ro13-9904 and Fever-of-Unknown-Origin

This is a case of a 5-month-old female infant diagnosed with primary meningococcal pericarditis. Pericarditis is a well-recognized but uncommon complication of meningococcal infection. Primary meningococcal pericarditis, defined as purulent pericarditis without any clinical evidence of disseminated meningococcemia, meningitis, or other foci of meningococcal infection, is exceedingly rare, with only 21 reported cases since the first case was reported in 1939. This case report of primary meningococcal pericarditis is the youngest case and only the second case reported in an infant in the English literature to date.

Topics: Anti-Bacterial Agents; Bacteremia; Cardiac Tamponade; Ceftriaxone; Female; Fever of Unknown Origin; Humans; Infant; Leukocyte Count; Meningococcal Infections; Pericardial Effusion; Pericarditis; Tachycardia, Sinus

Fever of unknown origin (FUO) is a rare but important disease. The definition of FUO has not changed in the last 50 years. Classical FUO is defined by an illness of at least 3 weeks duration with fever greater than 38 masculine C, and no established diagnosis after 1 week of hospital investigation. The causes of FUO can be divided in four categories: infectious diseases, noninfectious inflammatory diseases, neoplasms, and others (miscellaneous). Recent studies have surprisingly shown that despite improved diagnostic procedures the percentage of patients with FUO, in which no diagnosis after intensive investigations in specialized centres can be found, has increased. However, finding the correct diagnosis in FUO is essential for these patients for psychological and vital reasons. Therefore and because of economic reasons patients with FUO should be investigated in specialized centres with a department for rheumatology and infectious diseases.

Topics: Aged; Anti-Bacterial Agents; Bacterial Infections; Ceftriaxone; Diagnosis, Differential; Fever of Unknown Origin; Glucocorticoids; Humans; Male; Medical History Taking; Middle Aged; Mucocutaneous Lymph Node Syndrome; Mycoses; Parasitic Diseases; Q Fever; Sprue, Tropical; Time Factors; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination; Virus Diseases; Whipple Disease

The diagnostic approach to the young febrile infant is a common dilemma for anyone caring for children. While historically these patients have been considered for automatic admission to the hospital, it seems prudent, because of the iatrogenic risks of hospitalization and in the interest of cost management, to identify those infants who can be safely, and effectively treated as outpatients. A clinical and laboratory process has been described to assist the clinician in this process. A thorough clinical examination accompanied by screening laboratory data will result in excellent results even in the youngest of our patients.

Topics: Ambulatory Care; Analgesics, Non-Narcotic; Bacterial Infections; Ceftriaxone; Fever of Unknown Origin; Hospitalization; Humans; Infant; Infant, Newborn; Physical Examination; Risk Factors; Severity of Illness Index

In this open label prospective multicenter trial, 420 patients with neutropenia < 1000/microliter, fever > 38.5 degrees C and hematological malignancies were treated with ceftriaxone. Acute leukemia (n = 238) and high-grade lymphoma patients (n = 182) from 35 centers were enrolled. Between February 1992 and January 1996, patients were treated with 2 g ceftriaxone i.v. per day either as monotherapy (n = 135), or in combination with aminoglycosides (n = 235), glycopeptides (n = 37), or other antimicrobial agents (n = 13). Patients' median age was 54 years (range 15 to 97) with a median Karnofsky-performance-score of 6.0. The median neutrophil counts were 400/microliter. Fever was of unknown origin (FUO) in 268 (63.8%) of patients. Clinically defined infections (CDI) were diagnosed in 152 (36.2%) cases, including 74 (17.8%) episodes with pneumonia. Response to the initial approach with ceftriaxone was observed in 56.2% of febrile episodes, including 93 (68.8%) treatment courses with ceftriaxone alone. Concerning defervescence of fever ceftriaxone monotherapy was successful as compared to ceftriaxone in combination. Analysis revealed a low risk characterized by higher neutrophil counts (> or = 500/microliter; p < 0.0001), better Karnofsky-performance-score (> or = 7; p = 0.01), duration of neutropenia (< or = 5 days; p = 0.008) from start of antimicrobial treatment and duration of neutropenia per cycle (< or = 10 days; p = 0.0016). At the end of the observation, an overall response was obtained in 88.3% of the patients (n = 371) without statistical difference between patients treated with ceftriaxone alone or in combination. Once daily ceftriaxone either alone or in combination was effective in patients with hematological malignancies. Monotherapy was effective in a low risk group characterized by neutrophil counts (> or = 500/microliter), a Karnofsky-performance-score (> or = 7) and a duration of neutropenia (< or = 5 days) at the commencement of treatment.

