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Fever without focus Dr Rafat Mosalli. Question 1 A 3 week old male infant is brought to your ED with a 2 day history of fever. He was born by uncomplicated.

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Presentation on theme: "Fever without focus Dr Rafat Mosalli. Question 1 A 3 week old male infant is brought to your ED with a 2 day history of fever. He was born by uncomplicated."— Presentation transcript:

1 Fever without focus Dr Rafat Mosalli

2 Question 1 A 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 38.9 C (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 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 38.9 C (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-up b. Discharge on oral amoxicillin with close follow-up c. LP and admission for parenteral antibiotics d. CXR to r/o pneumonia e. Stool for analysis and culture, and outpatient follow-up

3 Question 2 A 7 week old girl is referred in to ED for evaluation of a rectal temperature of 39.2 C. 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:A 7 week old girl is referred in to ED for evaluation of a rectal temperature of 39.2 C. 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: a.IM ceftriaxone in the ED b.Admission to the hospital for IV antibiotics c.Discharge with follow-up in 24 hours d.Admission to the hospital for observation e.Discharge on amoxicillin

4 Question 3 A 19 month old boy comes to the ED with a 3 day history of fever. He appears well but his tympanic T is 39.8 C. 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). BCs are sent.A 19 month old boy comes to the ED with a 3 day history of fever. He appears well but his tympanic T is 39.8 C. 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). BCs are sent. Appropriate management at this point will be to: Appropriate management at this point will be to: a. Obtain a urine sample b. Administer IM ceftriaxone c. Perform an LP d. Obtain a CXR e. Discharge on antipyretics

5 Objectives DefinitionsDefinitions Which patients need in-depth evaluation and treatment?Which patients need in-depth evaluation and treatment? What laboratory studies are indicated for various age ranges?What laboratory studies are indicated for various age ranges? Which patients need treatment with antibiotics?Which patients need treatment with antibiotics? Which patients should be hospitalized?Which patients should be hospitalized?

6 Definitions FeverFever Fever without focusFever without focus Fever of unknown originFever of unknown origin Occult bacteremiaOccult bacteremia Serious bacterial infection (SBI)Serious bacterial infection (SBI)

7 What is fever? Rectal temperature > 38 C, either at physicians office, ED, or documented at home by a reliable parent or other adult

8 Different body sites Rectal standardRectal standard Oral lowerOral lower Axillary lowerAxillary lower Tympanic lowerTympanic lowerDocumented: In the absence of antipyreticsIn the absence of antipyretics In ED or office or by hx from reliable parents/adultsIn ED or office or by hx from reliable parents/adults

9 Frequency of febrile illness 35% of unscheduled ambulatory care visits35% of unscheduled ambulatory care visits 65% of kids see doc before age 2y65% of kids see doc before age 2y Majority (75%) for T < 39 CMajority (75%) for T < 39 C 13% T > % T > 39.5

10 Fever of Unknown Origin 1. Fever of 38 C or greater which has continued for a 2 to 3 weeks 2. Absence of localizing clinical signs 3. Negative simple investigations

11 Fever without focus An acute febrile illness in which the etiology of the fever is not apparent after a careful history and physical examination.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 cause20% of childhood fevers have no apparent cause Baraff et al, Pediatrics 1993; 92:1-12 Baraff et al, Pediatrics 1993; 92:1-12

12 Occult bacteremia …a positive blood culture in the setting of well appearance and without focus (e.g. no pneumonia)…a positive blood culture in the setting of well appearance and without focus (e.g. no pneumonia) Fleisher et al, J Pediatrics 1994 Fleisher et al, J Pediatrics 1994

13 Occult bacteremia organisms Streptococcus pneumonia > 85% Streptococcus pneumonia > 85% Haemophilus influenzae type B Haemophilus influenzae type B (now rare – previously 10%) Neisseria meningitidis 3-5% Neisseria meningitidis 3-5% Others:Others: S. aureus S. aureus S. pyogenes (GAS) S. pyogenes (GAS) Salmonella species Salmonella species

14 Outcomes of occult bacteremia without antibiotics Persistent fever56%Persistent fever56% Persistent bacteremia21%Persistent bacteremia21% Meningitis9%Meningitis9% S. pneumonia 6% S. pneumonia 6% H. Influenzae 26% (now rare) H. Influenzae 26% (now rare)

15 Age is quite matter >10 % of well-appearing young infants with a temperature >38°C has a serious bacterial infection or meningitis>10 % of well-appearing young infants with a temperature >38°C has a serious bacterial infection or meningitis Only 39°C (manifest bacteremiaOnly 39°C (manifest bacteremia

