Evaluation and Management of Fever in Infancy.ppt

Evaluation and Management of Fever in InfancyManish Shah,MDManish Shah,MDAssistant ProfessorAssistant ProfessorBaylor College of MedicineBaylor College of MedicineDepartment of PediatricsDepartment of PediatricsSection of Emergency MedicineSection of Emergency Medicine1 1Goals(By the end of this lecture,you should be able)(By the end of this lecture,you should be able)To describe the significance of fever in infancyTo specify the decision making involved in evaluating an infants feverTo evaluate laboratory findings to anticipate the subsequent plan of care2 2ObjectivesTo provide specific facts to families about the significance of their infants feverTo appropriately determine the evaluation and treatment in febrile infantsTo correctly analyze laboratory findings in febrile infants3 3Evaluation of FeverWHY,WHEN,and HOW?4 4DefinitionsFeverFever F=38 C F=38 C F=39 C F=39 CFever without a Source(FWS)in 20%Fever without a Source(FWS)in 20%Serious Bacterial Infections(SBI)in 10%Serious Bacterial Infections(SBI)in 10%Bacteremia in 3%Bacteremia in 3%1%1%Urinary tract infections in 7%Urinary tract infections in 7%Meningitis in 1%Meningitis in 8 weeks)(8 weeks)-E.Coli-E.Coli-Klebsiella-Klebsiella-Proteus-Proteus-Strep.Pneumoniae-Strep.Pneumoniae-Hemophilus influenzae B-Hemophilus influenzae B-Neisseria meningitidis-Neisseria meningitidis-Staph.Aureus-Staph.Aureus-Salmonella-SalmonellaNelsons Textbook of Pediatrics,16th EditionByington et al,Pediatrics.2003;111(5):964-68 6 6A Tale of 3 Cities1980s1980s ALLALL 2 month olds admitted for fever 2 month olds admitted for fever19851985 RochesterRochester criteria developed criteria developed19851985 Hemophilus influenza B(HiB)vaccine licensedHemophilus influenza B(HiB)vaccine licensed19921992 Evaluation of Ceftriaxone after sepsis eval(Evaluation of Ceftriaxone after sepsis eval(BostonBoston)1993,19991993,1999 PhiladelphiaPhiladelphia criteria developed,revised criteria developed,revised19931993 Practice guideline for fever in 0-36 month infantsPractice guideline for fever in 0-36 month infants20002000 7 valent pneumococcal conjugate vaccine(PCV-7)licensed7 valent pneumococcal conjugate vaccine(PCV-7)licensed7 7Rochester CriteriaInfants 90 daysInfants 90 daysLow riskLow risk criteria:criteria:No sign of ear,soft tissue,or skeletal infectionNo sign of ear,soft tissue,or skeletal infection WBC count between 5-15(x10WBC count between 5-15(x103 3)Band count 1500/mmBand count 1500/mm Normal urinalysisNormal urinalysis Stool WBC 5/hpf(if sent)Stool WBC 5/hpf(if sent)Risk of SBI:Risk of SBI:Low risk:0.7%(UTI;no bacteremia)Low risk:0.7%(UTI;no bacteremia)High risk:25%(10%w/bacteremia)High risk:25%(10%w/bacteremia)Dagan et al,J Ped.1985;107(6)855-608 8Boston CriteriaInfants 28-89 days who met these criteria:Infants 28-89 days who met these criteria:Well appearingWell appearing No source of fever on examNo source of fever on exam Peripheral WBC ct 20 Peripheral WBC ct 