Bacteremia may also occur in the 3- to 36-month age group without clinically recognized septicemia or focal SBI. This "occult" bacteremia (OB) has been found to have an incidence of 3 percent of children 3 to 36 months of age with rectal temperatures of 39°C or higher, a well clinical appearance, and no major focal bacterial infection.67 The most common organism responsible is Streptococcus pneumoniae, which accounts for 90 percent of OB. Streptococcus pneumoniae OB most often resolves spontaneously but carries a 10 percent risk of complicating SBI, including a 3 percent risk of meningitis. 8 Haemophilus influenzae type b (HIB) has historically been reported to account for 10 percent of OB, with a 50 percent risk of progression to SBI, including a 25 percent risk of meningitis. 9 However, the impact of the HIB vaccine on the incidence of HIB-related bacteremic disease has been dramatic, virtually eliminating this organism as a potential pathogen in adequately immunized patients.10 Other organisms, such as Neisseria meningitidis and Salmonella sp., contribute a minority of cases but with a high rate of subsequent focal SBI. Although uncommon, group A b-hemolytic streptococcus has been reported as a cause of bacteremia, often associated with primary varicella infection. 11 Initial studies reported that untreated OB, without reference to the specific etiology, carries a 10 percent risk of progression to complicating focal meningitis. 12 However, no studies have been performed since the universal introduction of the HIB vaccine, and the actual risk of progression from OB to complicating focal SBI in adequately immunized children is likely much lower.8 Two developments will profoundly develop the future management of bacteremia and SBI due to S. pneumoniae. The widespread emergence of penicillin- and cephalosporin-resistant strains of S. pneumoniae has complicated the choice of optimal therapy for bacteremia, SBI and meningitis in particular. Antibiotic treatment within the prior month has been demonstrated to be a risk factor for infection due to a resistant strain. 13 Of potentially greatest importance to the emergency physician caring for a febrile child, a newly developed polyvalent pneumococcal vaccine has recently completed phase III clinical trials and was shown to reduce by 90 percent the incidence of all pneumococcal bacteremia and meningitis in immunized infants.14
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