Pediatric emergency medicine trisk 2261 2261
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Goals of Treatment
The goals of treatment are to recognize which children may be at higher risk for bacteremia than the general
pediatric population (e.g., asplenic children, children with central venous catheters [CVCs], neutropenic children)
and to be cognizant of the most common organisms causing bacteremia seen in a given region. Thus, knowledge of
local antibiotic resistance patterns is critical for the ED physician.
Clinical Considerations
Clinical recognition: Children at highest risk for bacteremia are under 2 years of age. For meningococcus, biphasic
peaks occur: one during infancy and a second during adolescence. Thus, algorithms for fever management focus
heavily upon young children due to higher incidence at this age and because the signs of occult bacteremia are
difficult to discern. In many tertiary care centers, the children at highest risk for bacteremia and sepsis are children
with indwelling CVC, neutropenia, or short gut. These children may have baseline tachycardia from anemia,
making triage recognition more problematic.
Triage considerations: Recognition of abnormal vital signs (e.g., tachycardia, hypothermia) and signs of poor
perfusion are critical for rapid initiation of resuscitation in the ED. Given the variation in normal vital sign ranges
through the pediatric age spectrum, recognition can be facilitated if alerts are built into electronic health records.
Clinical assessment: Several studies have attempted to stratify the risk of bacteremia and other serious bacterial
infections in febrile children. Table 94.2 describes clinical and laboratory predictors of serious bacterial infection
in young children.
Management: Empiric antibiotic management depends upon knowledge of the most common causes of
bacteremia in a community. While there has been a decline in pneumococcal isolates causing occult bacteremia,
there have been increases in the rates of penicillin- and cephalosporin-resistant pneumococcal isolates. As such, if
there is concern for invasive pneumococcal disease, initiating treatment with vancomycin and a third-generation
cephalosporin (cefotaxime or ceftriaxone) would be appropriate. In the event that the isolate is cephalosporin
susceptible, a cephalosporin would be a much more effective bactericidal drug than vancomycin. However, if
resistance to a cephalosporin is present, then the child is receiving a drug to which the isolate retains susceptibility.
This regimen would also provide coverage for the most common other causes of bacteremia and sepsis in
immunocompetent children outside the neonatal period. If staphylococcal disease is suspected, children could
receive nafcillin as well; in the event that they have methicillin-susceptible S. aureus (MSSA), nafcillin is far more
bactericidal than vancomycin. In immunocompromised hosts, the causes of bacteremia are more diverse, and
antipseudomonal coverage should be considered a priori. In addition, these children may also be at higher risk for
antibiotic-resistant organisms from prior antibiotic exposure(s). Reviewing prior culture data to evaluate for a
history of infection with drug-resistant organisms can help optimize ED-based management. Empiric coverage
with vancomycin and an antipseudomonal beta-lactam (e.g., cefepime, ceftazidime, piperacillin/tazobactam) may
be considered.