20 CSF wbc ct 10CSF wbc ct CThese patients were not given antibiotics0.3%had a SBI(bacteremia)Baker et al,NEJM.1993;329(20):1437-1441 Baker et al,Pediatrics.1999;103:627-631 10101111Immunization StatusNigrovic et al,Clin PEM.2004;5(1):13-19 1212Evaluation Criteria in FWSAGEAGEUTIUTIBACTEREMIABACTEREMIAMENINGITISMENINGITIS0-60 DAYS0-60 DAYS61-90 DAYS61-90 DAYS3-6 MOS3-6 MOS7-12 MOS7-12 MOS13-24 MOS13-24 MOS24 MOS24 MOSUA+cxUA+cx(ALL)(ALL)UA+cxUA+cx(ALL)(ALL)Urine Urine dipdip+cx+cx(ALL)(ALL)Urine Urine dipdip+cx+cx(Uncirc*;all)(Uncirc*;all)Urine Urine dipdip+cx+cx(Only)(Only)Only if Only if symptomaticsymptomaticOnly if Only if symptomaticsymptomaticOnly if Only if symptomaticsymptomaticOnly if immuniz.Only if immuniz.not up to datenot up to dateOnly if immuniz.Only if immuniz.not up to datenot up to dateCBC+cx CBC+cx(ALL)(ALL)CBC+cx CBC+cx(ALL)(ALL)CBC+cx CBC+cx(ALL)(ALL)CSF+cxCSF+cx(ALL*)(ALL*)CSF+cxCSF+cx(If labs abnl)(If labs abnl)Only if Only if symptomatic*symptomatic*Only if Only if symptomaticsymptomaticOnly if Only if symptomaticsymptomatic*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-offBaraff et al,Ann Emerg Med.1993;22(7):1198-1210 1313Recognizable Viral SyndromesThe following illnesses are a reliable source of a The following illnesses are a reliable source of a fever in infants fever in infants 3 months:3 months:CroupCroup VaricellaVaricella HerpanginaHerpangina BronchiolitisBronchiolitisThe risk ofThe risk of Bacteremia is 0.2%Bacteremia is 0.2%NONO CBC/cx required CBC/cx required UTI is the same as those with a FWSUTI is the same as those with a FWSUA/cx UA/cx ISIS required requiredGreenes et al,J Ped Inf Dis.1999;18(3):258-261 1414Recognizable Viral SyndromesSome data in 0-90 day old infants Influenza and RSV studiedInfluenza and RSV studiedMeningitis not foundMeningitis not foundBacteremia was rareBacteremia was rareUTI was present w/RSV UTI was present w/RSV UA and cx should be UA and cx should be checkedcheckedPneumonia was commonPneumonia was commonControversy in this age group about need for further evaluationSmitherman et al,Pediatrics.2005;115(3):710-18 Titus et al,Pediatrics.2003;112(2):282-841515EnteritisMost febrile patients with diarrhea have viral gastroenteritisCriteria for sending a stool cultureBloody or mucoid stoolBloody or mucoid stool5 WBCs/hpf on stool microscopic exam5 WBCs/hpf on stool microscopic examAntibiotic treatmentOnce recommended for above criteriaOnce recommended for above criteriaHUS risk with antibioticsHUS risk with antibioticsBaraff et al,Ann Emerg Med.1993;22(7):1198-1210 Wong et al,NEJM.2000;342(26):1930-6 1616Occult PneumoniaPre PCV-726%of 5 year olds with FWS 26%of 20K 20K have occult pneumonia have occult pneumonia Post PCV-7 predictors of occult pneumoniaWBC WBC 20 K 20 K(+LR=2.14)(+LR=2.14)Fever Fever 5 days 5 days(+LR=2.24)(+LR=2.24)10 days of cough 10 days of cough(+LR=2.25)(+LR=2.25)Without a cough,routine CXR are unnecessaryMurphy et al,Acad Emerg Med.2007;14(3):243-9 