Chapter 76 Systemic Bacterial Infection
PATHOPHYSIOLOGY
Infants and toddlers with a systemic bacterial infection often present with few, nonspecific signs of illness. The younger the child, the more difficult it is to recognize a bacterial infection by history. If a systemic bacterial infection is suspected, urgent investigation is performed, which is called a septic workup, and immediate intravenous antibiotic therapy is administered to prevent the illness from becoming life-threatening.
The risk of a systemic bacterial illness is generally believed to be higher in febrile infants under 3 months of age than in older febrile infants. The types of systemic bacterial infections are septicemia, occult bacteremia, and meningitis. Septicemia is the presence of microorganisms in the blood, with a localized or systemic diseaase in an ill-appearing child. Occult bacteremia is a bacteremia with a benign appearance and no other apparent source of serious infection. Factors increasing the risk of bacteremia are young age, premature birth, previous serious illness, chronic illness, ill appearance, fever, elevated white blood cell (WBC) count, and elevated absolute neutrophil count. Meningitis is an acute inflammation of the meninges and cerebrospinal fluid from a bacterial pathogen.
The most common serious bacterial infections in children older than 3 months of age are meningitis, bacteremia, urinary tract infection, pneumonia, soft-tissue infections, and enteric infections. The occurrence of a child having an acute episode of fever with a systemic illness is greater in children older than 3 months of age. Conversely, owing to an infant’s immature immune system, infants younger than 1 month of age rarely become febrile, and more often hypothermia is seen with systemic bacterial infections. However, most febrile young children have self-limited viral infections.
INCIDENCE
1. In febrile infants under 3 months of age with a rectal temperature of 100.4° F (38.0° C) or higher, the prevalence of serious bacterial illness is approximately 8% to 10%.
2. The risk of occult bacteremia in children 3 to 36 months of age with fever but without localizing signs is approximately 2% to 10%.
3. Group B Streptococcus (GBS) now accounts for most bacterial infections in infants younger than 3 months of age.
4. Streptococcus pneumoniae is the most prevalent bacterial infection in healthy children older than 3 months of age.
5. Fever in children from 3 to 36 months of age is seen more often between November and March.
6. Approximately 10% of children with bacteremia will develop a systemic bacterial infection.
7. Hearing impairment is the most common sequela from meningitis.
CLINICAL MANIFESTATIONS
LABORATORY AND DIAGNOSTIC TESTS
Refer to Appendix D for normal values and ranges of laboratory and diagnostic tests.
1. Complete blood count with differential—to evaluate any evidence of infection
2. Erythrocyte sedimentation rate, C-reactive protein level—to assess for an inflammatory process
3. Blood culture—to detect and identify bacterial pathogens
4. Urinalysis and urine culture of specimen obtained by catheterization or suprapubic tap; 20% of children with urinary tract infection (UTI) have normal urinalysis but can have subsequent positive culture results
5. Lumbar puncture, cerebrospinal fluid detects bacterial and viral pathogens
6. Stool smear for WBCs and culture if gastroenteritis is suspected—to detect enteral pathogens
7. Chest radiographic studies—to detect lung abnormalities such as pneumonia
MEDICAL MANAGEMENT
The goals of therapy are to treat the underlying process causing the infection and reduce the incidence of negative sequelae. Bacterial infections should be treated with appropriate antimicrobial therapy. Febrile infants younger than 1 month of age who appear toxic should receive intravenous (IV) antimicrobials in the hospital with 48 to 72 hours of observation. Infants from 30 to 60 days of age who appear ill and/or have abnormal laboratory studies should be admitted to a hospital for IV antimicrobials and observed for 48 to 72 hours. There continues to be debate on treatment approaches for infants older than 3 months of age. Well-appearing infants older than 3 months of age without abnormal laboratory values may be followed at home or hospitalized for 48 to 72 hours of observation. If infants are followed at home, careful observation by the caregivers and assurance of follow-up with the health care provider is required.
NURSING ASSESSMENT
NURSING INTERVENTIONS
1. Monitor child’s vital signs and neurologic status (including palpation of anterior fontanelle) as often as condition warrants.
2. Observe for rashes, petechiae, purpura, and/or vesicles.
3. Administer intravenous antibiotics; monitor for side effects.
4. Institute isolation procedures; simple isolation may be acceptable if cerebrospinal fluid (CSF) gram stain is without organisms (check hospital policy).
5. Monitor child’s hydration status (IV and oral intake, urine output, skin turgor, edema, daily weights).
6. Monitor for cardiovascular compromise (skin color, skin temperature, capillary refill, level of consciousness).
7. Sponge with tepid water and unbundle child to reduce fever.
9. Continue the infant or child on a regular diet, if tolerated.
10. Monitor for fluid overload from additional IV fluid volume while administering IV antimicrobials.
11. Provide emotional support to child during lumbar puncture and other tests; restrain child to prevent injury (refer to Appendix F).
12. Provide emotional support to family; provide and reinforce information about condition and hospitalization (refer to Appendix F).
Discharge Planning and Home Care
1. Instruct parents verbally and with written reinforcement about administration of medications and monitoring for side effects.
2. Instruct parents to follow up with health care provider, as instructed.
3. Provide with home health referral if child is going home with IV antimicrobials.
4. Instruct parents on good handwashing practices for children with viral infections and/or enteropathies.
5. Instruct parents to maintain adequate fluid and nutritional intake and observe for signs of dehydration.
6. Repeat hearing screen for those infants and children with meningitis.
CLIENT OUTCOMES
1. Child will be free from complications of infection.
2. Child will remain normothermic.
3. Child will have consistent weight gain.
4. Child will remain hemodynamically stable.
5. Family will use effective coping mechanisms in managing anxiety.
6. Family will understand home care and follow-up care.
7. Child will adapt positively and resume age-appropriate activities.
Byington CL, et al. Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infection. Pediatrics. 2004;113(6):1662.
Hannah FS, Macias CG. Evaluation and management of fever in the neonate and young infant (less than three months of age), 2006. (website): www.utdol.com/utd/content/topic.do?topicKey=ped_emer/2114&view=print Accessed February 23
Jaskiewicz JA. Febrile infants at low risk for serious bacterial infection: An appraisal of the Rochester criteria and implications for management. Pediatrics. 1994;94(3):390.
Lee GM, Harper MB. Risk of bacteremia for febrile young children in the post-haemophilus influenzae type b era. Arch Adolesc Med. 1998;152(7):624.
McCarthy PL. Fever. Pediatr Rev. 1998;19(12):401.
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