1. The Febrile Child: Treat ‘em or Street ‘em
David Chaulk
Pediatric EM Fellow
January 2004

2. Overview Cases Temperature Measurement Who Cares? Schools of Thought
Scoring Systems
Empiric Therapy
Changes in Prevalence & Changes in Management
Recognizable Illnesses
CPS Guidelines
Cases Revisited

3. Case 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. At his two week check-up he was noted to be gaining weight appropriately. His vital signs are: T 38.9C (R), HR 140, RR 40, and BP 90/60. He is sleepy but easily rousable. Physical exam is normal apart from a slightly dull left tympanic membrane. His peripheral 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

4. Case 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). BC, UC are sent. Acceptable management options for this child would include any one of the following except:
IM ceftriaxone in the ED
Admission to the hospital for IV antibiotics
Discharge with follow-up in 24 hours
Admission to the hospital for observation
Discharge on amoxicillin
Any other investigations?
Might be useful to initially exclude the LP, and see if people would do this. This is important issue to talk about since it’s controversial. The evidence is complicated, and worthwhile talking about.

5. Case 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). BC’s are sent.
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

6. Temperature Measurement
Source
Fever
Problem
Rectal
> 38
Invasive, takes time
Oral
0.5 lower
Technique dependent
Axillary
1.0 lower
? Reliability
? variability
Tympanic
For axillary, not just the issue of reliability, but also the issue of variability.

7. Temperature Measurement
Rectal is gold standard based on study from 1937!
Controversial! Tympanic very accurate or very inaccurate
Lanham 1999…tympanic misses too many febrile children
Shinozaki, 1998…rectal inaccurate because of poor blood supply to rectum, T is slow to change
Physiologically, T controlled by hypothalamus
Hypothalamus and Tympanic Membrane have same blood supply (common carotid)

8. Temperature Measurement CPS Guidelines
Age Recommended technique
Birth to 2 years
1. Rectal (definitive)
2. Axillary (screening)
Over 2 years to 5 years
1. Rectal 2. Tympanic 3. Axillary
Older than 5 years
1. Oral 2. Tympanic 3. Axillary

9. Who cares?
65% of children 0-2 will visit a physician for a febrile illness
10-20% of PED visits, 20-30% ped office visits
50% are fever without source
Most represent self-limited illness
Small precentage with Serious Bacterial Illness…but who?

10. A few Definitions… Fever without Source Fever of Unknown Origin
“…An acute febrile illness in which the etiology of the fever is not apparent after a careful history and physical examination.”
Baraff et al, Pediatrics 1993; 92:1-12
Fever of Unknown Origin
Fever > 2 to 3 weeks
Absence of localizing signs
Failure of simple diagnostic efforts

11. A few Definitions… Occult Bacteremia Serious Bacterial Infections
“…a positive blood culture in the setting of well appearance and without focus (e.g. no pneumonia), BUT may be in the presence of URTI, otitis media, diarrhea, or wheezing”
Fleisher et al, J Pediatrics 1994
Serious Bacterial Infections
“…SBI include meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia and enteritis”
Baraff et al, Pediatrics 1993; 92:1-12

12. Occult Bacteremia Strep pneumo. >85% N.meningitidis 3-5% Others GAS
Staph aureus
Salmonella spp
HiB
Now rare, previously was ~10%

13. Bacteremia < 2 mos, T > 38 incidence is 2-3%
Avner and Baker, Emerg Med Clin NA 2002;20(1)
3-36 mos, T < 39 incidence is <2%
Klein, Ped Inf Dis J 2002;21(6):584-8
2002 data, ie. Post HiB era
Should quote the source & size of sample size.

14. Untreated Bacteremia Outcomes
Persitent fever 56%
Persistent bacteremia 21%
Meningitis 9%
S.pneumo 6%
HiB 26% (no longer seen)
My recollection is that this data is old – pre HIB & certainly pre-Prevnar.

15. Scoring Systems Demographic and Clinical Parameters Lab Screens:
Age, temperature, clinical appearance
Lab Screens:
CBC, ESR, U/A
Initially very promising…ultimately not so “hot”

16. Scoring Systems Can we identify high risk kids?
Yale Observational Score
611 children, 192 bacteremic
Median score was the same for both groups
A high score was a good marker
Specificity and NPV ~97%
Sensitivity and PPV ~5%
Not great screening tool (screens should be sensitive)
Also important to emphasis inability of PE – even with low threshold to pick up all septic children.

