2Question 1A 3 week old male infant is brought to your ED with a 2 day history of fever. He was born by uncomplicated vaginal delivery at 37 weeks gestation following a normal pregnancy.. His vital signs are: T 38.9C (R), HR 140, RR 40, and BP 90/60. He is sleepy but easily arousable. Physical exam is normal apart from a slightly dull left tympanic membrane. WBC is 16,000, his UA shows 3 WBC/hpf. BC and UC are sent. Your management at this point would consist of:a. Discharge on antipyretics with close follow-upb. Discharge on oral amoxicillin with close follow-upc. LP and admission for parenteral antibioticsd. CXR to r/o pneumoniae. Stool for analysis and culture, and outpatient follow-up
3Question 2A 7 week old girl is referred in to ED for evaluation of a rectal temperature of 39.2C. Her PE is normal. Her UA is negative, her WBC is 9,000 (70% neuts, 28% lymphs, 2% bands), and her LP reveals a CSF WBC count of 8. BC, UC, and CSF cultures are sent. Acceptable management options for this child would include any one of the following except:IM ceftriaxone in the EDAdmission to the hospital for IV antibioticsDischarge with follow-up in 24 hoursAdmission to the hospital for observationDischarge on amoxicillin
4Question 3A 19 month old boy comes to the ED with a 3 day history of fever. He appears well but his tympanic T is 39.8C. His chest is clear, his abdomen is soft, and he is circumcised. No source can be found for his fever. A CBC reveals a WBC of 8200 (60% neuts, 27% bands). BC’s are sent.Appropriate management at this point will be to:a. Obtain a urine sampleb. Administer IM ceftriaxonec. Perform an LPd. Obtain a CXRe. Discharge on antipyretics
5Objectives Definitions Which patients need in-depth evaluation and treatment?What laboratory studies are indicated for various age ranges?Which patients need treatment with antibiotics?Which patients should be hospitalized?
6Definitions Fever Fever without focus Fever of unknown origin Occult bacteremiaSerious bacterial infection (SBI)
7What is fever?Rectal temperature > 38C, either at physician’s office, ED, or documented at home by a reliable parent or other adult
8Different body sites Rectal standard Oral 0.5-0.6 lower Axillary lowerTympanic lowerDocumented:In the absence of antipyreticsIn ED or office or by hx from reliable parents/adultsTympanic age and technique specific; long tortuous ear canal in small kidsRectal preferred in under 3 months of ageAbdomen-toe temperature differential as method of distinguishing overbundling from true fever
9Frequency of febrile illness 35% of unscheduled ambulatory care visits65% of kids see doc before age 2yMajority (75%) for T < 39 C13% T > 39.5
10Fever of Unknown Origin 1. Fever of 38C or greater which has continued for a 2 to 3 weeks 2. Absence of localizing clinical signs 3. Negative simple investigations
11Fever without focus“An acute febrile illness in which the etiology of the fever is not apparent after a careful history and physical examination.”20% of childhood fevers have no apparent causeBaraff et al, Pediatrics 1993; 92:1-12
12Occult bacteremia“…a positive blood culture in the setting of well appearance and without focus (e.g. no pneumonia)Fleisher et al, J Pediatrics 1994
13Occult bacteremia organisms Streptococcus pneumonia > 85%Haemophilus influenzae type B(now rare – previously 10%)Neisseria meningitidis 3-5%Others:S. aureusS. pyogenes (GAS)Salmonella species
14Outcomes of occult bacteremia without antibiotics Persistent fever 56%Persistent bacteremia 21%Meningitis 9%S. pneumonia 6%H. Influenzae 26% (now rare)
15Age is quite matter>10 % of well-appearing young infants with a temperature >38°C has a serious bacterial infection or meningitisOnly <2 %of well-appearing older infants and young children with a temperature >39°C (manifest bacteremia
16Serious Bacterial Infection “…Include meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia and enteritis”Baraff et al, Pediatrics 1993; 92:1-12
17Fever Practice Guidelines CPS guidelines: Management of the febrile one-to 36-month-old child with no focus of infection.Paediatr Child Health 1996;1: *re-affirmedApril 2002“American” consensus guidelines: Practice guideline for the management of infants and children 0-36 months of age with fever without source.Baraff et al, Pediatrics 1993;92:1-12
18Case scenarios - fever By age group: < 1 month of age 1 – 3 months
19Why according to ageBecause in young infants there's a greater probability of serious bacterial infection so more aggressive approach to the evaluation and management of fever is warranted.