Topics: Acute Disease; Adolescent; Adult; Aged; Aged, 80 and over; Ceftriaxone; Drug Administration Schedule; Drug Therapy, Combination; Female; Fever of Unknown Origin; Hematologic Neoplasms; Humans; Infusions, Intravenous; Leukemia; Lymphoma, Non-Hodgkin; Male; Middle Aged; Neutropenia; Opportunistic Infections; Prospective Studies; Treatment Outcome

The optimal management of fever in granulocytopenic cancer patients remains controversial. Antibiotic monotherapy is increasingly an option for the initial empiric treatment of febrile granulocytopenic patients with solid tumors. Available data show that response to empiric therapy is often more related to disease classification (solid tumors vs. acute leukemia) than to the regimen used. In this study we based empiric monotherapy on the underlying disease (solid tumors) in treating 33 episodes of fever in 26 granulocytopenic children with cancer. We investigated the potential effectiveness of single daily doses of ceftriaxone administered empirically in febrile granulocytopenic children with solid tumors. Fever was treated successfully with ceftriaxone monotherapy in 91% (30/33) of febrile episodes. None of the patients died as a result of primary infection. These results suggest that empirical monotherapy with once-daily ceftriaxone is safe and effective. In addition, when compared with other extended-spectrum cephalosporins such as ceftazidime, once-daily administration of ceftriaxone reduces cost and patient inconvenience, allowing convenient parenteral therapy even on an outpatient basis.

Topics: Adolescent; Agranulocytosis; Ceftriaxone; Cephalosporins; Child; Child, Preschool; Female; Fever of Unknown Origin; Humans; Infant; Male; Neoplasms; Prospective Studies; Risk Factors

Hematologic malignancies and cancer patients who become neutropenic as a result of disease or myelosuppressive cytotoxic therapy are at a high risk of developing life-threatening infections, and hence empirical antibiotic therapy is administered promptly. We investigated once daily regimen of amikacin, for dose-dependent bactericidal activity and post-antibiotic effects, plus ceftriaxone, with a long-half life to maximise time-dependent bactericidal activity. Microbiologically proven septicemia were 11 out of 49 febrile episodes (22.5%) and 10 (91%) of these were due to gram-negative bacilli, mostly Enterobacteriaceae. The overall success of the regimen was 63.3 per cent of patients, with no significant toxicity. In conclusion, our findings suggest that once-daily administration of amikacin plus ceftriaxone in the initial treatment of febrile episodes in neutropenic patients produces satisfactory results and more cost-effective compared with other antibiotic regimens requiring 3-4 doses a day.

Topics: Adolescent; Adult; Aged; Amikacin; Ceftriaxone; Drug Therapy, Combination; Female; Fever of Unknown Origin; Humans; Male; Middle Aged; Neutropenia; Sepsis

Topics: Adult; Anti-Bacterial Agents; Aortitis; Ceftriaxone; Fever of Unknown Origin; Gonorrhea; Humans; Male; Neisseria gonorrhoeae; Positron Emission Tomography Computed Tomography

Isolated pulmonary valve endocarditis (PVE) is a rare condition. Known risk factors in previous case reports were intravenous drug abuse and congenital heart disease. Epidemiology of PVE has been changing. It is now being reported specially following invasive healthcare-related procedures even in patients with structurally normal heart. Vast majority of patients present with respiratory symptoms and diagnosis of endocarditis may be challenging unless there is high index of suspicion. Various microorganisms had been isolated as aetiological agents; however,

