310 likes | 722 Views
28 d/o male infant, rectal temp 100.4. Healthy, term deliveryWent home with momNo previous hospitalizationsNo chronic illnessesNever been on antibioticsNot treated for unexplained hyperbilirubinemiaNo intrapartum h/o mother for fever, HSV, GBS, nor antibiotic treatmentImmunizations: Hep B Vaccine in nursery.
E N D
1. Fever in the Pediatric Patient:Who to Work Up and How Valerie Wrede, MD, Capt, USAF, MC
Medical Director, Emergency Services
Misawa Air Base, Japan
USAFP Conference, 14 Mar 2007
2. 28 d/o male infant, rectal temp 100.4 Healthy, term delivery
Went home with mom
No previous hospitalizations
No chronic illnesses
Never been on antibiotics
Not treated for unexplained hyperbilirubinemia
No intrapartum h/o mother for fever, HSV, GBS, nor antibiotic treatment
Immunizations: Hep B Vaccine in nursery
3. 28 d/o male infant, rectal temp 100.4 ROS: negative
eating well, normal urination, acting normal, no cough/congestion/emesis/diarrhea
PE: non-toxic, alert, cooing
VS: 130, 35, 100% RA, 100.4
No focal bacterial infection including:
No purulent otitis media
No skin or soft tissue infection
No bone or joint infection
4. 28 d/o male infant, rectal temp 100.4 True fever?
Yes
Focal infection?
No
Toxic or high-risk?
Infants < 28 or 30 days are high-risk
5. What is Fever? Physiology Response to Infection or Inflammation
> 100.4 Rectal
Not Necessarily Bad
100.4 – 101.9 Low grade
102 – 103.9 Moderate
> 104 Discomfort
> 106 Fever itself harmful
6. What MUST be done? RECOMMENDATION: Infants between 1 and 28 days old with a fever should be presumed to have a serious bacterial infection.
Name of AAFP-approved source of systematic evidence review: National Guideline Clearinghouse
Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence Class I" or overwhelming evidence from "strength of evidence Class II" studies that directly address all the issues)
7. Serious Bacterial Infections=SBI Bacterial Meningitis
Sepsis/Bacteremia
Bacterial Pneumonia
UTI’s
Bacterial Enteritis
Soft Tissue Infections/Cellulitis
Bone and Joint Infections
8. 28 d/o male infant, rectal temp = 100.4 Work-up
CBC with diff
Blood cultures
Urinalysis
Urine culture
Lumbar Puncture
9. 28 d/o male infant, rectal temp = 100.4 CBC with Diff
Abnormal WBC >15,000 or <5,000
WBC—no predictive value in determining risk of meningitis (Bonsu, 2003 [Q])
Band-to-Neutrophil ratio <0.2 improves negative predictive value for SBI to 98%
(Baker, 1993 [A])
10. 28 d/o male infant, rectal temp = 100.4 Urine Culture
Urinalysis
Abnormal microscopy = spun urine > 10 wbc/hpf
Gram stain more sensitive and specific than simple UA or dipstick
Obtain catheterized specimen
11. 28 d/o male infant, rectal temp = 100.4 Lumbar Puncture
If not obtained due to
Failed procedure
Traumatic LP
Parental refusal
Still start antibiotics
12. 28 d/o male infant, rectal temp = 100.4 Consider
CXR, if respiratory symptoms
Stool culture, if diarrhea
Herpes Simplex Virus cultures
Other viral cultures, if clinically indicated
13. 28 d/o male infant, rectal temp = 100.4 Management
Hospitalize
Ampicillin and 3rd Generation Cephalosporin or Gentamycin
Follow cultures minimum of 36 hours
Consider referral
Discharge Criteria
14. 60 d/o female infant with rectal temp 100.4 Healthy, term delivery
Went home with mom
No previous hospitalizations
No chronic illnesses
Never been on antibiotics
Not treated for unexplained hyperbilirubinemia
No intrapartum h/o mother for fever, HSV, GBS, nor antibiotic treatment
Immunizations: Hep B vaccine in nursery
15. 60 d/o female infant with rectal temp 100.4 ROS: negative
eating well, normal urination, acting normal, no cough/congestion/emesis/diarrhea
PE: no apparent distress, alert, interactive
VS: 124, 38, 99% RA, 99.6 (Tylenol given at home)
No focal bacterial infection including:
No purulent otitis media
No skin or soft tissue infection
No bone or joint infection
16. 60 d/o female infant with h/o rectal temp 100.4 True Fever?
