Physical Examination

Infants should be undressed completely to enable a full assessment. Vital signs are important to evaluate. For instance, tachypnea may be a clue to lower respiratory tract infection. Crying and the ease of consolability should be evaluated. Inconsolable crying, or increased irritability when handled, is frequently seen in infants with meningitis. Although fullness of the anterior fontanelle may be noted in some of these infants, other signs of meningeal irritation, such as nuchal rigidity, are most often absent. A head-to-toe evaluation should be carried out to determine whether there is a focus of infection, such as an inflamed eardrum or evidence of cellulitis.

Clinical assessment of the severity of illness of young, febrile infants is, however, problematic. Young infants lack social skills, such as the social smile, and their ability to interact with examiners is limited. There is a report in the literature of an infant with group B streptococcal bacteremia who was judged by house staff and faculty to be clinically well.12 The absence of any diagnostic abnormalities in the medical history or on physical examination suggests the need for extensive laboratory tests to detect occult infection. These tests would include a complete blood count (CBC) and differential, erythrocyte sedimentation rate (ESR), blood culture, lumbar puncture, chest x-ray, urinalysis and culture, and a stool culture if there is a history of diarrhea, particularly if leukocytes are noted on a stool smear. Some authors also recommend a quantitative C-reactive protein as an index of serious bacterial infection. 1 d8 Urinary tract infections may not produce symptoms other than fever, and so a urinalysis and culture should be included routinely in the evaluation. Urinary tract infections may be associated with bacteremia in up to 30

percent of infected infants1 25 and are the single most common bacterial infection in this age group.

The recognition of occult serious infection in well-appearing young, febrile infants is problematic. Most investigators agree that no single variable can correctly identify these infants. Combinations of variables are more helpful in the differentiation process. Criteria have been identified by a number of investigators, but are generally referred to as the Rochester criteria for low risk for serious bacterial infection in infants younger than 3 months of age. These criteria include nontoxic appearance, no soft tissue infection, white blood cells (WBCs) between 5000 and 15,000/mm 3, bands less than 1500/mm3, normal urinalysis, and stool with less than 5 WBCs/hpf (high power field) in infants with diarrhea.1 1? The risk of serious bacterial infection in the absence of these variables is about 0.2 percent.

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