Topics: Anti-Bacterial Agents; C-Reactive Protein; Ceftriaxone; Chest Pain; Echocardiography; Endocarditis, Bacterial; Enterococcus faecalis; Fever of Unknown Origin; Gram-Positive Bacterial Infections; Humans; Male; Middle Aged; Pulmonary Valve

A 17-year-old male presented with diarrhoea and malaise following his return from Kenya and Tunisia. He was managed as a case of traveller's diarrhoea. Stool cultures were negative for pathogenic bacterial growth. Two weeks later he presented with worsening lower back pain. MRI of lumbosacral spine suggested L1 osteomyelitis. CT-guided spinal aspirate grew no organisms and repeat viral serology and blood cultures (including tuberculosis screening) were negative. He was treated with a 6-week course of ceftriaxone. Back pain did not improve and a repeat MRI scan 8 weeks after his antibiotic course indicated progressive changes in L1 extending to L2 with an intradiscal abscess. Repeat CT-guided spinal aspirate grew Salmonella arizonae sensitive to cotrimoxazole and ceftriaxone. He was treated with intravenous ceftriaxone and cotrimoxazole for 12 weeks. A 4-month follow-up MRI scan showed progressive improvement of the L1/L2 discitis with resolution of intradiscal fluid.

Topics: Adolescent; Anti-Bacterial Agents; Ceftriaxone; Diarrhea; Epidural Abscess; Fever of Unknown Origin; Humans; Kenya; Low Back Pain; Lumbar Vertebrae; Magnetic Resonance Imaging; Male; Salmonella Infections; Travel; Treatment Outcome; Tunisia

Mercury intoxication may present in a wide range of clinical forms from a simple disease to fatal poisoning. This article presents a case of acute mercury poisoning, a rare condition that presents challenges for diagnosis with fever of unknown origin.. A 52-year-old Caucasian woman was admitted to the hospital with high fever, sore throat, a rash over her entire body, itching, nausea, and extensive muscle pain. She had cervical, bilateral axillary and mediastinal lymphadenopathies. We learned that her son and husband had similar symptoms. After excluding infectious pathologies, autoimmune diseases and malignancy were investigated. Multiple organs of our patient were involved and her fever persisted at the fourth week of admission. A repeat medical history elicited that her son had brought mercury home from school and put it on the hot stove, and the family had been exposed to the fumes for a long period of time. Our patient's serum and urine mercury levels were high. She was diagnosed with mercury poisoning and treated accordingly.. Mercury vapor is a colourless and odorless substance. Therefore, patients with various unexplained symptoms and clinical conditions should be questioned about possible exposure to mercury.

Topics: Acute Disease; Anti-Bacterial Agents; Bronchodilator Agents; Ceftriaxone; Chelation Therapy; Clarithromycin; Diagnosis, Differential; Doxycycline; Exanthema; Female; Fever; Fever of Unknown Origin; Humans; Mercury; Mercury Poisoning; Middle Aged; Penicillamine; Treatment Outcome

The prevalence of nalidixic acid-resistant Salmonella Typhi (NARST) infection is increasing worldwide. We are reporting an unusual case of infected haematocolpos presenting as urinary obstruction in a patient with fever of unknown origin (FUO). This case report highlights the importance of quinolone-resistant typhoid fever in the differential diagnosis of any acute febrile illness in countries, like India, where Salmonella infection is endemic.

Topics: Anti-Bacterial Agents; Anti-Infective Agents; Ceftriaxone; Child; Ciprofloxacin; Diagnosis, Differential; Drug Resistance, Bacterial; Female; Fever of Unknown Origin; Hematocolpos; Humans; Metronidazole; Nalidixic Acid; Salmonella typhi