17. Scoring Systems Can we identify low risk kids?
Three main scoring systems
Philadelphia, Rochester and Boston Criteria
All are similar but there are differences
Main risk factors identified
Age (3 groups. 0-28d, 28-90d, 3-36m)
Temperature T > % with OB
Petechiae – 15-20% SBI
WBC >15,000, bands>1000 – 5 fold  in OB
Toxic appearance
Lethargy/irritabilty Poor eye contact
Poor perfusion Hypo/hyperventilation
Cyanosis

18. Philadelphia
Rochester
Boston
Age
1-2 months
0-2 months
1-3 months
Temperature
38.2C
38.0C
History
Not specified
Term infant
Previously well
No recent vacc /abx
Not dehydrated
Physical examination
Well-appearing (IOS < 10)
Well-appearing
Laboratory parameters (defines lower-risk patients)
Wbc < 15,000
BNR < 0.2
UA < 10 WBC/hpf
Urine gram stain –ve
CSF <8 WBC
CSF gm stain –ve
CXR clear
Stool: no blood, few or
no WBC’s on smear
WBC > 5,000; < 15,000
Abs band ct <1500
< 5 WBC/hpf stool smear
* No LP required!
CSF < 10
WBC < 20,000
Higher risk patients
Hospitalize + empiric abx
Hospitalize + empiric abx
Lower risk patients
Home
No antibiotics
Follow-up required
Empiric abx (IM ceftriaxone)

19. Statistics Philadelphia Rochester Boston SBI (low risk) % 1.1 5.4
1.1
5.4
NPV %
100
98.9
94.6
Sensitivity %
92.4 ?

21. Are neonates really different?
Philadelphia criteria applied to 3-28 d
254 pts, 43% low risk (managed as OP)
32 (12.6%) with SBI
17 UTI’s, 8 OB, 4 BM
5 low risk infants has SBI
Would miss 20:1000 of infants with SBI
Empiric antibiotics standard of care in this age group

22. Empiric Antibiotics 28-90 d
Lieu, 1992
Decision analysis based on 6 management strategies for management of fever >38 in d infants
Worst Strategy
Clinical judgement
Most Effective
Full septic work up, IM ceftriaxone and outpatient management
It’s a bit confusing because you alternate different age groups. Would be best to focus on 0-3 month (breaking it into 0-1 and 1-3 months) & then on 3 – 36 months.

23. Empiric Antibiotics 3-36 mos
Couple of big studies…neither great
Bass, 1993
519 children 3-36 mos, 11.6% with OB
Compared clavulin to ceftriaxone in children with T>40 or T>39.5 and WBC>15
No difference between groups
Fleisher, 1994
6733 patients, 2.9% with OB
Compared amoxil to ceftriaxone
“…ceftriaxone eradicated bacteremia, had fewer focal complications and less persitent fever…”
Important to clearly emphasize this is in children months of age.

24. Us Vs. Them Survey of AAP general pediatricians 610 (67%) responded
40% indicated that parents frequently ask for abx when MD feels it is not warranted
48% stated parents pressure them to prescribe
30% stated they comply with that pressure
Parental pressure viewed as leading cause for unnecessary abx
MD versus parents

25. Us Vs. Them Should Fever be Treated? Pros Cons Decreases disomfort
Dereases parental anxiety
Extreme may cause brain damage (exceedingly rare)
Limited/minimal evidence that it may reduce febrile seizures
Cons
Harm of antipyretics may outweigh benefits
Fever is a normal physiologic response
Fever is usually short lived and benign
May obscure diagnostic/prognostic signs

26. Us Vs. Them: Pyrexiophobia
91% of caregivers believed fever was harmful
21% listed brain damage and 14% listed death as effects of fever
25% gave antipyretics for fever < 37.8
85% awakened the child to treat fever
14% gave acetaminophen too frequently
44% gave ibuprofen too frequently
65% of pediatricians believed fever in and of itself could be dangerous to the child
Repeated by Anna Karwowska, similar results but less impressive…the way you ask the question

27. Changes and Controversies
Eradication of HiB
Decreasing Prevalence of Strep pneumo
Increasing resistance of Strep pneumo
Fever in infant with recognizable illness

28. HiB Vaccine (1987) Prior to vaccine: 1994-95
10-15% of OB and majority of SBI
12,000 cases/year(US) invasive HiB in <5yo
300 cases/year (likely lower now)
Invasive HiA/F are still uncommon but may emerge as serious pathogens

29. Prevnar/Pneumovax PCV7 (7 serotypes) studied in Northern California
Large herd effect noticed
34% of < 5 yo children immunized
62% reduction in invasive PC seen
Finnish otitis media study
Strep isolates from OM cultures
Significant reduction in the 7 serotypes
33% increase in other serotypes

30. Prevnar/Pneumovax PCV7 estimated to be 97% effective
Excellent but will still see dz
Will still see PC in
Other serotypes
Vaccine failures
Unimmunized children
Immunocompromised children
Bottom line:
Shouldn’t change our respect for OB/SBI in young children…yet

