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Bacteremia

Bacteremias


Presentation

Bacteremia may present with a lot of signs and symptoms depending on the site of the primary infection, comorbid events and stage of the disease.

The following system-wise presentation are eminent in the majority of bacteremia cases:

General Appearance: Patients in severe bacteremia may present with pallor and lethargy due to blood coagulation and destruction. Oxygen desaturation during fulminant disease may present with cyanosis.

Systemic response: Fever is the most common heralding sign of infection and bacteremia in both children and adults due to a set point resetting which may lead to diaphoresis (excessive sweating). Older people may present with hypothermia due to incompetent immune response.

Head and Neck: Micro-hemorrhages of the conjunctiva may occur with DIC.

Chest and Heart: Patients will appear frequent and shallow breathing with severe bacteremia due to metabolic acidosis that decreases the blood pH. Heart murmurs are accentuated with bacterial endocarditis.

Abdomen: Enlargement and hardening of the abdomen may be observable if bacteremia complicates to peritonitis. Bleeding via the anus may be observed with blood coagulation complications

Extremities: Extremities may appear cold and clammy due to vasodilation with cytokine proliferation. Pulses may be less palpable due to late signs of septic shock.

Fever
  • Fever on the day of FUBC was associated with higher rates of positive FUBC for gram-positive cocci (GPC) but not GNB. Mortality and care in the intensive care unit were not associated with positive FUBC.[ncbi.nlm.nih.gov]
  • We discuss the challenges of making this diagnosis and review the literature on rat bite fever.[ncbi.nlm.nih.gov]
  • In the same way, bacteremia may stand as a complication of a primary diseases like typhoid fever, staphylococcal skin infections, and streptococcal pneumonia.[symptoma.com]
  • Abstract A 40-year-old woman with systemic lupus erythematosus (SLE) presented with high-grade fever and severe thrombocytopenia. Acalculous cholecystitis and thrombocytopenia were initially suspected to be complicated with SLE and vasculitis.[ncbi.nlm.nih.gov]
  • Catheters were removed within 48 h after admission in 2 cases, and 5 days after admission in the last case, subsiding fever. In 2 children, paired blood cultures were not able to identify bacteremia.[ncbi.nlm.nih.gov]
Chills
  • A multivariate analysis with the age, chills, platelet count and urine nitrite test results revealed that older age, positive urinary nitrite test results and chills tended to be associated with bacteremia, respectively.[ncbi.nlm.nih.gov]
  • The severity of chills graded on an ordinal scale (shaking chills, LR, 4.7; 95% CI, 3.0-7.2) may be more useful.[ncbi.nlm.nih.gov]
  • She was admitted to our hospital complaining of fever and chills, and her physical examination revealed left costovertebral angle tenderness. Computed tomography showed hydronephrosis and complete ureteral obstruction due to tumor invasion.[ncbi.nlm.nih.gov]
  • Fever, chills, tachycardia, and tachypnea are common acute manifestations of bacteremia.[icd9data.com]
  • She was admitted to our hospital with complaints of a fever, chills, and nausea.[ncbi.nlm.nih.gov]
High Fever
  • It also may progress into septicemia, a more serious blood infection that is always accompanied by symptoms such as chills, high fever, rapid heartbeat, severe nausea, vomiting and confusion.[orasurgery.com]
  • Sepsis or blood infection is a serious health condition, in which microbes invade the blood (usually from existing severe infection, like pneumonia) and trigger high fever, rapid breathing and heartbeat.[healthhype.com]
  • Some of the symptoms of bacteremia are: High fever Hypothermia Hypoxemia A rapid heart beat Rapid breathing Nausea Paleness Weakness The above mentioned symptoms are normally felt when bacteremia is progressing and becoming septic however when mild bacteremia[howshealth.com]
  • These septicemias were constantly characterized by intermittent high fever, although shock was infrequent. Young individuals or other patients without predisposing host factors were frequently afflicted.[cdc.gov]
Rigor
  • In both guidelines CD 12,14,15 it is plain to see that we need more clinical studies with high levels of scientific evidence for a more adequate and rigorous implementation of their recommendations.[medintensiva.org]
  • Immediately after, he developed chills and rigors but left the dental clinic. He was subsequently found collapsed outside the clinic. He had no other significant past medical or travel history.[casesjournal.biomedcentral.com]
Poor Oral Hygiene
  • Although neutropenic patients with poor oral hygiene are exclusively vulnerable to Capnocytophaga bacteremia, this case was unique because such predisposing conditions were not noted.[ncbi.nlm.nih.gov]