Five years ago a 52-year-old patient presented with arthritis of the small and large joints. Further symptoms were relapsing fever, unspecific gastrointestinal complaints with meteorism but no diarrhea, fatigue and impaired concentration. Subsequently increasing lower back pain developed. A lumbar-disc lesion was already known.. Inflammatory markers were elevated including leucocytosis. Gastroscopy with intestinal biopsies and colonoscopy remained without pathologic findings. Whipple's disease was excluded, but unspecific lymphozyte infiltration of the duodenal mucosa was described. Magnetic resconance imaging of the lumbar spine showed spondylodiscitis in L3/4 which was punctured, and polymerase chain reaction revealed Tropheryma whipplei DNA. Retrospectively, this was also found in the intestinal biopsies of three years ago.. After initial exclusion of Whipple's disease an unspecific systemic inflammatory disease had been presumed, and the patient had been treated with immunomodulatory therapies in alternating combinations. Steroids improved the symptoms but an increasing dosage of steroids was required. After the detection of Tropheryma whipplei and diagnosis of Whipple's disease the patient received ceftriaxon for a period of two weeks, subsequently cotrimoxazol for one year. Inflammatory activity decreased but unspecific symptoms remained almost unaffected.. The differential diagnosis in patients with fever, elevated inflammatory markers and gastrointestinal symptoms must include Whipple's disease. A Tropheryma whipplei PCR from duodenal biopsies should be performed because of its higher sensitivity compared to histology alone.

Topics: Anti-Bacterial Agents; Biopsy, Needle; Ceftriaxone; Diagnosis, Differential; Discitis; DNA, Bacterial; Duodenum; Fever of Unknown Origin; Humans; Intestinal Mucosa; Lumbar Vertebrae; Magnetic Resonance Imaging; Male; Middle Aged; Polymerase Chain Reaction; Rheumatic Diseases; Tomography, X-Ray Computed; Tropheryma; Whipple Disease

We report the case of a 39-year old patient with septicemia treated for pharyngitis with antibiotics since a few days. She wasn't able to swallow her antibiotics anymore because of dysphagia. Radiologic examination revealed pulmonary infiltrates and Vena iugularis interna-thrombosis. These findings and anamnesis led to the diagnosis of Lemierre syndrome inspite of lacking detection of bacteria. After changing the antibiotic therapy and start of anticoagulation further course of illness was favorable. The long duration of hospitalization was indepted to high morbidity typically seen in Lemierre syndrome.

Topics: Adult; Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Anticoagulants; Ceftriaxone; Clindamycin; Deglutition Disorders; Diagnosis, Differential; Drug Therapy, Combination; Female; Fever of Unknown Origin; Fusobacterium Infections; Fusobacterium necrophorum; Humans; Jugular Veins; Pneumonia, Bacterial; Sepsis; Syndrome; Thrombosis; Tomography, X-Ray Computed; Tonsillitis; Ultrasonography

Topics: Amoxicillin; Anti-Bacterial Agents; Arthritis, Rheumatoid; Ceftriaxone; Drug Combinations; Female; Fever of Unknown Origin; Glucosamine; Humans; Meningitis, Aseptic; Middle Aged; Sulfasalazine; Treatment Outcome; Withholding Treatment

A 40-year-old teacher fell ill one week after returning from a two weeks back-packing trip to Thailand and Laos. He developed high fever, severe headache, myalgias and a conjunctivitis.. CRP and liver enzymes were elevated. The patient developed acute renal failure. Total leucocyte count was normal but the differential count showed an extreme left shift. Imaging procedures revealed hepato-splenomegaly and enlarged kidneys. TREATMENT, COURSE AND DIAGNOSIS: The patient was treated with moxifloxacin and ceftriaxon based on the initial suspicion of a severe infection potentially due to leptospirosis. This treatment led to a rapid improvement of the patient's condition and also of the laboratory findings. Leptospirosis could be confirmed by the seroconversion of specific antibodies to L. grippotyphosa 2 1/2 weeks after onset of complaints (initial serology negative).. In febrile travelers returning from Southeast Asia, leptospirosis has to be considered especially in case of severe headache, myalgias, elevated liver enzymes and renal failure and a history of close contact to potentially contaminated water (rivers, lakes). Diagnosis is confirmed by the detection of specific antibodies.

