Written by Joshua Belfer
Spoon Feed
In well-appearing children with ≥5 days of fever, bacteremia is exceedingly rare (~0.3%), suggesting routine blood testing and cultures have very low diagnostic yield.
Well children, long fevers, negative cultures
Prolonged fever often triggers expanded workups in children, driven by concern for occult invasive bacterial infection. However, data to support this approach, especially in well-appearing patients, are limited, and practice patterns remain highly variable.
This retrospective, single-center study evaluated 742 well-appearing children ≤18 years presenting to the ED with ≥5 days of fever (per parental history), aiming to determine the prevalence of bacteremia and other bacterial infections. Blood cultures were obtained in 44%, identifying just 2 cases of bacteremia (0.26%), both with focal sources (pneumonia, gastroenteritis). Other bacterial infections occurred in 15.6%, predominantly pneumonia (11.9%), followed by UTI (2.5%). Despite the low bacteremia yield, testing was common (CBC/CRP ~45%), and 33.6% received antibiotics, including 24% without confirmed bacterial infection.
The retrospective design, incomplete testing across all patients, and reliance on radiographic pneumonia as a proxy for bacterial infection limit generalizability and may overestimate bacterial disease burden.
How will this change my practice?
Finding bacterial infection in the well-appearing child with prolonged fever is one of the big challenges of the pediatric ER. This is a nice “pause before you click the order set” paper. For the well-appearing child with 5 days of fever, this suggests that we don’t necessarily have to send the labs “just to be safe.” The pretest probability of bacteremia is negligible, and there’s always the potential of downstream harm—false positives, unnecessary antibiotics, or parental anxiety.
Instead, do a careful history, exam, and targeted testing. Labs and cultures should usually be reserved for children who don’t look right or for those with a specific clinical concern (i.e. Kawasaki Disease). Nearly a quarter of children without a confirmed bacterial infection received antibiotics, highlighting how easily diagnostic uncertainty and lab abnormalities can lead to potentially unnecessary antibiotics. Bottom line, this paper suggests that prolonged fever alone is not an indication for a sepsis workup in a well-appearing child.
Source
Prevalence and Characteristics of Bacteremia in Children With Prolonged Fever and Well Appearance Attending the Pediatric Emergency Department. Pediatr Infect Dis J. 2026 Apr 6. doi: 10.1097/INF.0000000000005234. Epub ahead of print. PMID: 41937232.
