Evaluation, management, and outcome of focal bacterial infections (FBIs) in nontoxic infants under two months of age
J Hosp Med
; doi:

To determine the risk of concomitant systemic infection (CSI) in infants who present with a focal bacterial infection (FBI), investigators from Joe DiMaggio Children’s Hospital in Hollywood, FL, and Cincinnati Children’s Hospital Medical Center (CCHMC) retrospectively reviewed charts from a consecutive series of infants under two months of age who presented to the CCHMC emergency department between January 2000 and December 2005. Participants were included if they were well-appearing on examination; had normal heart rate, respiratory rate, blood pressure, and oxygen saturation for age; and received a discharge diagnosis of FBI. FBIs were pre-defined as soft tissue infection, cellulitis, mastoiditis, abscess, otitis media (OM), omphalitis, mastitis, mammitis, paronychia, balanitis, posthitis, impetigo, or lymphadenitis. CSIs were defined as bacteremia, urinary tract infection (UTI), meningitis, septic arthritis, osteomyelitis, or pneumonia. Patients with immunodeficiency, a central venous catheter, tracheostomy, gastrostomy tube, chronic lung disease, previous admission for bacterial infection, or who were taking systemic antibiotics were excluded. The authors also sought to determine the risk of CSI in relation to the presence of fever, recorded at home or in the emergency room.

Two hundred forty-six patients under 60 days of age were diagnosed with a FBI. Thirty-seven of these met exclusion criteria and charts from 12 others could not be found. Of the 197 remaining participants, 158 were afebrile and 39 had fever. The mean age was 29.6 days (40.7 days for the febrile and 26.8 days for the afebrile). Four FBI patients (3 febrile, 1 afebrile) had a documented CSI for an overall risk of 2.0%. Of the three febrile patients, two had Escherichia coli UTIs and one had Streptococcus pneumoniae bacteremia accompanying periorbital cellulitis. The only afebrile infant with a CSI was an 11-day-old male who presented with OM and had an E coli UTI. An afebrile 11-day-old female infant with mastitis and a normal urinalysis had both E coli and normal flora on urine culture that was considered contaminated by the primary team. If this were considered a UTI, it would increase the overall risk of CSI to 2.5% among infants presenting with FBI and 1.3% among those who were afebrile. Febrile infants had a statistically higher risk of CSI than afebrile infants (OR=13.08; 95% CI, 1.32–129.46). The authors conclude that the risk of CSI in well-appearing afebrile infants with a FBI is small, but that febrile infants with a FBI have a risk of CSI similar to young infants presenting with fever without a source.

There are several guidelines for the management of a well-appearing, febrile infant younger than 2 months of age who is without a source of fever.1 More recently the literature has assessed the risk of CSI in young infants who have a clinically apparent or laboratory-confirmed viral infection, where the risk...

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