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

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Presentation on theme: "The Febrile Child: Treat em or Street em David Chaulk Pediatric EM Fellow January 2004."— Presentation transcript:

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: 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 Any other investigations?

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). BCs 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 SourceFeverProblem Rectal> 38Invasive, takes time Oral0.5 lowerTechnique dependent Axillary1.0 lower? Reliability ? variability Tympanic0.5 lowerTechnique dependent

7 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) Temperature Measurement

8 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 Temperature Measurement CPS Guidelines

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 –…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 1.Fever > 2 to 3 weeks 2.Absence of localizing signs 3.Failure of simple diagnostic efforts

11 Occult Bacteremia –…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 A few Definitions…

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

13 Bacteremia 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): data, ie. Post HiB era

14 Untreated Bacteremia Outcomes Persitent fever 56% Persistent bacteremia 21% Meningitis 9% –S.pneumo 6% –HiB 26% (no longer seen)

15 Scoring Systems Demographic and Clinical Parameters –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)

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/irritabiltyPoor eye contact Poor perfusionHypo/hyperventilation Cyanosis

18 PhiladelphiaRochesterBoston Age1-2 months0-2 months1-3 months Temperature 38.2 C38.0 C HistoryNot specifiedTerm infant Previously well No recent vacc /abx Not dehydrated Physical examinationWell-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 WBCs on smear WBC > 5,000; < 15,000 Abs band ct <1500 UA < 10 WBC/hpf < 5 WBC/hpf stool smear * No LP required! CSF < 10 UA < 10 WBC/hpf CXR clear WBC < 20,000 Higher risk patientsHospitalize + empiric abx Lower risk patientsHome No antibiotics Follow-up required Home No antibiotics Follow-up required Home Empiric abx (IM ceftriaxone) Follow-up required

19 Statistics PhiladelphiaRochesterBoston SBI (low risk) % NPV % Sensitivity % ?

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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 UTIs, 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 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

23 Empiric Antibiotics 3-36 mos Couple of big studies…neither great –Bass, 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, patients, 2.9% with OB Compared amoxil to ceftriaxone …ceftriaxone eradicated bacteremia, had fewer focal complications and less persitent fever…

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

25 Us Vs. Them Pros –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 Should Fever be Treated?

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 < % 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

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: –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 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: –Shouldnt change our respect for OB/SBI in young children…yet Prevnar/Pneumovax

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

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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 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 Fever and Recognizable Illness

35 Occult Pneumonia Bachur, 1999 Prospective cohort study – 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 UTIs 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 > 39fever > 2 days White raceage < 1 year Absence of another potential source

37 All with UTI had at least one risk factor Presence of any two factors –Sensitivity 95% –Specificity 31% UTIs in the Febrile Child

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 youre completely lost! What are the guidelines? What do you really need to know?

40 CPS Guidelines (www.cps.ca) 0-28 dayswww.cps.ca 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 days NOT low risk CPS – toxic or unduly lethargic –FSWU (BC,UC,LP) –Admit –Broad spectrum IV antibiotics

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

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

44 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. CPS Guidelines 3-36 months

45 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 CPS Guidelines Empiric Antibiotics

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

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: 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

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). BCs 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…. Heres what you need to know! 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): hospitalize +/- abx +/- labs, home, +/- abx home, no antibiotics +/- labs, home, no antibiotics

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