31. Pneumococcal Resistance Kaplan, 1998
Three year MC study
1291 systemic pneumococcal infections
Resistance increased annually over the study period
Penicillin resistance 21%
Ceftriaxone resistance 9%
Resistance changes region to region
Ottawa has ~20% resistant Strep pneumo

33. Fever and Recognizable Illness
Kupperman, 1997
Risk of bacteremia and UTI in febrile children with and without bronchiolitis
432 children, 0-24 mos
Children with bronchiolitis had significantly fewer positive cultures
Blood 0% compared to 2.7%
Urine 1.9% compared to 13.6%
0 children < 2 mos with bronchiolitis had bacteremia or UTI

34. Fever and Recognizable Illness
Greene, 1999
5 year retrospective
Children 3-36 mos with T >39
1347 children with recognizable viral syndrome
Croup, varicella, bronchiolitis, stomatitis
Blood cultures in 65%
2 of 876 (0.2%) were culture positive

35. Occult Pneumonia Bachur, 1999 Prospective cohort study CXR postive in
< 5 yo children with T >39 and WBC > 20k
CXR in 225/278
CXR postive in
40% with suggestive clinical exam
26% of those without clinical evidence
Recommends empiric cxr in fever without source

36. UTI’s in the Febrile Child
Most frequent SBI and may present with fever only
Prevalence 3.3% in febrile infants
Gorelick, 2000
Clinical Decision Rule
T > 39 fever > 2 days
White race age < 1 year
Absence of another potential source

37. UTI’s in the Febrile Child
All with UTI had at least one risk factor
Presence of any two factors
Sensitivity 95%
Specificity 31%
Not a uti talk, but studies have shown that under 2 years bag specimen inadequate

38. Febrile Seizures Trainor, 1999
Multi-centered analysis of ED management
455 children
1.3% bacteremic
5.9% UTI
12.5% abnormal CXR
135 had LP…all normal
In other words, manage like any other kid with fever

39. So…now you’re completely lost!
What are the guidelines?
What do you really need to know?

40. CPS Guidelines (www.cps.ca) 0-28 days
No CPS guidelines documented for 0-28 d
American Concensus Guidelines (Baraff, 1993)
Full Septic Work up (all risk groups)
LP (culture, cell counts and glucose/protein)
Blood culture
Urine (routine, microscopy and culture)
If diarrhea, stool smear and culture
If resp symptoms, CXR
Admit, + IV antibiotics

41. CPS Guidelines 29-90 days NOT low risk
CPS – “toxic or unduly lethargic”
FSWU (BC,UC,LP)
Admit
Broad spectrum IV antibiotics

42. CPS Guidelines 29-90 days Low Risk American Option
No investigations
Careful outpatient follow up, no treatment
American Option
FSWU
Ceftriaxone
RTED in 24h for re-assessment
In reality, somewhere in between

43. CPS Guidelines 3-36 months
Toxic Appearance
FSWU
Admit
IV antibiotics

44. CPS Guidelines 3-36 months
Non Toxic, T < 39.5
Observe only (if follow up assured)
Non Toxic, T >39.5
CBC to decide if BC/UC and empiric therapy are needed
If WBC < 15k observe if follow up assured
If follow up not assured a more aggressive approach may be indicated.

45. CPS Guidelines Empiric Antibiotics
If treating emprically:
Amoxicillin 60 mg/kg/day or
Ceftriaxone 50 mg/kg
“…,and neither a substitute for for careful decision-making or follow-up.” Long, 1994
American guidelines are ceftriaxone

46. Blood Culture (+) 3-36 mos Pneumococcus All other bacteria
Persistent fever
Admit, FSWU, IV abx
Afebrile/well-looking
Repeat culture, no treatment
All other bacteria

47. Case 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. At his two week check-up he was noted to be gaining weight appropriately. His vital signs are: T 38.9C (R), HR 140, RR 40, and BP 90/60. He is sleepy but easily rousable. Physical exam is normal apart from a slightly dull left tympanic membrane. His peripheral 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

48. Case 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:
IM ceftriaxone in the ED
Admission to the hospital for IV antibiotics
Discharge with follow-up in 24 hours
Admission to the hospital for observation
Discharge on amoxicillin

49. Case 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). BC’s are sent.
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

50. After all that…. Here’s what you need to know!
hospitalize +/- abx
+/- labs, home, +/- abx
home, no antibiotics
+/- labs, home, no antibiotics
Infants < 28 days:
Infants 1-3 months
Infants and children 3 months to 3 yrs (T < 39C):
Infants and children 3 months to 3 years (T  39C):