A5V4d

Feverish illness in children
8.5 Causes and incidence of serious bacterial infection
Antimicrobial therapy has significantly improved the outcome for children with SBI. The appropriate
antibiotic treatment for SBI will often not be determined for 24–36 hours, since it takes this period of
time to grow bacteria and determine their antibiotic sensitivities. However, antibiotic treatment should
not be withheld until the causative organism and its antibiotic sensitivities are confirmed, since the
child may die or suffer harm in the meantime. Empirical antibiotic treatment is therefore given to
children likely to have serious illness. Knowledge of the common organisms causing SBI in children
will help decide which antibiotics should be used as empirical treatment for children likely to have SBI.
Review questions
What are the most common organisms causing serious illness in young children with fever?
What is the incidence of serious illness in young children with fever?
Narrative evidence
A search for UK-based cohort studies after 1992 found four EL 2+ retrospective studies. 121,201–203 The
studies varied in baseline characteristics. For example, one study 121 recruited children aged 8 days to
16 years and another had children of 2 weeks to 4.8 years. 202 Moreover, some studies 201 recruited
based on the presenting features of infectious disease or meningococcal disease 121 while others
recruited children with a diagnosis of pneumonia 202 or bacterial meningitis. 203
Hospital Episode Statistics (HES) was also reviewed as a proxy of incidence of serious illness in
England and Wales. The data suggested that UTI (217.2/100,000), pneumonia (111.9/100,000),
bacteraemia (105.3/100,000) and meningitis (23.8/100,000) were the most likely infections in children
aged 7 days to 5 years admitted to hospital in England and Wales. 204
Moreover, the likely organisms to cause these infections are Neisseria meningitidis, Streptococcus
pneumoniae, Escherichia coli, Staphylococcus aureus and Haemophilus influenzae type b. In children
less than 3 months of age, group B streptococcus and listeria may also cause SBI. 203
Evidence summary
Serious bacterial infection in a child presenting to hospital with fever but without an identified focus is
likely to be bacteraemia, meningitis, UTI or pneumonia. The likely organisms to cause these infections
are Neisseria meningitidis, Streptococcus pneumoniae, Escherichia coli, Staphylococcus aureus and
Haemophilus influenzae type b (rare in immunised children). In children less than 3 months of age,
group B streptococcus and listeria may also cause SBI.
GDG translation
The GDG noted the causes of SBI and the likely organisms at various ages. The GDG believes that
this information could be used to decide which antibiotics could be used when it is decided to treat a
suspected SBI without apparent source and in the absence of the results of microbiological cultures.
A third-generation cephalosporin (e.g. cefotaxime or ceftriaxone) might not be the treatment of choice
for all these organisms but was felt to be adequate initial treatment. This empirical antibiotic treatment
could be altered once culture results became available or the focus of infection became apparent.
Recommendations
Number Recommendation
68 In a child presenting to hospital with a fever and suspected serious bacterial
infection, requiring immediate treatment, antibiotics should be directed against
Neisseria meningitidis, Streptococcus pneumoniae, Escherichia coli,
Staphylococcus aureus and Haemophilus influenzae type b. A third-generation
cephalosporin (for example, cefotaxime or ceftriaxone) is appropriate, until culture
results are available. For infants younger than 3 months, an antibiotic active against
listeria (for example, ampicillin or amoxicillin) should be added. [2007]
69 Refer to local treatment guidelines when rates of bacterial antibiotic resistance are
significant. [2007]
186