Topics: Acute Kidney Injury; Adult; Anti-Bacterial Agents; Anti-Infective Agents; Asia, Southeastern; Aza Compounds; Ceftriaxone; Fever of Unknown Origin; Fluoroquinolones; Humans; Leptospirosis; Male; Moxifloxacin; Quinolines; Travel; Treatment Outcome

A case of pyrexia from abroad presenting to the emergency department is discussed. The causes of such pyrexia are outlined and the investigations are described. We stress that vaccination is not foolproof from acquiring an infection from abroad.

Topics: Adult; Anorexia; Anti-Bacterial Agents; Bradycardia; Ceftriaxone; Communicable Disease Control; Contact Tracing; Disease Notification; Emergency Treatment; England; Female; Fever of Unknown Origin; Humans; Incidence; Microbial Sensitivity Tests; Pakistan; Paratyphoid Fever; Risk Factors; Salmonella paratyphi A; Travel; Vaccination; Vomiting

A 69-year-old man was admitted to our hospital with severe headache, recurrent episodes of fever and deterioration of general health. He returned from a vacation in Tuscany (Italy) a few days before admission. Physical examination revealed slight nuchal rigidity and an elevated body temperature of 37.8 C but was otherwise unremarkable.. Differential blood count showed a lymphocytopenia. Other abnormal laboratory findings included an elevated blood sedimentation rate and a slightly increased C-reactive protein value. Abdominal sonography demonstrated a marginally enlarged spleen.. A lumbar puncture was performed. Cerebrospinal fluid analysis revealed a lymphocytic meningitis. Serological examination of a blood sample showed specific IgM-antibodies against sandfly fever Naples virus (SFNV), subtype Toscana virus (TOSV). After this diagnosis had been made initially instituted intravenous administration of antibiotics and antiviral medication were discontinued. The patient's symptoms improved rapidly under symptomatic treatment. Slight headaches without episodes of fever persisted for a few weeks without residual neurological symptoms.. A history of travel should always be sought in patients with clinical signs for meningitis. Considering the increasing spread and incidence of SFNV and its subtype Toscana in mediterranean countries, such virus should be kept in mind when treating patients who present such symptoms after returning from those countries during the summer season.

Topics: Acyclovir; Aged; Antiviral Agents; Ceftriaxone; Diagnosis, Differential; Drug Therapy, Combination; Fever of Unknown Origin; Germany; Humans; Male; Meningitis, Viral; Phlebotomus Fever; Sandfly fever Naples virus; Travel

A 65-year-old previously healthy man was referred because of high fever, progressive dyspnea and retrosternal pain for 2 days. On admission, the patient was already in a reduced general condition, blood pressure was 120/70 mmHg, heart rate irregular at 75/min and temperature at 39.7 degrees C. Auscultation of the heart revealed distant heart sounds, murmurs were not present, but mild rales were heard over both lung bases. Jugular veins were congested.. ECG showed a generalized ST-segment elevation with preserved R-waves, slightly depressed PR-segment and atrial bigemini. Chest X-ray revealed an enlarged cardiac silhouette with signs of a pneumopericardium. Transthoracic echocardiography showed a circular pericardial effusion and haemodynamic impairment. Percutaneous pericardiocentesis revealed a purulent effusion with microbiological proof of pneumococci. The primary infectious focus was a maxillary sinusitis caused by pneumococci.. Bacterial pericarditis due to by haematogenous spread of pneumococci.. Antibiotic therapy consisted of intravenous ceftriaxon and gentamicin. To rinse the pericardial space and drain the thick, purulent effusion subxiphoidal, pericardiocentesis and insertion of a drainage tube were done. Physiological saline was put into the pericardial space several times a day, drained and analysed microbiologically. In the meantime rinsing of the infected maxillary sinus was performed. Transthoracic echocardiography was done repeatedly to rule out complications of bacterial pericarditis, especially constrictive pericarditis. The pericardial tube was removed after proof of a sterile drainage 9 days after insertion. The patient was discharged after 4 weeks of hospitalization without clinical or echocardiographic signs of diastolic dysfunction.. Suspected bacterial pericarditis must be treated as an emergency and confirmed or ruled out by percutaneous pericardiocentesis.

