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Pediatric Emergency Care:
Original Articles

Sepsis Workup in Febrile Infants 0–90 Days of Age With Respiratory Syncytial Virus Infection

Oray-Schrom, Pinar MD; Phoenix, Carlene MD; St. Martin, Dacelin MD; Amoateng-Adjepong, Yaw MD, MPH, PhD

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Abstract

Objectives: To ascertain the incidence, determinants, and outcome of sepsis workup in febrile infants aged 0–90 days with respiratory syncytial virus (RSV) infection.

Design: Retrospective chart review.

Results: 191 infants with RSV, 21.5% younger than 28 days, were identified; 101 (52.9%) were febrile and 90 were afebrile. Among the febrile infants, 84.2% had blood cultures, 68.3% had urine cultures, and 58.4% had lumbar punctures. Complete sepsis workup was done in 52.5% of the febrile cohort, including 77.3% of those aged less than 28 days. There were 5 cases of urinary tract infection (UTI) [7.2%, 95% confidence interval (CI) = 2.4–16.1] and 1 case of bacteremia (1.2%, 95% CI = 0.0–6.4) among the tested febrile patients. There was no case (0%, 95% CI = 0.0–6.1) of meningitis. Age, maximum temperature, irritability, apnea, decreased intake, chest x-ray findings, and white blood cell count were not predictive of a positive culture. Only 7.8% of the afebrile patients had complete sepsis workup. Fever [risk ratio (RR) = 5.8, 95% CI = 2.8–12], absence of wheezing (RR = 2.1, 95% CI = 1.3–3.6), and age less than 28 days (RR = 1.6, 95% CI = 1.2–2.2) were independent predictors of complete sepsis workup. Overall, complete sepsis workup was associated with a higher rate of antibiotic use (RR = 10.7, 95% CI = 4.9–23.4), increased hospitalization (RR = 2.1, 95% CI = 1.0–4.7), and prolonged hospital stay (median of 2 days vs. 1 day, P = 0.003) compared with those without complete workup.

Conclusion: Considerable variability exists in the sepsis workup of febrile infants with suspected RSV infection at our site. Concomitant UTIs are common in febrile, RSV-infected infants.

Annual epidemics of respiratory syncytial virus (RSV) infection flood pediatric emergency departments (ED) and hospital wards during the winter and early spring seasons with infants suffering from bronchiolitis and other respiratory illnesses. 1,2 Many of these infants are younger than 90 days. 2 Many are febrile at the time of presentation and tend to defervesce without any specific therapy. Nonetheless, confronted with a febrile young infant, many pediatricians and emergency room physicians perform a battery of diagnostic tests, the so-called sepsis workup, looking for concurrent serious bacterial infections like meningitis, bacteremia, or urinary tract infection (UTI). A typical complete sepsis workup consists of cultures of blood, urine, and cerebrospinal fluid (CSF), white blood cell (WBC) count, urinalysis, and CSF analysis (cell count, protein, glucose, and Gram stain). 3 Some studies include routine chest x-rays in full sepsis workups. Sepsis evaluations have been performed routinely in young febrile infants because of the similarity of the fever patterns between viral disease and bacterial infection, unreliability of predicting serious bacterial infections from clinical symptoms, urinalysis or WBC, and need for prompt antimicrobial therapy in young infants with bacteremia or UTI. 4 Concomitant and secondary bacterial infections in patients with viral diseases are known to occur. 5–17 These bacterial infections tend to be focal, mainly pneumonia or acute otitis media. 11,12,14 Much of the existing data pertain to children 3 months or older. 5–8 Currently, there is no consensus on the necessity of such a workup in the very young infant when there is certainty of viral, specifically RSV, infection. This is a retrospective cohort study ascertaining the incidence, determinants, and outcome of sepsis workup in febrile infants aged 0–90 days infected with RSV. We hypothesized a priori that concomitant bacterial infections are rare in febrile RSV-infected infants and that variability exists in the approach of physicians to suspected, febrile RSV-infected infants.

© 2003 Lippincott Williams & Wilkins, Inc.

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