Yes
Focal Infection?
No
Toxic or high-risk?
No
17. Is it a true fever? RECOMMENDATION: A response to antipyretic medication does not change the likelihood of a child having serious bacterial infection and should not be used for clinical decision making.
Name of AAFP-approved source of systematic evidence review: National Guideline Clearinghouse
Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence Class I" or overwhelming evidence from "strength of evidence Class II" studies that directly address all the issues)
18. Is it a true fever? Rectal temp preferred
Center for Reviews and Dissemination Reviewers 2002 [M], Hooker 1993 [C], Reisinger 1979 [C]
Parental report by touch
Sensitivity 82-89%, specificity 76-86%
Graneto 1996 [C], Hooker 1996 [C], Singht 1990 [C]
19. Low Risk for SBI “Rochester Criteria” Baker, 1993 [A] Prior history of being healthy
Born at term (37 wks gestation)
Not previously hospitalized
No chronic illnesses
Not hospitalized longer than mother
Not treated for unexplained hyperbilirubinemia
Not received antimicrobial agents
No intrapartum history of mother for fever, GBS, nor antibiotics
20. Low Risk for SBI “Rochester Criteria” Baker, 1993 [A] No focal bacterial infection on physical exam
No purulent otitis media
No skin or soft tissue infection
No bone or joint infection
Negative laboratory screen
21. 60 d/o female infant with h/o rectal temp 100.4 Work-up
CBC
Blood culture
UA
Urine culture
Consider LP if….
22. 60 d/o female infant with h/o rectal temp 100.4 Delay or omit LP if
Low Risk using strict screening criteria
Available, reliable f/u in 12-24 hours
Provider confident parent will f/u
Provider and family agree on plan
Antibiotic therapy will not be started
23. 60 d/o female infant with h/o rectal temp 100.4 Consider
CXR, if respiratory symptoms
Stool culture, if diarrhea
HSV cultures
95% present prior to 22 days of life
Other viral cultures
24. 60 d/o female infant with h/o rectal temp 100.4 Management
High-risk or toxic: Hospitalize, IV Antibiotics
Low-risk, non-toxic:
Consider outpatient management
Follow-up in 12-24 hours
Low-risk doesn’t equal no risk
25. 60 d/o infant Cough/congestion/rhinorrhea
Rectal temp of 100.4
Older Sibling has URI
Non-toxic and Not High-risk
26. 60 d/o infant True fever? Yes
Focal Infection? Yes, URI
Is temperature explained by physical exam findings? Yes
Toxic or high-risk? No
Controversy over age-cut offs:
Cincinnati Children’s Hospital: 60 days
UpToDate; Pantel, 2004: 90 days
27. 60 d/o infant with URI: w/o & Management CXR, since respiratory symptoms
CXR: no infiltrate
Nasal saline spray and suction
Education: Warning Signs to Return
Consider Tylenol (not Motrin)
Follow-up at 24 hours (nurse call)
28. PROS Study Pantel, 2004 Pediatricians
Office setting
3,066 febrile infants < 3 months of age
Bacteremia 1.8 %
Bacterial Meningitis 0.5%
29. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 PMH
Healthy, term delivery
Went home with mom
No previous hospitalizations
No chronic illnesses
Never been on antibiotic therapy
30. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 No sick contacts
Immunizations: up to date—
Received 3 doses of Hib and PCV-7
ROS
Eating well, Acting normal
Normal urination
No cough/congestion
No emesis/diarrhea
31. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 PE: no apparent distress, alert, active
VS: 124, 30, 99% RA, 102.2
No focal bacterial infection including:
No purulent otitis media
No skin or soft tissue infection
No bone or joint infection
32. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 True Fever?
Yes
Focal Infection?