Topics: Aged; Ceftriaxone; Diagnosis, Differential; Diagnostic Imaging; Dyspnea; Fever of Unknown Origin; Follow-Up Studies; Gentamicins; Humans; Male; Maxillary Sinusitis; Microbial Sensitivity Tests; Pericarditis; Pneumococcal Infections; Suction; Therapeutic Irrigation

A 55 year old female was admitted as a case of pyrexia of unknown origin (PUO) of 2 months duration. She had developed throat ache, progressive dysphagia for both solids and liquids, dry cough and retrosternal pain for one week. Examination revealed fever, tachycardia, tachypnoea and a soft tissue warm tender, erythematous, non-fluctuant swelling in lower anterior neck with chest findings suggestive of bilateral pleural effusion. Plain X-rays of the neck and chest strengthened the clinical suspicion of cellulitis of lower neck with bilateral pleural effusion. CT scan confirmed the radiologic findings and also revealed pericardial effusion and thickening; small mediastinal lymphadenopathy and mediastinitis. Patient responded to parenteral antibiotics (ceftriaxone and metronidazole) and hydrocortisone with complete resolution in 10 days.

Topics: Anti-Bacterial Agents; Anti-Infective Agents; Ceftriaxone; Female; Fever of Unknown Origin; Humans; India; Mediastinitis; Metronidazole; Middle Aged; Tomography, X-Ray Computed

Administration of broad-spectrum antibiotics as empiric therapy to febrile granulocytopenic patients has become a widely accepted practice. In order to evaluate the cost-effectiveness of ceftriaxone plus amikacin in single daily doses as empiric treatment for febrile granulocytopenic children with cancer, a retrospective review (January-December 1996) of all febrile episodes at our institution was carried out. Overall, 101 febrile episodes in 89 granulocytopenic children with cancer were empirically treated with a once-daily ceftriaxone plus amikacin combination. 59/101 (59%) patients had absolute granulocyte count lower than 100/mm3 at entry; 46 (45%) were affected by solid tumors, 16 (15%) by Hodgkin's disease or lymphoma, and 30 (30%) patients underwent bone marrow transplantation. The ceftriaxone plus amikacin combination was effective in 72/101 (72%) patients with a median time to defervescence of 3 days (range, 1-4). We also evaluated the economic advantages of the ceftriaxone plus amikacin once-daily regimen when compared with another treatment regimen such as ceftazidime plus amikacin requiring three daily doses. Compared with the multiple daily dose regimen of ceftazidime plus amikacin, there is a cost saving of US $11 (17,500 Italian liras) and US $66 (105,000 Italian liras) for both 1-day and 6-day treatments, respectively, by using the single daily dose regimen of ceftriaxone plus amikacin. The potential of ceftriaxone to lower costs in hospitalized patients depends upon its comparable efficacy with other extended-spectrum beta-lactams, in which case it can reduce overall treatment costs because of its once-daily administration schedule.

Topics: Adolescent; Agranulocytosis; Amikacin; Anti-Bacterial Agents; Ceftriaxone; Cephalosporins; Child; Child, Preschool; Cost Control; Drug Administration Schedule; Drug Therapy, Combination; Female; Fever of Unknown Origin; Humans; Infant; Male; Neoplasms; Retrospective Studies; Treatment Outcome

Topics: Adolescent; Adult; Ambulatory Care; Antineoplastic Combined Chemotherapy Protocols; Ceftriaxone; Child; Child, Preschool; Drug Therapy, Combination; Fever of Unknown Origin; Humans; Infant; Neoplasms; Neutropenia; Teicoplanin

Febrile neutropenic children with cancer were eligible for outpatient management with intravenous ceftriaxone therapy if they displayed selected low-risk criteria. Nineteen children were enrolled. All patients had sterile blood cultures, and only one of them was hospitalized because of persistent fever. This pilot study suggests that selected children with febrile neutropenia might be successfully managed without hospitalization.