Workup

The following laboratory workups are used in occult and persistent bacteremia:

  • Blood Culture and Sensitivity testing: This diagnostic test isolates the bacteria and determines the ideal antibiotic to be used in the disease.
  • Urinalysis: Assess the possibility of urinary tract infection in patients.
  • White blood cell (WBC) count: This is the most common test used in Bacteremia. A WBC count of more than 15 per high power field demonstrates occult and persistent bacteremia.
  • Absolute neutrophil count (ANC): This test is 76-82% sensitive for occult bacteremia illustrated in a figure of 7,000-10,000 ANC [8].
  • Cerebrospinal fluid (CSF) analysis: Harvested through a lumbar tap, CSF analysis is a valuable tool in determining meningitis.
Pneumoperitoneum
  • A computed tomography scan revealed pneumoperitoneum and peritoneal effusions. INTERVENTIONS: The patient was treated with effective empiric antibiotic therapy, and delayed surgery.[ncbi.nlm.nih.gov]

Treatment

In non-complicated bacteremia, the symptom of fever may be treated with acetaminophen. In general, bacteremia may clinically be treated with empiric doses of antibiotics and antifungal to shorten its clinical course and reduce complication.

Empiric treatments should always be reassessed with periodic blood cultures to rule out bacterial resistance to the treatment [9].

In meningitis, parenteral antibiotics were found to be more effective than oral antibiotics for treatment and in reducing its sequelae [10].

Complication of metabolic acidosis with sepsis should be controlled by altering it with parenteral sodium bicarbonate. Uncontrolled systemic inflammation may be allayed by the introduction of hydrocortisone in the blood stream.

Those in shock may be stabilized by the use of plasma expanders and intravenous fluids.

Prognosis

Occult bacteremia is arbitrarily self-limiting to all patient. In severe bacteremia cases however, risk were significantly higher in the age group below 3 months and beyond 55 years old. The absence of prior immunizations worsens the prognosis.

Morbidity state of children and adults will also be an indispensable predictor of bacteremia prognosis. The nature of the invading bacteria may influence the outcome of bacteremia. The World Health Organization (WHO) has conveyed that more than 6 million children die from pneumococcal infections presenting in either bacteremia, meningitis or pneumonia in developing countries worldwide [7].

Complications

Patients may present with the following complications with persistent and severe bacteremia:

  • Sepsis: Uncontrolled bacteremia may proliferate and induce this systemic state and response. Sepsis may further complicate to septic shock or disseminated intravascular coagulation (DIC) and eventually death.
  • Abscesses: Local bacteremia may spread to the skin and give rise to abscess.
  • Meningitis: This represents the bacterial infection of the brain’s meninges.
  • Peritonitis: Bacteremia that emanates from the intestine or stomach may complicate to involve the peritoneum.
  • Endocarditis: Inflammation of the heart that are usually seeded from prosthetic heart valves or dental procedures.
  • Organ failure: An endstage organ damage may be eminent in overwhelming infections.

Etiology

Bacteremia may be occult or persistent (overwhelming) in nature. It may arise from any infections of the body like the lungs, abdomen, skin or urinary system.

Bacteremia may also incite infections of susceptible organs and may coexist with these primary infections of the bones (osteomyelitis), brain (meningitis) and the heart (endocarditis).

In the same way, bacteremia may stand as a complication of a primary diseases like typhoid fever, staphylococcal skin infections, and streptococcal pneumonia.

Epidemiology

The incidence of isolated bacteremia may be challenging because of the existence of comorbid illnesses that disrupts the clinical presentation. With this regard, cohort studies tag bacteremia with common signs of significant temperature elevation, clinical appearance, associated risk factors and laboratory criteria.

