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Arch Dis Child. 2009 Feb;94(2):144-7. doi: 10.1136/adc.2007.130583. Epub 2008 Jun 6.

Outcomes of febrile children without localising signs after pneumococcal conjugate vaccine.

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  • 1Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina 27710, USA.



Evaluation of children with fever without localising signs (FWLS) has barely changed in the USA since 1993 despite reduced invasive disease after the introduction of Haemophilus influenzae type b conjugate vaccine and conjugate pneumococcal vaccine (PCV7). PCV7 is now recommended in the UK for children under 2 years of age, and new NICE guidelines have been issued for managing feverish children in the UK in anticipation of PCV7's efficacy. We compared rates of bacterial infections in children aged 3-36 months with FWLS in the pre- and post-PCV7 eras to define current trends and evaluate existing guidelines.


We identified all paediatric blood cultures performed in an emergency department before and after PCV7. We subsequently identified all children aged 3-36 months with FWLS and reviewed their medical records.


We identified 148 patients with FWLS in the pre-PCV7 period and 275 patients after PCV7. There were 17 positive cultures before PCV7 (10 pathogens and seven contaminants) and 14 positive cultures (but only one pathogen) after PCV7. This represented a 94.6% decrease overall (p = 0.009) and a 100% decrease in Streptococcus pneumoniae. Rates of urinary tract infections (UTIs) were unchanged (6.8% vs 7.6%); UTIs are now the most prevalent bacterial infection in this group. Over 50% of patients still received empirical antibiotics.


Based on our data, the emphasis in managing children with FWLS should be on diagnosing UTI. Guidelines for evaluating children with FWLS in countries using PCV7 should emulate the NICE model and reflect the trends identified in this study.

[PubMed - indexed for MEDLINE]
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