Topics: Adolescent; Ambulatory Care; Antineoplastic Combined Chemotherapy Protocols; Bacteremia; Ceftriaxone; Cephalosporins; Child; Child, Preschool; Female; Fever of Unknown Origin; Humans; Infant; Infusions, Intravenous; Leukocyte Count; Male; Neoplasms; Neutropenia; Neutrophils; Platelet Count; Treatment Outcome

A study of 534 febrile infants ages 4 to 8 weeks evaluated for sepsis assessed the efficacy of the Milwaukee Protocol (MP) for selecting patients at low risk for serious bacterial infection (SBI) who might benefit from outpatient management. Two groups were compared: 1) Infants with uncompromised presentation (UP) who met all MP criteria received ceftriaxone 50 mg/kg and were discharged, then reevaluated within 24 hours. 2) Infants with compromised presentation (CP) who did not meet MP criteria were hospitalized for antibiotic therapy pending culture results. Of 391 CP patients, 23 (5.9%) had SBI; of 143 UP patients, 1 (0.7%) had SBI (P < .02). The MP criteria had a sensitivity of 96% and a 99% negative predictive value for distinguishing SBI outcome. The only UP patient with SBI was afebrile and had a negative repeat blood culture after 24 hours, and recovered with no complications. Managing UP infants as outpatients avoided 48 to 72 hours of hospitalization, decreasing health-care costs by an estimated total of $465,170.

Topics: Bacterial Infections; Ceftriaxone; Clinical Protocols; Emergency Service, Hospital; Evaluation Studies as Topic; Fever of Unknown Origin; Humans; Infant; Infant, Newborn; Outpatients; Prospective Studies; Risk Factors; Wisconsin

Topics: Anti-Bacterial Agents; Ceftriaxone; Fever of Unknown Origin; Humans; Infant; Infusions, Intravenous; Injections, Intramuscular; Meningitis, Bacterial

Young infants with fever are at risk for serious bacterial infection, but no consensus exists on the optimal approach to diagnosis and treatment. Although the traditional recommendation is always to perform all sepsis tests, including lumbar puncture, and administer intravenous (IV) antibiotics until culture results are negative, recent studies suggest administering intramuscular (IM) ceftriaxone with outpatient follow-up or using laboratory and clinical data to exclude low-risk patients from hospitalization, further testing, and antibiotic treatment. A decision analysis model was used to evaluate six strategies for the diagnosis and treatment of infants aged 28 to 90 days with temperature greater than or equal to 38.0 degrees C. Data from the literature, data from a 1991 study of 503 febrile infants, and direct, short-term costs from the Children's Hospital of Philadelphia were used as model inputs. The model was run for a hypothetical cohort of 100,000 febrile infants who did not require admission for focal infection or for other reasons that clearly necessitated admission. The model included six strategies: (1) no intervention; (2) all sepsis tests (lumbar puncture, blood culture, urine culture, white blood cell count, and urinalysis) followed by hospitalization and IV antibiotics for all infants; (3) all sepsis tests followed by IM ceftriaxone and outpatient management for most infants; (4) blood and urine cultures with white blood cell count and urinalysis followed by either lumbar puncture and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants; (5) white blood cell count and urinalysis followed by either lumbar puncture, blood and urine cultures, and IV antibiotics for high-risk infants or outpatient management without antibiotics for low risk infants; and (6) clinical judgment followed by either all sepsis tests and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants. The two "all sepsis tests" strategies prevented the most cases of death or neurologic impairment, 78% (when IV antibiotics were used) and 76% (when IM ceftriaxone was used) of all potential cases. The most cost-effective strategy was to use all sepsis tests followed by IM ceftriaxone for all patients without meningitis, at an incremental cost of only $3900 per sequela prevented relative to no intervention. Strategies under which only those patients selected as high-risk by laboratory

Topics: Ambulatory Care; Bacterial Infections; Ceftriaxone; Cost-Benefit Analysis; Decision Trees; Fever of Unknown Origin; Hospitalization; Humans; Infant; Infant, Newborn; Leukocyte Count; Models, Statistical; Sensitivity and Specificity; Treatment Outcome; Urinalysis