Korean J Pediatr Infect Dis.  2012 Dec;19(3):121-130.

Etiology and Clinical Manifestations of Fever in Infants Younger than 3 Months Old: A Single Institution Study, 2008-2010

• Seok JY
• Kang JE
• Cho EY
• Choi EH
• Lee HJ

Abstract

PURPOSE
The purpose of this study is to investigate clinical features and causative organisms in febrile infants younger than three months, to help identification of high risk patients for serious bacterial infection (SBI).
METHODS
A total of 313 febrile infants younger than three months, who had visited Seoul National University Children's Hospital from January 2008 to December 2010 were included. Clinical features, laboratory findings, causative organisms, and risk factors of SBI were analyzed by retrospective chart review. Causative bacterial or viral pathogens were identified by gram stain and cultures, rapid antigen tests, or the polymerase chain reaction from clinically reliable sources.
RESULTS
Among 313 infants, etiologic organisms were identified in 127 cases (40.6%). Among 39 cases of bacterial infections, Escherichia coli (66.7%) and Streptococcus agalactiae (12.8%) were common. Enterovirus (33.7%), respiratory syncytial virus (19.8%), and rhinovirus (18.8%) were frequently detected in 88 cases of viral infection. Patients with SBI (39 cases) showed significantly higher values of the white blood cell count (14,473+/-6,824/mm3 vs. 11,254+/-5,775/mm3, P=0.002) and the C-reactive protein (6.32+/-8.51 mg/L vs. 1.28+/-2.35 mg/L, P<0.001) than those without SBI (274 cases). The clinical risk factors for SBI were the male (OR 3.7, 95% CI 1.5-8.9), the presence of neurologic symptoms (OR 4.8, 95% CI 1.4-16.8), and the absence of family members with respiratory symptoms (OR 3.6, 95% CI 1.2-11.3).
CONCLUSION
This study identified common pathogens and risk factors for SBI in febrile infants younger than three months. These findings may be useful to guide management of febrile young infants.

Keyword

Fever; Infant; Newborn; Bacterial infections; Sepsis

MeSH Terms

Bacterial Infections
C-Reactive Protein
Enterovirus
Escherichia coli
Fever
Humans
Infant
Infant, Newborn
Leukocyte Count
Male
Neurologic Manifestations
Polymerase Chain Reaction
Respiratory Syncytial Viruses
Retrospective Studies
Rhinovirus
Risk Factors
Sepsis
Streptococcus agalactiae
C-Reactive Protein

Figure

• 

  Fig. 1 Algorithm for the management of fever in infants younger than 3 months old

Reference

1. Nelson DS, Walsh K, Fleisher GR. Spectrum and frequency of pediatric illness presenting to a general community hospital emergency department. Pediatrics. 1992. 90:5–10.

2. Baskin MN. The prevalence of serious bacterial infections by age in febrile infants during the first 3 months of life. Pediatr Ann. 1993. 22:462–466.

3. DeAngelis C, Joffe A, Wilson M, Willis E. Iatrogenic risks and financial costs of hospitalizing febrile infants. Am J Dis Child. 1983. 137:1146–1149.

4. Dagan R, Powell KR, Hall CB, Menegus MA. Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. J Pediatr. 1985. 107:855–860.

5. Dagan R, Sofer S, Phillip M, Shachak E. Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections. J Pediatr. 1988. 112:355–360.

6. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med. 1993. 329:1437–1441.

7. Lee JH, Cho HK, Kim KH, Kim CH, Kim DS, Kim KN, et al. Etiology of invasive bacterial infections in immunocompetent children in Korea (1996-2005): a retrospective multicenter study. J Korean Med Sci. 2011. 26:174–183.

8. Levine DA, Platt SL, Dayan PS, Macias CG, Zorc JJ, Krief W, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics. 2004. 113:1728–1734.

9. Gómez B, Mintegi S, Benito J, Egireun A, Garcia D, Astobiza E. Blood culture and bacteremia predictors in infants less than three months of age with fever without source. Pediatr Infect Dis J. 2010. 29:43–47.

