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to develop serious bacterial infections such as septic arthritis, osteomyelitis,
meningitis, or sepsis. Historically, some febrile children, 2 to 24 months of age,
with temperatures greater than 39°C (102°F) and no clear source of infection
were evaluated with a CBC and blood culture for risk of occult bacteremia. The
WBC count was used by some to determine the risk of occult bacteremia and
guide empiric antibiotic use. However, as the risk of occult bacteremia has
decreased, the previous strategy of screening has become less valuable. As
mentioned previously, with the licensure of the PCV, rates of invasive
pneumococcal infections including occult bacteremia have decreased. Studies
from the post-Hib vaccine and post-PCV era indicate the risk of occult bacteremia
in immunized children to be less than 1%. Currently, in an immunized population,
a detailed history and physical examination and close follow-up are advocated
over screening laboratory evaluations. Additional laboratory testing in children 2
to 24 months of age who are well appearing without focal source of fever is not
recommended.
Rapid viral testing may be helpful in evaluating patients with specific
symptoms or signs of a viral illness and complex medical situations, but in
general is not indicated in most children without significant comorbidities.
Several recent investigations have shown a decreased risk of bacterial infections
with positive rapid tests for specific viruses. As technology for viral testing
becomes more rapid, more accurate, and most cost-effective, there will likely be a
growing role for rapid viral testing in decision making, including need for
additional testing and antimicrobial therapy, for certain clinical scenarios. Despite
positive viral tests, children should be evaluated for secondary bacterial infection
through careful examination, especially those patients who have an atypical
course based on their duration or severity of their symptoms. Caution should be
taken when interpreting results of rapid antigen tests for influenza, which have
been shown to have poor sensitivity and positive predictive value, particularly
when clinical suspicion of disease is high. Newer generation PCR-based tests for
influenza have substantially higher sensitivity and specificity, close to 100%;
thus, it is important to understand the test characteristics of the test used when

making clinical decisions.
Children older than 24 months of age can usually be managed on the basis of
degree of irritability, evidence of meningeal signs, and/or other foci of infection
found on history and physical examination. These children need not be screened
routinely for occult bacteremia or other occult infections. After excluding
meningitis, there are several important infections that may be present in illappearing, febrile children in this age group, without obvious initial focus. These