Bacterial infections often missed in febrile children in the ER

By Dr. Ananya Mandal, MDApr 22 2010

In a new study researchers reveal that up to one third of children with fever due to bacterial infections do not receive antibiotics in the emergency department and 20% of kids receive antibiotics unnecessarily.

Jonathan C. Craig, of the University of Sydney, and colleagues reported online on April 20^th in British Medical Journal that a computer based algorithm based on standard test results was better at assessing febrile children and allotting the correct treatment sooner.

According to estimation by 85-95% of emergency physicians only 5% febrile children had serious bacterial infections. However case data has shown that 7.2% had pneumonia, bacteremia, or a urinary tract infection. According to this study authors, “Emergency department physicians tend to underestimate the likelihood of serious bacterial infection in young children with fever, leading to under treatment with antibiotics.”

The Study

This study scientists analyzed all cases of under-five children who presented with fever from 2004-2006 in the emergency department of Children's Hospital of Westmead, in suburban Sydney. A total of 16,000 patients were assessed with complete follow up of 14,400 kids. The authors delineated nearly 40 clinical signs and symptoms and entered them into the hospital's electronic records database for all patients. Physicians were then asked to make their diagnosis among any of the 10 potential causes and set appropriate treatments.

Results

Thereafter on analyzing the results some 1,054 kids were seen to be suffering from serious bacterial infections on the basis of imaging and/or culture results, with some children having more than one. Except 26 all cases were of urinary tract or bloodstream or were pneumonia. However antibiotics were not prescribed for 33% patients with urinary tract infections and pneumonia and 19% of bacteremia. These children however did receive antibiotics eventually and of the 363 initial cases of infection, only 8 were still ill after a mean of 10.2 days and none had fever.

On the flip side 20% kids (2,686 out of 13,557) received antibiotics in spite of the fact that they did not have bacterial infections. The physicians' diagnoses of bacterial infection had low sensitivity (10 to 50 percent) but high specificity (90 to 100 percent), while the diagnostic model provided a broad range of values for sensitivity and specificity.

Recommendations

According to authors there are often reasons for withholding immediate antibiotics even when bacterial infections are suspected. For example a blood or urine culture needs to be done before administration of antibiotics that can distort the original infection picture in reports. But a delay in the administration of antibiotics can also cause recurrence of the infection. The authors thus recommend two methods to deal with the problem:

1. Use of a computer algorithm like the one they devised to aid diagnosis
2. Use a more standardized, evidence-based interpretation of urinalysis and chest radiograph results

Point of view

But two researchers (Matthew J. Thompson and Ann Van den Bruel) from the University of Oxford in England have written in the editorial of the same issue that it would be some time before adoption of these measures may be deemed appropriate. They wrote, “Before widespread implementation, we will need to have evidence showing the effect of using such a model on patient management and outcomes.” They also suggested inclusion of other infections like meningitis, osteomyelitis or bone infection and septic arthritis or infection of joints. They wrote, “These are rare but crucial to identify, so excluding them may limit the model's usefulness.”

Lacunae

The original study researchers have mentioned some of the drawbacks of their study like inadequacy of microbiological and/or radiological verification in some children and no concrete estimates of the prevalence of these illnesses in the emergency.