Bachur et al,Ann Emerg Med.1999;33(2):166-173 1717Interpreting the Results1818Screening vs.Definitive testsCBC,UA,and CSF cell counts are screening testsDisadvantage:Not as accurate as a cultureDisadvantage:Not as accurate as a culture1/5 of those w/bacteremia have a nl CBC1/5 of those w/bacteremia have a nl CBC1/5 of those w/UTI have a nl UA 1/5 of those w/UTI have a nl UA Cultures are definitive testsDisadvantage:1-2 days required for resultsDisadvantage:1-2 days required for resultsTake home point send cultures if concerned about SBI1919Causes of SBIsAGEAGEUTI CAUSESUTI CAUSESBACTEREMIA+BACTEREMIA+MENINGITIS CAUSESMENINGITIS CAUSESNeonatesNeonates(0-(0-8 weeks)8 weeks)-E.Coli-E.Coli-Grp B Strep-Grp B Strep-Enterococcus-Enterococcus-Grp B Strep-Grp B Strep-E.Coli-E.Coli-Listeria-ListeriaOlderOlder(8 weeks)(8 weeks)-E.Coli-E.Coli-Klebsiella-Klebsiella-Proteus-Proteus-Strep.Pneumoniae-Strep.Pneumoniae-Hemophilus influenzae B-Hemophilus influenzae B-Neisseria meningitidis-Neisseria meningitidis-Staph.Aureus-Staph.Aureus-Salmonella-SalmonellaNelsons Textbook of Pediatrics,16th EditionByington et al,Pediatrics.2003;111(5):964-68 2020UTI ScreeningShaw et al,Pediatrics.1998;101(6):e12121UTI Treatment 2 months2 months Admit on Abx;risk of urosepsisAdmit on Abx;risk of urosepsisAmpicillin to cover EnterococcusAmpicillin to cover EnterococcusGentamicin(2-4 weeks)to cover E.coli/other gram negGentamicin(2-4 weeks)to cover E.coli/other gram negCefotaxime(2-4 weeks)to cover E.coli/other gram neg2-5 months2-5 months Controversial;inpatient or outpatient OKControversial;inpatient or outpatient OK 6 months6 months Send home on PO AbxSend home on PO Abx3 3rdrd generation cephalosporin generation cephalosporinHoberman et al,Pediatrics.1999;104(1):79-862222Bacteremia ScreeningWhite Blood Cell(WBC)count5-15 K;Rochester 5-15 K;Rochester (most conservative)(most conservative)20 K;Boston20 K;Boston15 K;Philadelphia15 K;PhiladelphiaBonsu et al,Acad Emerg Med.2004;11(12):1297-1301 Approximate normal values(%)L30 M5 E3 B2 N602323Bacteremia ScreeningNeutrophils;akaSegmented neutrophils(“segs”)Segmented neutrophils(“segs”)Polymorphonuclear cells(“polys”or“PMNs”)Polymorphonuclear cells(“polys”or“PMNs”)Composed of mature and immature forms:ANC=(WBC)x(%Neutrophils+%Bands)ANC=(WBC)x(%Neutrophils+%Bands)“Left Shift”2424Bacteremia ScreeningBands1500;Rochester1500;RochesterN/A;BostonN/A;BostonBand:Neutrophil ratio 0.2;PhiladelphiaBand:Neutrophil ratio 10,000 is concerning for bacteremiaCRP,Procalcitonin,and IL-6Kupperman et al,Ann Emerg Med.1998;31(6):679-687 2525Abnormal CBCAll patients 0-28 daysAll patients 0-28 days Admit on antibioticsAdmit on antibiotics Ampicillin and Gentamicin*Ampicillin and Gentamicin*28 days28 days 50 mg/kg Ceftriaxone 50 mg/kg Ceftriaxone andand physician follow up in 24 physician follow up in 24 hours hours Admit if physician follow-up not possible+/-AbxAdmit if physician follow-up not possible+/-Abx Ampicillin(0-8 weeks)Ampicillin(0-8 weeks)3 