Antibiotic Administration to Treat Possible Occult Bacteremia in Febrile Children

We performed a prospective, randomized, placebo-controlled, double-blind clinical trial of antibiotic administration to treat possible occult bacteremia in febrile children. A total of 955 children aged 3 to 36 months with temperatures 3=39.0°C and no focal bacterial infection were enrolled at the emergency departments of two children's hospitals from January 1982 until July 1984. Blood samples for culture were obtained, and the children were randomly assigned to receive either oral amoxicillin or placebo and were restudied approximately 48 hours after enrollment. Data were also collected on 228 children who could not be randomly assigned. Twenty-seven of the randomly assigned children (2.8 percent) had bacteremic infections with pathogenic organisms {Streptococcus pneumoniae, Haemophilus influenzae, and salmonella). There were no differences in the incidence of major infectious morbidity associated with bacteremia between the antibiotic and placebo groups — 2 of 19 patients (10.5 percent) in the antibiotic group and 1 of 8 (12.5 percent) in the placebo group—although the power for this comparison was low. Antibiotics reduced fever (P<0.005) and improved the clinical appearance (P = 0.07) in the children with bacteremia but not in those without bacteremia. Although there were no statistically significant differences in the incidence of side effects, diarrhea tended to occur more often in the patients treated with amoxicillin (15 vs. 11 percent, P<0.10). We conclude that our data do not support the routine use of standard oral doses of amoxicillin in febrile children who do not have evidence of focal bacterial disease. (N Engl J Med 1987; 317:1175–80.) HIGH fever (temperature ≥39.0°C) is one of the most common symptoms prompting medical visits of infants and toddlers. Most febrile children have self-limited viral illnesses, but between 3 and 15 percent have bacteremic infections, predominantly with Streptococcus pneumoniae (65 percent), Haemophilus influenzae (25 percent), Neisseria meningitidis (5 percent), or salmonella species (5 percent).^{1 2 3 4} Although half these patients have a recognizable focal bacterial infection, the conditions of many are indistinguishable from those of their counterparts with viral illnesses.^{5 6 7 8} Clinical and laboratory assessments at the time of the first visit have proved to be only moderately useful in helping to identify children.