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Fever: Nuts and Bolts

Fever: Nuts and Bolts. Nightfloat Curriculum 2010-2011 Lucile Packard Children’s Hospital Residency Program. Teaching Goals. Assess patient with fever Initiate laboratory evaluation and empiric therapy Determine which patients are at high risk of developing sepsis . Definition of fever.

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Fever: Nuts and Bolts

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  1. Fever:Nuts and Bolts Nightfloat Curriculum 2010-2011 Lucile Packard Children’s Hospital Residency Program

  2. Teaching Goals • Assess patient with fever • Initiate laboratory evaluation and empiric therapy • Determine which patients are at high risk of developing sepsis

  3. Definition of fever • 38.0 • Neonates (birth-2 months) • BMT patients • Oncology patients (sustained ≥38 x 1 hour) • 38.5 • Oncology patients (≥38.5 once) • 39.0 • Previously healthy children, nontoxic appearing • These are general guidelines, individual patients/services may have different parameters

  4. Assessment • Vital signs • Repeat physical exam • Overall appearance (sick, toxic) • Central/peripheral lines • Incisions/wounds • VP shunt/tracheostomy/gastrostomy tube • Oral mucosa/perineal area for neutropenic patients • Perfusion • Call for help if concerning vital signs/exam • Hospitalist • Rapid response team (RRT)/PICU

  5. Laboratory evaluation • CBC with differential • Blood culture • Urinalysis and urine culture for at-risk patients • Circumcised males < 6 months • Uncircumcised males < 1 year • Females < 2 years • Oncology/BMT patients • History of UTI/pyelonephritis • Catheterized (except oncology/BMT) or clean-catch

  6. Laboratory evaluation (2) • Lumbar puncture • Neonates ≤ 2 months • Ill-appearing • Altered mental status • Studies: • Gram stain and culture • Cell count and differential • Protein and glucose • Extra tube for additional studies (enteroviral PCR, HSV PCR, CA encephalitis project)

  7. Laboratory evaluation (3) • Consider CRP, ESR • Consider chest x-ray • Consider nasopharyngeal DFA • For immunosuppressed patients consider: • CMV PCR • EBV PCR • Additional imaging (CT scan)

  8. Management • Neonates ≤ 2 months • If < 28 days old • Ampicillin: meningitis 100 mg/kg/dose q6 hrs • non-meningitis 50 mg/kg/dose q6 hrs • AND Cefotaxime: meningitis 75 mg/kg/dose q6 hrs • non-meningitis 50 mg/kg/dose q6 hrs • OR Gentamicin: 2.5 mg/kg/dose q8 hrs • Acyclovir: 20 mg/kg/dose q8 hrs • If 29-60 days old • Ceftriaxone: meningitis 50 mg/kg/dose q12 hrs • non-meningitis 50 mg/kg/dose q24 hrs • AND Ampicillin (see above) • OR Vancomycin 15 mg/kg/dose

  9. Management (2) • Oncology patients: febrile neutropenia • Ceftazidime: GNR (including Pseudomonas) • Meropenem: GNR (including Pseudomonas), anaerobes (ill/septic patients) • Amikacin: double-coverage for GNR resistant to gentamicin or tobramycin (ill/septic patients) • Vancomycin: skin, central line, esp AML, relapsed leukemia (Staph/Strep viridans) • Flagyl/clindamycin: mucositis, typhlitis (anaerobes) • BMT patients • Ceftazidime • Vancomycin • These are general guidelines, individual patients/services may have different regimens

  10. High-risk patients • Neonates • Transplant recipients • Bone marrow • Solid organ • Oncology patients • Undergoing therapy, mucositis, central line • Most chemotherapy: nadir ~ 10 days after rx • Asplenic patients, including sickle cell

  11. Case # 1 • 4-month-old well-appearing girl admitted for croup and respiratory distress. Develops fever to 39.1.

  12. Case # 2 • 12-year old boy with AML, in induction, admitted for febrile neutropenia. Currently on ceftazidime and vancomycin. Develops another fever to 38.5, chills, and new dizziness shortly after receiving antibiotics.

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