16 Serious Bacterial Infection …Include meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia and enteritis…Include meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia and enteritis Baraff et al, Pediatrics 1993; 92:1-12 Baraff et al, Pediatrics 1993; 92:1-12

17 Fever Practice Guidelines Fever Practice Guidelines CPS guidelines: Management of the febrile one-to 36-month-old child with no focus of infection.CPS guidelines: Management of the febrile one-to 36-month-old child with no focus of infection. Paediatr Child Health 1996;1:41-45 *re-affirmed Paediatr Child Health 1996;1:41-45 *re-affirmed April 2002 April 2002 American consensus guidelines: Practice guideline for the management of infants and children 0-36 months of age with fever without source.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 Baraff et al, Pediatrics 1993;92:1-12

18 Case scenarios - fever By age group:By age group: < 1 month of age < 1 month of age 1 – 3 months 1 – 3 months 3 – 36 months 3 – 36 months

19 Why according to age Because 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. Because 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.

20 Febrile infant < 1 month American consensus recommendations American consensus recommendations All should have:All should have: Full septic w/uFull septic w/u CSF cultures, gm stain, cell count/diff, gluc/protCSF cultures, gm stain, cell count/diff, gluc/prot Blood culturesBlood cultures Urine routine, micro, cultureUrine routine, micro, culture If diarrhea, stool exam (smear and culture)If diarrhea, stool exam (smear and culture) If resp sx: CXRIf resp sx: CXR ADMIT, IV antibiotics, orADMIT, IV antibiotics, or ADMIT, observe without antibioticsADMIT, observe without antibiotics

21 Febrile infants 1-3 m of age According to validated criteria E.g. Rochester score E.g. Rochester score Low and high riskLow and high risk

22 Febrile infants < 3 months risk of bacteremia If meets low risk Rochester 0.2% (1:500)If meets low risk Rochester 0.2% (1:500) criteria criteria If meets low risk criteria 0.7-1%If meets low risk criteria 0.7-1% but < 1 month but < 1 month

23 Febrile infants 1-3 m of age Hi Risk: American and Canadian Consensus recommendations ADMIT to hospital with full septic w/uADMIT to hospital with full septic w/u BC, UC, LPBC, UC, LP Broad-spectrum parental antibioticsBroad-spectrum parental antibiotics

24 Febrile infants 1-3m of age low risk Febrile infants 1-3m of age low risk Option 1 (American):Option 1 (American): Blood culture Urine culture LP Ceftriaxone 50 mg/kg IM Return for re-evaluation w/i 24 hours Option 2 (American and CPS) Option 2 (American and CPS) No investigation (or urine culture only ) Careful outpatient observation, without treatment, close follow-up

25 Follow-up of Infants 1-3m old Within 24 hoursWithin 24 hours Repeat exam for source, sequelaeRepeat exam for source, sequelae Review, repeat labsReview, repeat labs Arrange ongoing follow-upArrange ongoing follow-up

26 Follow-up of 1-3m If blood culture positiveIf blood culture positive ADMIT for sepsis evaluationADMIT for sepsis evaluation Parenteral antibiotics pending resultsParenteral antibiotics pending results If urine culture positiveIf urine culture positive Persistent fever: ADMIT for sepsis evaluation and parenteral abx tx pending resultsPersistent fever: ADMIT for sepsis evaluation and parenteral abx tx pending results Afebrile and well: outpatient antibioticsAfebrile and well: outpatient antibiotics

27 Fever Without Source Age 3 – 36 Months

28 Risk of occult bacteremiaRisk of occult bacteremia 3-11%, mean 4.3% for T>39 C3-11%, mean 4.3% for T>39 C Risk greater withRisk greater with Higher temperaturesHigher temperatures WBC > 15,000 (13% vs 2.6%)WBC > 15,000 (13% vs 2.6%) Risk of pneumococcal meningitis (w/o abx tx) 0.21% (1:500)Risk of pneumococcal meningitis (w/o abx tx) 0.21% (1:500)

29 How should a child with FWF be evaluated? Detailed history and thorough physical examinationDetailed history and thorough physical examination avoid indiscriminately ordering a large battery of tests.avoid indiscriminately ordering a large battery of tests.