20Febrile infant < 1 month “American” consensus recommendationsAll should have:Full septic w/uCSF cultures, gm stain, cell count/diff, gluc/protBlood culturesUrine routine, micro, cultureIf diarrhea, stool exam (smear and culture)If resp sx: CXRADMIT, IV antibiotics, orADMIT, observe without antibioticsGBS, E. coli, Listeria
21Febrile infants 1-3 m of age According to validated criteriaE.g. Rochester scoreLow and high risk
28Fever Without Source Age 3 – 36 Months Risk of occult bacteremia3-11%, mean 4.3% for T>39CRisk greater withHigher temperaturesWBC > 15,000 (13% vs 2.6%)Risk of pneumococcal meningitis (w/o abx tx) % (1:500)
29How should a child with FWF be evaluated? Detailed history and thorough physical examinationavoid indiscriminately ordering a large battery of tests.Laboratory studies should be directed as much as possible toward the most likely diagnostic possibilities.
31FWS – age 3-36 months: Consensus Recommendations CHILD NON-TOXIC, T < 39CNo diagnostic tests or antibioticsAcetaminophen 15 mg/kg prn for feverReturn if fever persists > 48 hours or the followings happened:
32Return to the Emergency Department if your child more fussy or won’t stop cryingtoo sleepy or drowsystiff neckWon’t stop vomitingnew rashHas a seizureGets any other new or worsening symptom(s) that concerns you
33FWS – age 3-36 months: Recommendations CHILD NON-TOXIC, T 39CUrine culture (for M < 6 month, F < 2 yrs age)BC – 2 optionsOption 1: obtain for all children with T 39COption 2: obtain if T 39C and WBC >15,000CXR, stool culture if indicated clinicallyAcetaminophen 15 mg/kg q4h for T 39CFollow-up in hours *no antibioticsNo antibiotics; supported by Baraff in annals of emerg med Dec 2000
34FWS – age 3-36 months: Consensus Recommendations CHILD APPEARS TOXIC:ADMIT to hospitalSepsis w/uParenteral abx
35Investigation options [ ] CBC [ ] blood culture [ ] urinalysis [ ] urine culture [ ] CXR [ ] LP [ ] NothingLaboratory studies should be directed as much as possible toward the most likely diagnostic possibilities.
36Choice of antibiotic If decide to treat empirically ceftriaxone or po Amoxicillin/clavulanate
37FWS – age 3-36 months: BC returns positive Pneumococcus:Persistent fever: ADMIT for sepsis w/u and parenteral abx pending sensitvityNatural course of pneumococcal bacteremia is resolution
38FWS – age 3-36 months: BC returns positive All Other Bacteria:ADMIT for sepsis w/u and parenteral abx pending sensitivity results
39FWS – age 3-36 months: Urine culture returns positive All organisms:ADMIT if febrile or ill-appearingOutpatient abx if afebrile and well
40Summary: FWS Hospitalize +/- abx Infants < 28 days: -According to risk score hospital Vs home, +/- abxHome, no antibiotics+/- labs, home, no antibioticsInfants < 28 days:Infants 1-3 monthsNon toxic children 3 m- 3 yrs (T < 39C)Non toxic children 3 m-3 y (T 39C):close follow-up in all!
41Regardless of PCV status Toxic highly Febrile Child Aged 3-36 mos Without Apparent Focus Be Managed ?Age 3-36 mosTemp. > 390CRegardless of PCV status"ill" , "toxic","lethargic"?>20,000WBC/mm3No? risk for bacteremia WBC fevermaleage 7-11 mosYes??Hospital/ Antibiotic RxYesYesConsiderAMOX or specify why other
42“ I think it is clear that the handwriting is on the wall saying that occult bacteremia is dead. It was dying when Hib disappeared and Prevnar has destroyed it.” contribution to Pediatric Emergency Medicine List Serve
43Heptavalent conjugate pneumococcal vaccine very efficaciousLikely to make most of the foregoing pneumococcal in 3-36 month group obsoleteFinally become routine by MCHGiven at 2,4,6 month and 12-15m? Mention C – reactive protein
44Effect in Target Age Group Invasive Pneumococcal Disease Rates in Children < 3 Years, ABCs, 77% (<1 yr) 83% (1 yr) 64% (2 yr)2003 vs baselinePCV71 yr<1 yr2 yrs2003 data are preliminaryFarely et al, ICP, Cancun, Mexico, August 2003
45~ 80% in invasive pneumococcal disease in children < 3 yrs Effect in Target Age Group Invasive Pneumococcal Disease Rates in Children < 3 Years, ABCs, 77% (<1 yr) 83% (1 yr) 64% (2 yr)2003 vs baseline~ 80% in invasivepneumococcal diseasein children < 3 yrs2003 data are preliminaryFarely et al, ICP, Cancun, Mexico, August 2003