3rdrd generation IV cephalosporin(Cefotaxime or Ceftriaxone)generation IV cephalosporin(Cefotaxime or Ceftriaxone)Baskin et al,J Ped.1992;120(1):22-7*Or Cefotaxime if 14 days2626Meningitis ScreeningCSF TestCSF TestNormalNormalBacterialBacterialAsepticAseptic(Usually viral)(Usually viral)WBCWBC(cells/mm(cells/mm3 3)30(30(28 days)*28 days)*28 days)28 days)10001000(50%PMNs50%PMNs)10*-50010*-500(variable differentialvariable differential)RBCRBC(cells/mm(cells/mm3 3)0 00 00 0GlucoseGlucose(mg/dL)(mg/dL)50-7550-7550808050-10050-100Gram stainGram stainNo bacteriaNo bacteriaBacteria presentBacteria presentNo bacteriaNo bacteriaNegrini et al,Pediatrics.2000;105(2):315-3162727Meningitis ScreeningBacterial Meningitis Score(BMS)Bacterial Meningitis Score(BMS)Gram stain Gram stain(2 points)(2 points)CSF protein 80 CSF protein 80(1 point)(1 point)Peripheral ANC 10,000 Peripheral ANC 10,000(1 point)(1 point)CSF ANC 1,000 CSF ANC 1,000(1 point)(1 point)Seizure Seizure(1 point)(1 point)Pretreated,2 months of age,Pretreated,1 1Admit to hospitalAdmit to hospitalAll othersAll others Send home or admit for pain control Send home or admit for pain controlNigrovic et al,JAMA.2007;297(1):52-60Most PredictiveNigrovic et al,Pediatrics.2002;110(4):712-192828Meningitis Treatment*0-28 daysIV Ampicillin IV Ampicillin IV Gentamicin*IV Gentamicin*4 weeksIV VancomycinIV VancomycinIV Cefotaxime(or Ceftriaxone)IV Cefotaxime(or Ceftriaxone)*use*use meningiticmeningitic doses for all antibiotics doses for all antibiotics*Or 3rd generation IV cephalosporin if GNR or 2 wks2929Treatment and DispositionAGEAGEUrineUrine+nitrite+nitrite oror+LELECBCCBCWBC 5 or WBC 15 15 ororANC ANC 10,000 10,000 ororBNR 0.2 in neonatesBNR 0.2 in neonates+/-Bands 1500+/-Bands 1500CSFCSFBMS BMS 1 1Pretreated w/Pretreated w/AbxAbxStool Stool 5 WBC5 WBC0-4 0-4 wkswksIV Amp/Gent,IV Amp/Gent,even if labs nleven if labs nlIV Amp/Gent,even if labs nlIV Amp/Gent,even if labs nlIV Amp/Gent,IV Amp/Gent,even if labs nleven if labs nlIV Amp/Gent,IV Amp/Gent,even if labs nleven if labs nl5-8 5-8 wkswksIV IV Amp/CefotaxAmp/CefotaxIV Amp/Cefotax orIV Amp/Cefotax orIV/IM Ceftriaxone w/24 hr follow-upIV/IM Ceftriaxone w/24 hr follow-upIV Amp/CefotaxIV Amp/CefotaxWait for Wait for cultureculture2-6 2-6 mosmosIV IV Cefotaxime Cefotaxime ororPO CefiximePO CefiximeIV Cefotax orIV Cefotax orIV/IM Ceftriaxone w/24 hr follow-upIV/IM Ceftriaxone w/24 hr follow-upIV Vanc+CefotaxIV Vanc+CefotaxWait for Wait for cultureculture6 6 mosmosPO CefiximePO CefiximeIV Cefotax orIV Cefotax orIV/IM Ceftriaxone w/24 hr follow-upIV/IM Ceftriaxone w/24 hr follow-upIV Vanc+CefotaxIV Vanc+CefotaxWait for Wait for cultureculture3030CASE SCENARIOS3131Case#12 wk with T=100.5.Vitals signs and exam otherwise normalEvaluation?CBC/cx,cath UA/cx,CSF cts/cxCBC:WBC=8(CBC:WBC=8(N N60 60 BandsBands0 0 L L30 30 MM5 5 E E3 3 B B2 2)UA:no nitrites,no leukocyte esteraseUA:no nitrites,no leukocyte esteraseCSF:wbc=15,rbc=2,glc=50,pro=50,GS negCSF:wbc=15,rbc=2,glc=50,pro=50,GS