Evaluation and Management of Fever in Infancy

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Evaluation and Management of Fever in Infancy,Manish Shah, MD,Assistant Professor,Baylor College of Medicine,Department of Pediatrics,Section of Emergency Medicine,1,Goals,(By the end of this lecture, you should be able),To describe the significance of fever in infancy,To specify the decision making involved in evaluating an infants fever,To evaluate laboratory findings to anticipate the subsequent plan of care,2,Objectives,To provide specific facts to families about the significance of their infants fever,To appropriately determine the evaluation and treatment in febrile infants,To correctly analyze laboratory findings in febrile infants,3,Evaluation of Fever,WHY, WHEN, and HOW?,4,Definitions,Fever, F = 38 C, F = 39 C,Fever without a Source (FWS) in 20%,Serious Bacterial Infections (SBI) in 10%,Bacteremia in 3%, 1%,Urinary tract infections in 7%,Meningitis in 8 weeks),-E. Coli,-Klebsiella,-Proteus,-Strep. Pneumoniae,-Hemophilus influenzae B,-Neisseria meningitidis,-Staph. Aureus,-Salmonella,Nelsons Textbook of Pediatrics, 16,th,Edition,Byington et al,Pediatrics,. 2003; 111(5): 964-68,6,A Tale of 3 Cities,1980s,ALL,2 month olds admitted for fever,1985,Rochester,criteria developed,1985,Hemophilus influenza B (HiB) vaccine licensed,1992,Evaluation of Ceftriaxone after sepsis eval (,Boston,),1993,1999,Philadelphia,criteria developed, revised,1993,Practice guideline for fever in 0-36 month infants,2000,7 valent pneumococcal conjugate vaccine (PCV-7) licensed,7,Rochester Criteria,Infants 90 days,Low risk,criteria:,No sign of ear, soft tissue, or skeletal infection,WBC count between 5-15 (x10,3,),Band count 1500/mm,Normal urinalysis,Stool WBC 5/hpf (if sent),Risk of SBI:,Low risk: 0.7% (UTI; no bacteremia),High risk: 25% (10% w/ bacteremia),Dagan et al,J Ped,. 1985; 107(6) 855-60,8,Boston Criteria,Infants 28-89 days who met these criteria:,Well appearing,No source of fever on exam,Peripheral WBC ct 20,CSF wbc ct , C,These patients were,not given,antibiotics,0.3% had a SBI (bacteremia),Baker et al,NEJM,. 1993; 329 (20):1437-1441,Baker et al,Pediatrics,. 1999; 103: 627-631,10,11,Immunization Status,Nigrovic et al,Clin PEM,. 2004; 5(1): 13-19,12,Evaluation Criteria in FWS,AGE,UTI,BACTEREMIA,MENINGITIS,0-60 DAYS,61-90 DAYS,3-6 MOS,7-12 MOS,13-24 MOS,24 MOS,UA + cx,(ALL),UA + cx,(ALL),Urine,dip,+ cx,(ALL),Urine,dip,+ cx,(Uncirc *;all ),Urine,dip,+ cx,(Only ),Only if symptomatic,Only if symptomatic,Only if symptomatic,Only if immuniz. not up to date,Only if immuniz. not up to date,CBC + cx,(ALL),CBC + cx,(ALL),CBC + cx,(ALL),CSF + cx,(ALL*),CSF + cx,(If labs abnl),Only if symptomatic*,Only if symptomatic,Only if symptomatic,*All,ill-appearing,patients should be evaluated based on clinical suspicion,*Some use 6 weeks as a cut-off,*Some use 9 months as a cut-off,Baraff et al,Ann Emerg Med,. 1993; 22(7): 1198-1210,13,Recognizable Viral Syndromes,The following illnesses are a reliable source of a fever in infants,3 months:,Croup,Varicella,Herpangina,Bronchiolitis,The risk of,Bacteremia is 0.2%,NO,CBC/cx required,UTI is the same as those with a FWS,UA/cx,IS,required,Greenes et al,J Ped Inf Dis,. 1999; 18(3): 258-261,14,Recognizable Viral Syndromes,Some data in 0-90 day old infants,Influenza and RSV studied,Meningitis not found,Bacteremia was rare,UTI was present w/ RSV, UA and cx should be checked,Pneumonia was common,Controversy in this age group about need for further evaluation,Smitherman et al,Pediatrics,. 