30 Physical examination: Toxic appearance Lethargy/irritabilityLethargy/irritability Poor/absent eye contactPoor/absent eye contact Poor perfusionPoor perfusion Hypo/hyperventilationHypo/hyperventilation CyanosisCyanosis

31 FWS – age 3-36 months: Consensus Recommendations CHILD NON-TOXIC, T < 39 CCHILD NON-TOXIC, T < 39 C No diagnostic tests or antibioticsNo diagnostic tests or antibiotics Acetaminophen 15 mg/kg prn for feverAcetaminophen 15 mg/kg prn for fever Return if fever persists > 48 hours or the followings happened:Return if fever persists > 48 hours or the followings happened:

32 Return to the Emergency Department if your child more fussy or wont stop cryingmore fussy or wont stop crying too sleepy or drowsytoo sleepy or drowsy stiff neckstiff neck Wont stop vomitingWont stop vomiting new rashnew rash Has a seizure Has a seizure Gets any other new or worsening symptom(s) that concerns youGets any other new or worsening symptom(s) that concerns you

33 FWS – age 3-36 months: Recommendations CHILD NON-TOXIC, T 39 CCHILD NON-TOXIC, T 39 C Urine culture (for M < 6 month, F < 2 yrs age)Urine culture (for M < 6 month, F < 2 yrs age) BC – 2 optionsBC – 2 options Option 1: obtain for all children with T 39 COption 1: obtain for all children with T 39 C Option 2: obtain if T 39 C and WBC >15,000Option 2: obtain if T 39 C and WBC >15,000 CXR, stool culture if indicated clinicallyCXR, stool culture if indicated clinically Acetaminophen 15 mg/kg q4h for T 39 CAcetaminophen 15 mg/kg q4h for T 39 C Follow-up in hours *no antibioticsFollow-up in hours *no antibiotics

34 FWS – age 3-36 months: Consensus Recommendations CHILD APPEARS TOXIC:CHILD APPEARS TOXIC: ADMIT to hospitalADMIT to hospital Sepsis w/uSepsis w/u Parenteral abxParenteral abx

35 Investigation options [ ] CBC [ ] blood culture [ ] urinalysis [ ] urine culture [ ] CXR [ ] LP [ ] Nothing

36 Choice of antibiotic If decide to treat empiricallyIf decide to treat empirically ceftriaxone or po Amoxicillin/clavulanate

37 FWS – age 3-36 months: BC returns positive Pneumococcus:Pneumococcus: Persistent fever: ADMIT for sepsis w/u and parenteral abx pending sensitvityPersistent fever: ADMIT for sepsis w/u and parenteral abx pending sensitvity

38 FWS – age 3-36 months: BC returns positive All Other Bacteria:All Other Bacteria: ADMIT for sepsis w/u and parenteral abx pending sensitivity resultsADMIT for sepsis w/u and parenteral abx pending sensitivity results

39 FWS – age 3-36 months: Urine culture returns positive All organisms:All organisms: ADMIT if febrile or ill-appearingADMIT if febrile or ill-appearing Outpatient abx if afebrile and wellOutpatient abx if afebrile and well

40 Summary: FWS Infants < 28 days: Infants 1-3 months Non toxic children 3 m- 3 yrs (T < 39 C) Non toxic children 3 m-3 y (T 39 C): Hospitalize +/- abx - According to risk score hospital Vs home, +/- abx Home, no antibiotics +/- labs, home, no antibiotics close follow-up in all!

41 41 Toxic highly Febrile Child Aged 3-36 mos Without Apparent Focus Be Managed ? Regardless of PCV status Hospital/ Antibiotic Rx YesYes "ill", "toxic", "lethargic" "ill", "toxic", "lethargic" ?? >20,000 WBC/mm3 >20,000 WBC/mm3NoNo?? risk for bacteremia WBC fever male age 7-11 mos risk for bacteremia WBC fever male age 7-11 mos YesYes ?? YesYes ConsiderConsider Age 3-36 mos Temp. > 39 0 C Age 3-36 mos Temp. > 39 0 C AMOX 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. 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

43 Heptavalent conjugate pneumococcal vaccine very efficaciousvery efficacious Likely to make most of the foregoing pneumococcal in 3-36 month group obsoleteLikely to make most of the foregoing pneumococcal in 3-36 month group obsolete Finally become routine by MCHFinally become routine by MCH Given at 2,4,6 month and 12-15m

44 44 Effect in Target Age Group Invasive Pneumococcal Disease Rates in Children < 3 Years, ABCs, <1 yr 2 yrs 1 yr 77% (<1 yr) 77% (<1 yr) 83% (1 yr) 83% (1 yr) 64% (2 yr) 64% (2 yr) 2003 vs baseline 2003 data are preliminary PCV7 Farely et al, ICP, Cancun, Mexico, August 2003

45 45 Effect in Target Age Group Invasive Pneumococcal Disease Rates in Children < 3 Years, ABCs, data are preliminary Farely et al, ICP, Cancun, Mexico, August 2003 ~ 80% in invasive pneumococcal disease in children < 3 yrs ~ 80% in invasive pneumococcal disease in children < 3 yrs 77% (<1 yr) 77% (<1 yr) 83% (1 yr) 83% (1 yr) 64% (2 yr) 64% (2 yr) 2003 vs baseline

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