Appeal type: Medical necessity
Decision: Upheld

This is a patient admitted for a positive blood culture thought to be bacteremia. The infant was seen 2 days prior to admission in the Emergency Department (ED) for temperature of 101 degrees Fahrenheit at home. She was also having a cough and nasal symptoms at that time. Testing in the emergency department (ED) including urinalysis, urine culture, cerebrospinal fluid (CSF) cell counts and culture, nasal polymerase chain reaction (PCR) testing for influenza and respiratory syncytial virus (RSV), and testing for inflammatory markers did not reveal any abnormalities to indicate a specific or suspected etiology for the fever. Infant was given Intramuscular ceftriaxone and discharged home.
The following day the blood culture was reported to be positive. The family was notified and the infant was brought back to the ED. At home, the infant had been feeding normally and was afebrile. At that time in the ED, she was afebrile and repeat testing was consistent with likely viral infection given the lymphocytic predominance on the complete blood count (CBC) with differential. The child was subsequently admitted for monitoring but did not require oxygen support or intravenous (IV) fluids.
The blood culture was initially reported to be positive with Gram negative rods and then revised to be positive for Gram variable rods and Gram positive cocci. The infant was started on broad empiric antibiotic coverage despite being clinically stable. The "positive" culture turned out to be a "contaminant."
The health plan's determination is upheld.
Fever and concerns of invasive bacterial disease in children under 3 years of age has been a field of study for many years and the cornerstone of pediatric infectious disease evaluation and treatment. The assessment of a febrile infant or toddler can be a challenge.
Clinically the child presented with symptoms and testing consistent with a febrile viral upper respiratory viral infection (URI). The treating institution may have been concerned about sepsis/bacteremia, also known as pediatric System Inflammatory Response Syndrome (SIRS) since a blood culture was obtained. In children, systemic inflammatory response syndrome (SIRS) is defined by:
"the presence of two or more of the following criteria, one of which must be abnormal temperature or leukocyte count. Core temperature of greater than (>) 38.5 degrees Centigrade (C) or less than (<) 36C which must be measured by rectal, oral, or central catheter probe. Tachycardia, defined as a mean heart rate >2 standard deviations (SD) above normal for age in the absence of external stimulus, chronic drugs, or painful stimuli; or otherwise unexplained persistent elevation over a 0.5- to 4-hour time period or for children < 1 year old: Bradycardia, defined as a mean heart rate < 10th percentile for age in the absence of external vagal stimulus, beta-blocker drugs, or congenital heart disease; or otherwise unexplained persistent depression over a 0.5-hour time period. Mean respiratory rate >2 SD above normal for age or mechanical ventilation for an acute process not related to underlying neuromuscular disease or the receipt of general anesthesia. Leukocyte count elevated or depressed for age (not secondary to chemotherapy-induced leukopenia) or >10% immature neutrophils."
The child had no clinical or laboratory evidence of SIRS. The concerns for bacteremia or sepsis as justification of the admission, are not reflected in the decision-making documented by the treating physicians.
This child was well and the initial information about the blood culture was most consistent with a contaminant based upon the time it became positive, the initial Gram stain and the types of organisms that were noted. This child could have been given intramuscular (IM) ceftriaxone again (if needed) and had 24-hour follow-up with his primary care provider while awaiting finalization of the positive blood culture and repeat blood cultures to be resulted.