2005; 115(3): 710-18,Titus et al,Pediatrics,. 2003; 112(2): 282-84,15,Enteritis,Most febrile patients with diarrhea have viral gastroenteritis,Criteria for sending a stool culture,Bloody or mucoid stool,5 WBCs/hpf on stool microscopic exam,Antibiotic treatment,Once recommended for above criteria,HUS risk with antibiotics,Baraff et al,Ann Emerg Med,. 1993; 22(7): 1198-1210,Wong et al,NEJM,. 2000; 342 (26):1930-6,16,Occult Pneumonia,Pre PCV-7,26% of ,20K have occult pneumonia,Post PCV-7 predictors of occult pneumonia,WBC,20 K,(+LR = 2.14),Fever,5 days,(+LR = 2.24),10 days of cough,(+LR = 2.25),Without a cough, routine CXR are unnecessary,Murphy et al,Acad Emerg Med,. 2007; 14(3): 243-9,Bachur et al,Ann Emerg Med,. 1999; 33(2): 166-173,17,Interpreting the Results,18,Screening vs. Definitive tests,CBC, UA, and CSF cell counts are,screening,tests,Disadvantage: Not as accurate as a culture,1/5 of those w/ bacteremia have a nl CBC,1/5 of those w/ UTI have a nl UA,Cultures are,definitive,tests,Disadvantage: 1-2 days required for results,Take home point, send cultures if concerned about SBI,19,Causes of SBIs,AGE,UTI CAUSES,BACTEREMIA + MENINGITIS CAUSES,Neonates,(0-,8 weeks),-E. Coli,-Grp B Strep,-Enterococcus,-Grp B Strep,-E. Coli,-Listeria,Older,( 8 weeks),-E. Coli,-Klebsiella,-Proteus,-Strep. Pneumoniae,-Hemophilus influenzae B,-Neisseria meningitidis,-Staph. Aureus,-Salmonella,Nelsons Textbook of Pediatrics, 16,th,Edition,Byington et al,Pediatrics,. 2003; 111(5): 964-68,20,UTI Screening,Shaw et al,Pediatrics,. 1998; 101(6): e1,21,UTI Treatment,2 months,Admit on Abx; risk of urosepsis,Ampicillin to cover Enterococcus,Gentamicin (2-4 weeks) to cover E.coli / other gram neg,2-5 months,Controversial; inpatient or outpatient OK,6 months,Send home on PO Abx,3,rd,generation cephalosporin,Hoberman et al,Pediatrics,. 1999; 104(1): 79-86,22,Bacteremia Screening,White Blood Cell (WBC) count,5-15 K; Rochester,(most conservative),20 K; Boston,15 K; Philadelphia,Bonsu et al,Acad Emerg Med,. 2004; 11(12): 1297-1301,Approximate normal values (%),L,30,M,5,E,3,B,2,N,60,23,Bacteremia Screening,Neutrophils; aka,Segmented neutrophils (“segs”),Polymorphonuclear cells (“polys” or “PMNs”),Composed of mature and immature forms:,ANC = (WBC) x (%Neutrophils + %Bands),“Left Shift”,24,Bacteremia Screening,Bands,1500; Rochester,N/A; Boston,Band:Neutrophil ratio 10,000 is concerning for bacteremia,CRP, Procalcitonin, and IL-6,Kupperman et al,Ann Emerg Med,. 1998; 31(6): 679-687,25,Abnormal CBC,All patients 0-28 days,Admit on antibiotics,Ampicillin and Gentamicin*,28 days,50 mg/kg Ceftriaxone,and,physician follow up in 24 hours,Admit if physician follow-up not possible +/- Abx,Ampicillin (0-8 weeks),3,rd,generation IV cephalosporin (Cefotaxime or Ceftriaxone),Baskin et al,J Ped,. 1992; 120(1): 22-7,*Or Cefotaxime if 14 days,26,Meningitis Screening,CSF Test,Normal,Bacterial,Aseptic,(Usually viral),WBC,(cells/mm,3,),30 (,1000,(,50% PMNs,),10*-500,(,variable differential,),RBC,(cells/mm,3,),0,0,0,Glucose,(mg/dL),50-75,80,50-100,Gram stain,No bacteria,Bacteria present,No bacteria,Negrini et al,Pediatrics,. 2000; 105(2): 315-316,27,Meningitis Screening,Bacterial Meningitis Score (BMS),Gram stain,(2 points),CSF protein 80,(1 point),Peripheral ANC 10,000,(1 point),CSF ANC 1,000,(1 point),Seizure,(1 point),Pretreated, ,1,Admit to hospital,All others, Send home or admit for pain control,Nigrovic et al,JAMA,. 2007; 297(1): 52-60,Most Predictive,Nigrovic et al,Pediatrics,. 