Research Applied to Clinical Practice
| Although most acute
infections in children usually respond to appropriate treatment or improve without
intervention, some severe infections can progress to lethal complications, such as
septicemia and septic shock. In infants younger than one year, especially those less than
three months of age, mortality rates approach 50% (Jafari & McCracken, 1992).
Therefore, when a febrile neonate presents to an Emergency Department (ED) or Urgent Care
(UC), a full work-up is indicated and admission to a hospital is the current standard
Signs and Symptoms of sepsis are highly variable and studies have attempted to find "classic signs" but have been inconclusive (Vincent, 1995). Especially in neonates, sepsis may start with minimal or nonspecific symptoms, and approximately one-third of cases are associated with concurrent meningitis, which is clinically indistinguishable from sepsis (Dashefsky, 1991). Sepsis must be considered in any neonate presenting to an Emergency Department or Urgent Care Center with a rectal temperature greater than 38° C or less than 36° C. Therefore, these patients must be triage classified as Emergent.
The incidence of sepsis shows a bimodal distribution, the first peak is in the neonatal period and the second is around the age of two years. The sepsis rate for infants less than 30 days of age ranges from 1 to 8 per 1000 live births (Hazelzet & DeGroot, 1994; Dashefsky, 1991; Gerdes, 1991; Gladstone, Ehrenkranz, & Edberg, 1990). In infants less than two months, the pathogens were group B streptococci, Escherichia coli, enterococci, and Listeria monctogenes (Dashefsky, 1991; S`aez-Llorens & McCracken, 1993). Recent epidemiological studies have shown a decreasing incidence of H. Influenza, coinciding with the use of Hib vaccine.
The following table lists some of the presenting complaints which studies have shown may indicate or are associated with an eventual diagnosis of sepsis (Zimmerman & Dietrich, 1987; Dashefsky, 1991; Gerdes, 1991; Gladstone, Ehrenkranz, & Edberg, 1990; Buck, Bundschu, & Gallati, 1994).
The treatment regime is currently under review in many of the journals, especially in view of the spread of managed care and capitation. In the past, common diagnostic protocols included: CBC and differential, Blood cultures, Catheterized urine, and Lumbar puncture for exam of cells, protein, and glucose. Leading ultimately to admission to the hospital in isolation, and initiating intravenous antibiotic therapy, pending culture results. Some providers are advocating only the CBC, and urinalysis in the ED, to determine causation of fever or infection, and only admit to hospital if causation cannot be found. Many providers are commonly ordering intramuscular or intravenous ceftriaxone as a "catch all" and discharging if causation cannot be found (Young, 1995; Ogborn, Soulen, & DeAngelis, 1995). Naturally, these practices have stirred the ranks of pediatric providers across the country, and brought about very heated debate (Baraff, Schriger, Bass, Fleisher, Klien, McCracken, & Powell, 1997; Schriger, 1997; Kramer, 1997).
Needless to say, interventions in neonates need to be more aggressive that those of older children, as their ability to fight infection is significantly compromised due to their developmental status, this is compounded in the premature neonate. As Sheehy (1992), states "any infant under three months of age with a fever should be evaluated as soon as possible to rule out serious bacterial infection." Henceforth, this expected practice for all care-givers in EDs and UCs.
For further information on current research in the treatment of Fever in patients of all ages see February 1998s Patient Care Connection Clinical Practice Challenge: The chilling truth about fevers. By my colleague Kristine Peterson (Critical Care CNS)
Baraff, L.J., Bass, J.W., Fleisher, G.R., Klein, J.O., McCracken, G.H., &
Powell, K.R. (1997). Commentary on practice guidelines. Pediatrics, 100, (1),
"Research Applied to Clinical Practice: Sepsis in Children"
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