Fever without localizing signs in children: A review in the post-Hib and postpneumococcal era

Fever without localizing signs in young infants and children has been a common problem for pediatric practitioners for decades. Prior to the introduction of vaccines against common childhood invasive pathogens, including Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae, extensive diagnostic workup of febrile infants and children was warranted to avoid missing serious bacterial infections. At that time, occult bacteremia occurred at a rate of 5.7%. Evaluation of febrile children was based on high and low risk criteria established by Dagan et al. and applied further in suggested clinical practice guidelines in 1993. After the introduction of effective Hib and PCV7 vaccines, the rate of serious bacterial infections has dramatically fallen, with occult bacteremia rates now 0-0.74%. Changes in the administration of intrapartum antibiotics to women at risk for transmitting Group B Streptococcus to neonates has significantly reduced the rates of early onset GBS disease in infants. Although the risk of serious infections is extremely low, management and evaluation of febrile children has remained essentially unchanged. This review summarizes the historical context of the management of the febrile child, discusses the developments that have been cause for re-evaluation and provides recommendations for management of the febrile child in this current era.