Reevaluation of outpatients with Streptococcus pneumoniae bacteremia

Background. The reevaluation process for outpatients recalled for Streptoco ccus pneumoniae bacteremia has not been standardized. Children who return i ll or with new serious focal infections require admission and parenteral an tibiotic therapy. Limited data exist to guide the follow-up management of t hose patients identified as having occult pneumococcal bacteremia. Objectives. Characterize the outcomes of outpatients with pneumococcal bact eremia based on their evaluation at follow-up. For patients who are well-ap pearing without serious focal infection, propose a management scheme for re evaluation. Methods. Retrospective review of outpatients with pneumococcal bacteremia. Patients with immunocompromise, those identified with focal bacterial infec tion at the initial visit, or those admitted at the initial visit were excl uded. Data were collected from the initial visit (when blood culture drawn) and follow-up visit with regard to clinical parameters, laboratory data, d iagnoses, and any antibiotic treatment. Decision tree analysis was used to generate a model to predict children at high risk for persistent bacteremia (PB). Results. A total of 548 episodes of pneumococcal bacteremia were studied. S eventy-three children received no antibiotic, 239 oral antibiotic, and 236 parenteral antibiotic at the initial visit. Median age, temperature, and wh ite blood cell (WBC) count were 13.5 months, 40.0 degrees C, and 20 400/mm( 3). Forty-one patients had PB or new focal infections (15 with PB alone, 4 had focal infection and PB). Eight patients had meningitis at follow-up. Ni nety-two percent returned because of notification of the positive blood cul ture result. A repeat blood culture was obtained in 92%, 23% had a lumbar p uncture, 33% had a chest radiograph, and 12% were admitted. PB was associat ed with the antibiotic treatment group, elevation of temperature, and WBC c ount at follow-up. A simple management scheme using 2 sequential decision n odes of antibiotic treatment (none vs any) and then temperature at follow-u p (>38.8 degrees C) would have predicted 16/19 patients with PB (sensitivit y = .84 and specificity = .86). Conclusions. All patients with pneumococcal bacteremia need prompt reevalua tion. For well-appearing patients without new focal infection, the utility of diagnostic testing (specifically repeat blood cultures) and the need for admission may be determined by the use of antibiotics at the initial evalu ation and the presence of fever at follow-up. The majority of patients can be managed as outpatients entirely. Patients who did not receive antibiotic s at the initial evaluation and those treated with oral antibiotics but rem ain febrile are at the highest risk for persistent bacteremia.