In a United States study, incidence of bacteremia in children less than 3 months old without prior Haemophilus influenza type B (HiB) immunization were noted to be 1-2.2% for non-toxic infants, and 10-11% in infants that are toxic [1]. However, in age group 3-36 months old, the risk of serious bacteremia climbs to 10-90% [2]. The most common causative agent in infants less than 3 months old is Eschericha coli at 42% of cases while group B Streptococcus at 23% of cases [3]. Infants and children with concurrent immunization lowers the risk of bacteremia to 0.5% incidence [4].

Sex distribution
Age distribution

Pathophysiology

Bacterial or viral invasion may triggers an immune response by releasing cytokines in the plasma. The assimilation of the cytokines causes a resetting of the thermoregulatory centers of the hypothalamus manifesting as fever (or increased of body temperature) [5]. The fidelity of the immune system dictates whether bacteremia is spontaneously resolved or whether it overwhelms the host.

Young children with immature immune system are unable to mount efficient immunoglobulin G (IgG) to combat encapsulated bacterial pathogens. Their opsonin and macrophage surface defense may also be underdeveloped to prevent bloodstream invasion [6]. Adult and child patients with immune-compromised states like those in antineoplastic drugs and those with inherent antibody defects may be a predictive sign for severe bacteremia. Prior immunizations with specific antigens may influence the type of invading organism in bacteremia among children.

Prevention

Routine multiple immunization at an early age may significantly reduce the risk of persistent bacteremia and may directly influence patient morbidity and mortality. High risk patients for endocarditis like those with cardiac implants and those undergoing dental procedures should be given prophylactic antibiotics to prevent fulminant bacteremia.

Dirty wounds and surgical wounds should be dressed with antiseptics liberally to prevent pathogens from invading the bloodstream. Inserted bladder catheters and nasogastric tubes should be done aseptically to reduce the risk of bacteria translocation leading to iatrogenic bacteremia.

Summary

Bacteremia is a clinical condition where there is transient proliferation of bacteria in the bloodstream. Majority of cases of bacteremia may result from tooth brushing, dental procedures, and simple medical procedures which may spontaneously resolve.

However, persistent bacteremia may develop from serious infections like pneumonia and osteomyelitis to cause life-threatening scenarios. Persistent bacteremia especially in an immune-compromised host may lead to a system-wide response referred to as sepsis.

Patient Information

Innocent fever in both children and adults should always be taken as a sign of impending disease and should be brought to medical attention to avoid untoward complications.

Self-medication with antibiotics should never be an option for other medicines may damage the kidneys or the liver if taken for the incorrect indication. Compliance to medications in bacteremia is of paramount importance to ensure recovery and prevent the immergence of resistant strains of bacteria.

References

Article

  1. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med. Jul 1993;22(7):1198-210
  2. Baraff LJ. Management of infants and children 3 to 36 months of age with fever without source. Pediatr Ann. Aug 1993;22(8):497-8, 501-4.
  3. Biondi E, Evans R, Mischler M, Bendel-Stenzel M, Horstmann S, Lee V, et al. Epidemiology of bacteremia in febrile infants in the United States. Pediatrics. Dec 2013;132(6):990-6. 
  4. Steele RW. Fever with bacteremia: a disappearing classic. Consultant for Pediatr. 2013;12:19-23.
  5. McCarthy PL. Fever. Pediatr Rev. Dec 1998;19(12):401-7
  6. Baker MD. Evaluation and management of infants with fever. Pediatr Clin North Am. Dec 1999;46(6):1061-72.
  7. Giebink GS. The prevention of pneumococcal disease in children. N Engl J Med. Oct 18 2001;345(16):1177-83.
  8. Kuppermann N. Occult bacteremia in young febrile children. Pediatr Clin North Am. Dec 1999;46(6):1073-109.
  9. Nilsson P, Laurell MH. Carriage of penicillin-resistant Streptococcus pneumoniae by children in day-care centers during an intervention program in Malmo, Sweden. Pediatr Infect Dis J. Dec 2001;20(12):1144-9.
  10. Fleisher GR, Rosenberg N, Vinci R, et al. Intramuscular versus oral antibiotic therapy for the prevention of meningitis and other bacterial sequelae in young, febrile children at risk for occult bacteremia. J Pediatr. Apr 1994; 124(4):504-12.

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Last updated: 2017-08-09 17:53