2002; 110(4): 712-19,28,Meningitis Treatment*,0-28 days,IV Ampicillin,IV Gentamicin*,4 weeks,IV Vancomycin,IV Cefotaxime (or Ceftriaxone),*use,meningitic,doses for all antibiotics,*Or 3,rd,generation IV cephalosporin if GNR or 2 wks,29,Treatment and Disposition,AGE,Urine,+ nitrite,or,+ LE,CBC,WBC ,15,or,ANC,10,000,or,BNR 0.2 in neonates,+/- Bands 1500,CSF,BMS,1,Pretreated w/ Abx,Stool,5 WBC,0-4 wks,IV Amp/Gent, even if labs nl,IV Amp/Gent, even if labs nl,IV Amp/Gent, even if labs nl,IV Amp/Gent, even if labs nl,5-8 wks,IV Amp/Cefotax,IV Amp/Cefotax or,IV/IM Ceftriaxone w/ 24 hr follow-up,IV Amp/Cefotax,Wait for culture,2-6 mos,IV Cefotaxime or,PO Cefixime,IV Cefotax or,IV/IM Ceftriaxone w/ 24 hr follow-up,IV Vanc + Cefotax,Wait for culture,6 mos,PO Cefixime,IV Cefotax or,IV/IM Ceftriaxone w/ 24 hr follow-up,IV Vanc + Cefotax,Wait for culture,30,CASE SCENARIOS,31,Case #1,2 wk with T=100.5. Vitals signs and exam otherwise normal,Evaluation?,CBC/cx, cath,UA,/cx,CSF,cts/cx,CBC: WBC = 8 (,N,60,Bands,0,L,30,M,5,E,3,B,2,),UA: no nitrites, no leukocyte esterase,CSF: wbc=15, rbc=2, glc=50, pro=50, GS neg,Management?,Admit,on Amp/Gent,32,Case #2,5 mo with T=103. Vitals signs and exam otherwise normal,Evaluation?,CBC/cx, cath urine,dip,/cx,CBC: WBC = 21 (,N,60,Bands,0,L,30,M,5,E,3,B,2,),UA: no nitrites, no leukocyte esterase,Management?,Get a,CXR,to r/o occult pneumonia,Give,50 mg/kg Ceftriaxone,and send,home,Treat with oral Amoxicillin if pneumonia present,33,Case #3,5 wk with T=101.4 Vitals signs and exam otherwise normal,Evaluation?,CBC/cx, cath UA/cx, CSF cts/cx,CBC: WBC = 16 (,N,50,Bands,20,L,20,M,5,E,3,B,2,),UA: no nitrites, no leukocyte esterase,CSF: wbc=5, rbc=2, glc=50, pro=50, GS neg,Management?,Give,50 mg/kg Ceftriaxone,and f/u w/ PMD in 24 hours,34,Case #4,7 mo with T=103.4, P=170, BP 70/40, R=38, O,2,=94%. 3 sec cap refill, circumcised, exam otherwise normal,Evaluation?,CBC/cx,CBC: WBC = 16 (,N,50,Bands,20,L,20,M,5,E,3,B,2,),Management?,NS 20 ml/kg; repeat as needed,Admit on IV Cefotaxime due to,ill appearance,35,Case #5,7 wk with T=101.9, P=120, BP 80/50, R=28, O,2,=97%; Exam otherwise normal,Evaluation?,CBC/cx, cath UA/cx, CSF cts/cx*,CBC: WBC = 8 (,N,60,Bands,0,L,30,M,5,E,3,B,2,),UA: + nitrites, no leukocyte esterase,CSF: wbc=5, rbc=2, glc=50, pro=50, GS neg,Management?,Admit on Amp/Cefotax,due to risk of urosepsis at this age,36,Case #6,2 yr with T=105 and bloody diarrhea. P=120, BP 80/50, R=28, O,2,=97%. Exam otherwise normal,Evaluation?,Stool culture,Management?,Discharge with supportive care,(no Abx);,follow up on stool culture,37,Case #7,5 mo with T=102.3, P=120, BP 80/50, R=28, O,2,=97%. Coarse BS, exam otherwise normal.,Evaluation?,Cath urine,dip,/cx,UA: no nitrites, no leukocyte esterase,Management?,Discharge w/ supportive care for,bronchiolitis,38,Case #8,13 mo with T=104, P=120, BP 80/50, R=28, O,2,=97%. Exam otherwise normal,Evaluation?,Cath urine dip/cx,UA: no nitrites, trace leukocyte esterase,Management?,Send home on,oral Cefixime,39,Case #9,7 mo with T=103.4, P=120, BP 80/50, R=28, O,2,=97%. Circumcised; exam normal,Evaluation?,No labs,Management?,Discharge with supportive care for febrile illness,40,Case #10,9 wk with T=103.4, P=150, BP 80/50, R=32, O,2,=97%. Circumcised; exam normal,Evaluation?,CBC/cx, cath UA/cx, CSF cts/cx,CBC: WBC = 14 (,N,70,Bands,2,L,18,M,5,E,3,B,2,),UA: no nitrites, no leukocyte esterase,Management?,Do LP:,CSF: wbc=500,(,N,50,L,45,M,5,), rbc=2, glc=50, pro=90, GS neg,Admit on IV Vanc/Cefotax until cx results known,41,QUESTIONS?,42,