No
33. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 Work-up
Urinalysis
Urine culture
Catheterized specimen
34. Urine Collection Sterile urine collection in well-appearing, febrile child without focal source if:
Female < 2 yrs of age
Male, if circumcised < 6 months
Male, if uncircumcised < 12 months
Additional risk factors
Emesis (without diarrhea)
Fever > 102.2
35. Urine Collection Catheterization if not toilet trained
Clean catch if toilet trained
Bag specimens not recommended
36. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 Consider Bacteremia and obtain CBC, blood cultures if:
PCV-7 or Hib not up to date for age
What to do for < 6 mo of age?
Appears ill
Fever > 40 degrees C
Meningococcal contact
37. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 CBC, blood cultures not recommended since:
well-appearing child
unremarkable history
PCV-7 and Hib up to date
Pre PCV-7 pneumococcal bacteremia was 1.7 percent
Now risk < 1%
38. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 Consider other SBI, but should have s/s of focal infection:
Viral, culture
Meningits, LP
Bacterial Enteritis, stool cx
Pneumonia, CXR
Have low threshold for ordering CXR if cough/congestion since children often don’t take in deep enough breath to get good lung exam
39. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 Management
UA results
Positive if Nit+, LE+, > 5 wbc/hpf
If UA positive, treat with oral antibiotics
F/u urine culture results
40. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 Education
Conversation with the parent:
Low-Risk is not No-Risk
Document risk of bacteremia in this patient <1% since PCV-7 and Hib UTD, parent agreed with above plan
Return for continued fevers for 48 hours, irritability, lethargy, or any other concerns
41. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 PMH
Healthy, term delivery
Went home with mom
No previous hospitalizations
No chronic illnesses
Has never been on antibiotic therapy
Circumcised in nursery
42. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 No sick contacts
Immunizations: up to date
Received 2 doses of Hib and PCV-7
ROS
Eating well, acting normal
Normal urination
No cough/congestion
No emesis/diarrhea
43. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 PE: no apparent distress, reaching for objects, interactive
VS: 128, 32, 99% RA, 102.2
No focal bacterial infection including
No purulent otitis media
No skin or soft tissue infection
No bone or joint infection
44. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 True fever?
Yes
Focal Infection?
No
45. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 Work-up
MUST DO: Urinalysis, urine culture
CONSIDER:
CBC, blood cultures because hasn’t received 3 doses of PCV-7 and Hib vaccine
46. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 Discuss with parent about amount of risk willing to tolerate
Risk of bacteremia approximately 1-2%
Exact unknown since not rec’d all doses of PCV-7
Pre-PCV 7 bacteremia 2%
Pre-PCV 7 risk of bacteremia progressing to meningitis 5%
Post-PCV 7 reduction in invasive pneumococcal disease 40%
Post-PCV 7 risk for developing meningitis 0.04%
47. Things to NOT forget It might not be an infection
3 yo male w/5 day h/o fevers to 103
Started on Amox 2 days ago for sinus infection, but fevers continued
PMH: unremarkable
48. 3 yo male with 5 days of fever to 103 ROS
Decreased oral intake
Decreased activity
Rash present
Red eyes
49. 3 yo male with 5 days of fever to 103 PE: uncomfortable appearing 3 yo male sitting still in mom’s lap
VS: 140, 90/50, 50, 98% RA, 103.6
Bilateral conjunctival swelling
Dry, fissured lips
Cervical adenopathy
Rash over trunk (scarlatiniform)
Skin changes of limbs (edema, desquamation)
50. 3 yo male with 5 days of fever to 103, Differential Diagnosis: Scarlet Fever
Stevens-Johnson Syndrome
Drug Eruption
Henoch-Schonlein Purpura
Toxic Shock Syndrome
Measles
Rocky Mountain spotted fever
Infectious mononucleiosis
Kawasaki Disease
51. 3 yo male 5 day h/o fevers to 103 Work-up
CBC, Blood cultures
CMP
UA, urine culture
ESR or CRP
CXR
EKG, echocardiogram, cath (looking for coronary artery aneyrusm
52. Kawasaki Disease Fever for at least five days
Four of the Five:
Bilateral bulbar conjunctival infection
Mucosal changes
Erythema, Edema of Ext, Periungual Desquamation
Rash, polymorphous, nonvesicular
Cervical adenopathy >1.5 cm, often unilateral
Treatment: O2, IVIG, Aspirin
53. Bibliography Available on request
valerie.wrede@misawa.af.mil
DSN 315-226-6647