Management of fever without source in young children presenting to an emergency room

Abstract

The management of fever without source in young children is controversial. To analyse the management approach in our paediatric emergency room, and to correlate it to existing practice guidelines. We indexed 2176 consecutive patients, aged 1 to 36 mo, seen in our emergency department because of fever > or = 38.5 degrees C. Patients with chronic illness, recent antibiotic use, focal bacterial infection or typical viral illness were excluded, and the management approach of the remaining 376 patients was analysed. The most common final diagnosis was acute febrile illness (n=228), whereas bacterial and viral infections were demonstrated in 120 and 28 patients, respectively. Most of the time, our residents correctly ordered complete blood count, chest radiograph and urinalysis in children for whom those investigations are recommended. A blood culture was rarely obtained, even in patients under empirical antibiotherapy. Residents often ordered chest radiograph and urinalysis in low-risk patients, and conflicted with guidelines when considering the prescription of empirical antibiotherapy. Their management allowed the early diagnosis and treatment of two pneumococcal bacteraemias, one meningococcal bacteraemia, seven urinary tract infections and 11 pneumonias, which would have been initially missed by strict adherence to the guidelines. Significant differences exist in the management of the young febrile child between our practice patterns and guidelines, without influence on patient outcome.