negManagement?Admit on Amp/Gent3232Case#25 mo with T=103.Vitals signs and exam 5 mo with T=103.Vitals signs and exam otherwise normalotherwise normalEvaluation?Evaluation?CBC/cx,cath urine CBC/cx,cath urine dipdip/cx/cx CBC:WBC=21(CBC:WBC=21(N N60 60 BandsBands0 0 L L30 30 MM5 5 E E3 3 B B2 2)UA:no nitrites,no leukocyte esteraseUA:no nitrites,no leukocyte esteraseManagement?Management?Get a Get a CXRCXR to r/o occult pneumonia to r/o occult pneumonia Give Give 50 mg/kg Ceftriaxone50 mg/kg Ceftriaxone and send and send homehome Treat with oral Amoxicillin if pneumonia presentTreat with oral Amoxicillin if pneumonia present3333Case#35 wk with T=101.4 Vitals signs and exam otherwise normalEvaluation?CBC/cx,cath UA/cx,CSF cts/cxCBC:WBC=16(CBC:WBC=16(N N50 50 BandsBands20 20 L L20 20 MM5 5 E E3 3 B B2 2)UA:no nitrites,no leukocyte esteraseUA:no nitrites,no leukocyte esteraseCSF:wbc=5,rbc=2,glc=50,pro=50,GS negCSF:wbc=5,rbc=2,glc=50,pro=50,GS negManagement?Give 50 mg/kg Ceftriaxone and f/u w/PMD in 24 hours3434Case#47 mo with T=103.4,P=170,BP 70/40,R=38,O2=94%.3 sec cap refill,circumcised,exam otherwise normalEvaluation?CBC/cxCBC:WBC=16(CBC:WBC=16(N N50 50 BandsBands20 20 L L20 20 MM5 5 E E3 3 B B2 2)Management?Management?NS 20 ml/kg;repeat as neededAdmit on IV Cefotaxime due to Admit on IV Cefotaxime due to ill appearanceill appearance3535Case#57 wk with T=101.9,P=120,BP 80/50,R=28,O2=97%;Exam otherwise normalEvaluation?CBC/cx,cath UA/cx,CSF cts/cx*CBC:WBC=8(CBC:WBC=8(N N60 60 BandsBands0 0 L L30 30 MM5 5 E E3 3 B B2 2)UA:+nitrites,no leukocyte esteraseUA:+nitrites,no leukocyte esteraseCSF:wbc=5,rbc=2,glc=50,pro=50,GS negCSF:wbc=5,rbc=2,glc=50,pro=50,GS negManagement?Admit on Amp/Cefotax due to risk of urosepsis at this age3636Case#62 yr with T=105 and bloody diarrhea.P=120,BP 80/50,R=28,O2=97%.Exam otherwise normalEvaluation?Stool cultureManagement?Discharge with supportive care(no Abx);follow up on stool culture3737Case#75 mo with T=102.3,P=120,BP 80/50,R=28,O2=97%.Coarse BS,exam otherwise normal.Evaluation?Cath urine dip/cxUA:no nitrites,no leukocyte esteraseUA:no nitrites,no leukocyte esteraseManagement?Discharge w/supportive care for bronchiolitis3838Case#813 mo with T=104,P=120,BP 80/50,R=28,O2=97%.Exam otherwise normalEvaluation?Cath urine dip/cxUA:no nitrites,trace leukocyte esteraseUA:no nitrites,trace leukocyte esteraseManagement?Send home on oral Cefixime3939Case#97 mo with T=103.4,P=120,BP 80/50,R=28,O2=97%.Circumcised;exam normalEvaluation?No labsManagement?Discharge with supportive care for febrile illness4040Case#109 wk with T=103.4,P=150,BP 80/50,R=32,9 wk with T=103.4,P=150,BP 80/50,R=32,OO2 2=97%.Circumcised;exam normal=97%.Circumcised;exam normalEvaluation?Evaluation?CBC/cx,cath UA/cx,CSF cts/cxCBC/cx,cath UA/cx,CSF cts/cx CBC:WBC=14(CBC:WBC=14(N N70 70 BandsBands2 2 L L18 18 MM5 5 E E3 3 B B2 2)UA:no nitrites,no leukocyte esteraseUA:no nitrites,no leukocyte esteraseManagement?Management?Do LP:Do LP:CSF:wbc=500 C