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Fever

Fever. PALS April 24, 2017. Overview. < 28 days and 28 to 60 days Bronchiolitis UTIs Pharyngitis AOM. Epidemiology. Epidemiology. Evolving epidemiology with GBS prophylaxis - Escherichia coli 56% of positive Bcx - Group B Streptococcus 21% of positive Bcx - Staphylococcus aureus

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Fever

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  1. Fever PALS April 24, 2017

  2. Overview • < 28 days and 28 to 60 days • Bronchiolitis • UTIs • Pharyngitis • AOM

  3. Epidemiology

  4. Epidemiology • Evolving epidemiology with GBS prophylaxis - Escherichia coli 56% of positive Bcx - Group B Streptococcus 21% of positive Bcx - Staphylococcus aureus 8% of positive Bcx - Listeria monocytogenes 0% of positive Bcx Consider HSV Greenhow TL, et al. Pediatrics (2012); 129:e590-6.

  5. Neonates • High(er) risk: • Prevalence • Pathogens • Immunity • Unreliable exam / tests • Risk Stratification? • Rochester, Philadelphia, Boston • Not helpful < 28 days

  6. Neonates Schwarz et al. Arch Dis Child. Oct, 2009

  7. Neonates • Summary: • Risk stratification inaccurate • Full Septic Work-up • Empiric antibiotics • Ampicillin AND • Gentamicin or Cefotaxime • Consider Acyclovir

  8. Infants 1-2 Months • Lower risk of SBI compared to neonates (6% vs 12%) • Battle of the East Coast: • Rochester vs. Philadelphia vs. Boston • Admit or Discharge?

  9. Rochester Criteria • Rochester Low Risk Criteria (<60 days) • Well appearing, term, no evidence of skin/skeletal/ear infection • Blood • WBC 5,000-15,000/mm3 • band neutrophils < 1,500/mm3 • Urine • < 10 WBC/hpf • Stool (if diarrhea present) • < 5 WBC/hpf

  10. Philadelphia Criteria • Philadelphia Low Risk Criteria (29-56 days) • Well appearing • Blood • WBC < 15,000/mm3 and Band:neutrophils < 0.2 • Urine • < 10 WBC/hpf and few or no bacteria on U/A • Stool (if diarrhea present) • Few or no WBCs • Chest x-ray • No evidence of pneumonia • CSF • < 8 WBC/hpf and no bacteria on gram stain

  11. Boston Criteria • Boston Low Risk Criteria (1-3 months) • Well appearing, no soft tissue/skeletal/ear infection • Blood • WBC < 20,000/mm3 • Urine • < 10 WBC/hpf or negative leukocyte esterase • Chest x-ray (if performed) • No evidence of pneumonia • CSF • < 10 WBC/hpf and no bacteria on gram stain • Low Risk: IM Ceftriaxone (50mg/kg) and home.

  12. Performance of Low Risk Criteria • Infants 1-2 months with fever: • Meningitis 0.4% • serum WBC and blood culture not predictive: 41% have normal CBC Baker MD, et al. N Engl J Med 1993; 329(20):1437-41. Baskin MN, et al. J Pediatr 1992; 120(1): 22-7. Bonsu BM, Harper MB. Ann Emerg Med 2003; 41: 206-14. Jaskiewicz JA, et al. Pediatrics 1994; 94(3): 390-6.

  13. Summary • Febrile infants between 1 and 2 months (w/o source) • UA, Ucx, CBC, BCx • Strongly consider LP • Low risk: discharge home with close follow-up (+/- Abx) • High risk or identified source: Abx for all • Inpatient <2 months, consider outpatient tx for UTI > 2 months

  14. Febrile Infant withViral Illness • Does a confirmed viral infection change management? • Neonates? • 1 to 2 months?

  15. Febrile Infant with RSV RSV + Bacteremia All were under 28 days of age (9, 10, and 19 do) None in 1 to 2 month age group 2 patients did not have URI or wheezing 1 patient had retractions

  16. Febrile InfantViral Source SBI in febrile infants 1-90 days

  17. Febrile Infant with Viral Source • Neonates • FSW (urine, bloodwork, LP) • Antibiotics • Admission (also for apnea monitoring if RSV+) • Between 1 and 2 months • Test urine • If U/A abnormal, send BCx and initiate antibiotics

  18. Febrile Infant after Immunizations Wolff and Bachur. AcadEmerg Med. 16(12): 1284-9 (2009)

  19. Febrile Infant after Immunizations Wolff and Bachur. AcadEmerg Med. 16(12): 1284-9 (2009)

  20. Summary

  21. Bronchiolitis • Fever less than 28 days: • FSW, IV Abx, admit • Fever between 28 and 60 days: • U/A (if positive BW, IV Abx, admit) • Routine CXR/viral testing not recommended • Routine cultures not recommended in those over age 2 months

  22. Bronchiolitis • Criteria for admission • Signs of severe respiratory distress • Supplemental O2 required for sats > 90% • Dehydration • Cyanosis or apnea • High risk patient

  23. Bronchiolitis *helpful in admitted patients

  24. UTIs

  25. UTIs • Treatment: < 2 months Admit and IV antibiotics > 2 months Oral Cephalexin 50mg/kg/d for 10 days if well appearing, toleraringPO fluids, well hydrated and follow-up cant be assured Otherwise inpatient IV antibiotics Arrange follow-up

  26. Pharyngitis • Very uncommon in those under age 3 • Routine testing and treatment not recommended • Swab those who are over age 3 and complain of sore throat • Treatment: Standard dose Amoxil x 10 days • If concerns for allergy: cephalosporins or macrolides

  27. AOM • Wait and watch unless under 6 months, severe otalgia, temperature > 39, recent AOM • Amoxil 80 to 90mg/kd/d divided BID: < 2 years: 10 days 2 to 5 years: 7 days > 5 years: 5 days

  28. Questions?

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