatives from theresuscitation councils of ILCOR:How to Develop Evidence-BasedGuidelines for Emergency CardiacCare: Quality of Evidence andClasses of Recommendations; also:Anonymous. Guidelines forcardiopulmonary resuscitation andemergency cardiac care. Emer-gency Cardiac Care Committee andSubcommittees, American HeartAssociation. Part IX. Ensuringeffectiveness of community-wideemergency cardiac care. JAMA1992;268(16):2289-2295.

Class Of Evidence Definitions

Each action in the clinical pathways section of EmergencyMedicine Practice receives an alpha-numerical score based onthe following definitions.

Direct all editorial or subscription-related questions to PinnaclePublishing, Inc.: 1-800-788-1900 or 770-992-9401

Fax: 770-993-4323

Pinnacle Publishing, Inc.P.O. Box 769389

Roswell, GA 30076-8220

E-mail: emer gmed@pinpub .com

Pinnacle Web Site: http://www .pinpub .com

Emergency Medicine Practice (ISSN 1524-1971) is published monthly (12 times per year)by Pinnacle Publishing, Inc., 1000 Holcomb Woods Parkway, Building 200, Suite 280,Roswell, GA 30076-2587. Opinions expressed are not necessarily those of thispublication. Mention of products or services does not constitute endorsement. Thispublication is intended as a general guide and is intended to supplement, rather thansubstitute, professional judgment. It covers a highly technical and complex subject andshould not be used for making specific medical decisions. The materials containedherein are not intended to establish policy, procedure, or standard of care. EmergencyMedicine Practice is a trademark of Pinnacle Publishing, Inc. Copyright 2000 PinnaclePublishing, Inc. All rights reserved. No part of this publication may be reproduced inany format without written consent of Pinnacle Publishing, Inc. Subscription price:$249, U.S. funds. (Call for international shipping prices.)

Publisher : Robert Williford. Vice Presiden t/General Manager : Connie Austin.Executiv e Editor: Heidi Frost.

Emergency Medicine Practice is not affiliatedwith any pharmaceutical firm

or medical device manufacturer.

15. Lumbar puncture:a. is indicated in children with no source

of infection who appear toxic despitetemperature reduction.

b. is indicated in all children with febrileseizures.

c. is never necessary in cases of priorantibiotic use.

d. does not occur in conjunction withotitis media.

16. Empiric antibiotic treatment:a. causes no side effects.b. is universally supported in the literature.c. may result in allergic reactions, diarrhea, or

serum sickness.d. is indicated for treatment of the common cold.

Health & Medicine

Febrile child