10. Bressan S, Andreola B, Cattelan F, Zangardi T, Perilongo G, Da Dalt L. Predicting severe bacterial infections in well-appearing febrile neonates: laboratory markers accuracy and duration of fever. Pediatr Infect Dis J. 2010. 29:227–232.

11. The WHO Young Infants Study Group. Bacterial etiology of serious infections in young infants in developing countries: results of a multicenter study. Pediatr Infect Dis J. 1999. 18:S17–S22.

12. Dagan R, Hall CB, Powell KR, Menegus MA. Epidemiology and laboratory diagnosis of infection with viral and bacterial pathogens in infants hospitalized for suspected sepsis. J Pediatr. 1989. 115:351–356.

13. Shin SH, Choi CW, Lee JA, Kim EK, Choi EH, Kim HS, et al. Risk factors for serious bacterial infection in febrile young infants in a community referral hospital. J Korean Med Sci. 2009. 24:844–848.

14. Nah SY, Hong JY, Choi EH, Lee HJ. Etiology and clinical features of acute viral lower respiratory tract infection in apparently healthy children. Korean J Pediatr. 1996. 39:1690–1699.

15. Kwon JH, Chung YH, Lee NY, Chung EH, Ahn KM, Lee SI. An epidemiological study of acute viral lower respiratory tract infections in hospitalized children from 2002 to 2006 in Seoul, Korea. Pediatr Allergy Respir Dis. 2008. 18:26–36.

16. Byington CL, Enriquez FR, Hoff C, Tuohy R, Taggart EW, Hillyard DR, et al. Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections. Pediatrics. 2004. 113:1662–1666.

17. Titus MO, Wright SW. Prevalence of serious bacterial infections in febrile infants with respiratory syncytial virus infection. Pediatrics. 2003. 112:282–284.

18. Yarden-Bilavsky H, Ashkenazi-Hoffnung L, Livni G, Amir J, Bilavsky E. Month-by-month age analysis of the risk for serious bacterial infections in febrile infants with bronchiolitis. Clin Pediatr (Phila). 2011. 50:1052–1056.

19. Huppler AR, Eickhoff JC, Wald ER. Performance of low-risk criteria in the evaluation of young infants with fever: review of the literature. Pediatrics. 2010. 125:228–233.

20. Baskin MN, O'Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr. 1992. 120:22–27.

21. Baker MD, Bell LM, Avner JR. The efficacy of routine outpatient management without antibiotics of fever in selected infants. Pediatrics. 1999. 103:627–631.

22. Bachur RG, Harper MB. Predictive model for serious bacterial infections among infants younger than 3 months of age. Pediatrics. 2001. 108:311–316.

23. Kourtis AP, Sullivan DT, Sathian U. Practice guidelines for the management of febrile infants less than 90 days of age at the ambulatory network of a large pediatric health care system in the United States: summary of new evidence. Clin Pediatr (Phila). 2004. 43:11–16.

24. Baraff LJ. Management of infants and young children with fever without source. Pediatr Ann. 2008. 37:673–679.

25. Putto A, Ruuskanen O, Meurman O, Ekblad H, Korvenranta H, Mertsola J, et al. C reactive protein in the evaluation of febrile illness. Arch Dis Child. 1986. 61:24–29.

26. Pulliam PN, Attia MW, Cronan KM. C-reactive protein in febrile children 1 to 36 months of age with clinically undetectable serious bacterial infection. Pediatrics. 2001. 108:1275–1279.

27. Baraff LJ, Bass JW, Fleisher GR, Klein JO, McCracken GH, Powell KR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Ann Emerg Med. 1993. 22:1198–1210.

28. Baker MD. Evaluation and management of infants with fever. Pediatr Clin North Am. 1999. 46:1061–1072.

29. Elder JS. Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, editors. Urinary tract infections. Nelson textbook of pediatrics. 2011. 19th ed. Philadelphia, PA: Saunders Elsevier;1829.

30. Libster R, Hortoneda JB, Laham FR, Casellas JM, Israele V, Polack NR, et al. Breastfeeding prevents severe disease in full term female infants with acute respiratory infection. Pediatr Infect Dis J. 2009. 28:131–134.