Management

Is there a role for the use of expectant antibiotics in children suspected of having occult bacteremia? Retrospective studies have all shown that early antibiotics diminished the incidence of persistent bacteremia. In a prospective randomized study comparing oral penicillin to no antibiotics, no improvement was reported in any bacteremic child who did not receive antibiotics.33 Other investigators report more equivocal results. Outpatient daily injections of ceftriaxone are being used by some physicians for children at increased risk of occult bacteremia. Controlled trials investigating the efficacy of this therapy have demonstrated a reduction in the incidence of meningitis in bacteremic children treated with ceftriaxone compared with those treated with oral or no antibiotics. Parenteral ceftriaxone should never be initiated without appropriate antecedent diagnostic studies. Treatment should be discontinued if cultures are negative. The risk from the overuse of ceftriaxone is the emergence of resistant organisms, a phenomenon that has already been observed.34 Current recommendations suggest that well-appearing infants between 3 and 36 months of age, with no focus of infection, and fever greater than or equal to 39.5°C (103.1°F) and WBCs over 15,000 or a temperature over 40.0°C (104°F), regardless of the white count, may be candidates for expectant antibiotic treatment with ceftriaxone at a dose of 50 mg/kg given twice 24 h apart. If cultures are negative after 48 h, no further treatment is needed. Any child who appears ill or toxic should be admitted to the hospital. Likewise, children who are felt to be at risk for a serious bacterial infection, and do not have reliable follow-up or the ability to return to the hospital, should also be admitted for inpatient management. 35

An additional dilemma surrounds the management of positive blood culture results. All patients with positive blood cultures should be recalled for repeat evaluation. If they are receiving appropriate antibiotics, are clinically well, and have been afebrile, they should be instructed to complete the course of therapy. If they are afebrile and clinically well but have never been treated with antibiotics, opinions differ regarding the need for additional blood cultures and antibiotic therapy. Generally, neither is necessary unless the child has developed a specific focus of infection. However, any patient who remains febrile or does poorly even if on antibiotics should receive complete septic evaluation (CBC, blood culture, lumbar puncture, chest film, and urine culture), be hospitalized, and receive parenteral antibiotics ( Fig. 110-1).

FIG. 110-1. Management of bacteremic children; 1"Sick": irritable, lethargic, anorexic, vomiting; fseptic W/U (workup): blood culture, lumbar puncture, chest x-ray, complete blood count, differential, urinalysis, urine culture; tfocus of infection: otitis media, pneumonia, cellulitis.

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