Presentation on theme: "The Febrile Child: Treat ‘em or Street ‘em"— Presentation transcript:
1The Febrile Child: Treat ‘em or Street ‘em David ChaulkPediatric EM FellowJanuary 2004
2Overview Cases Temperature Measurement Who Cares? Schools of Thought Scoring SystemsEmpiric TherapyChanges in Prevalence & Changes in ManagementRecognizable IllnessesCPS GuidelinesCases Revisited
3Case 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. At his two week check-up he was noted to be gaining weight appropriately. His vital signs are: T 38.9C (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-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
4Case 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). BC, UC 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 amoxicillinAny 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.
5Case 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
6Temperature Measurement SourceFeverProblemRectal> 38Invasive, takes timeOral0.5 lowerTechnique dependentAxillary1.0 lower? Reliability? variabilityTympanicFor axillary, not just the issue of reliability, but also the issue of variability.
7Temperature Measurement Rectal is gold standard based on study from 1937!Controversial! Tympanic very accurate or very inaccurateLanham 1999…tympanic misses too many febrile childrenShinozaki, 1998…rectal inaccurate because of poor blood supply to rectum, T is slow to changePhysiologically, T controlled by hypothalamusHypothalamus and Tympanic Membrane have same blood supply (common carotid)
8Temperature Measurement CPS Guidelines Age Recommended techniqueBirth to 2 years1. Rectal (definitive)2. Axillary (screening)Over 2 years to 5 years1. Rectal 2. Tympanic 3. AxillaryOlder than 5 years1. Oral 2. Tympanic 3. Axillary
9Who cares?65% of children 0-2 will visit a physician for a febrile illness10-20% of PED visits, 20-30% ped office visits50% are fever without sourceMost represent self-limited illnessSmall precentage with Serious Bacterial Illness…but who?
10A 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; 92:1-12Fever of Unknown OriginFever > 2 to 3 weeksAbsence of localizing signsFailure of simple diagnostic efforts
11A 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 1994Serious Bacterial Infections“…SBI include meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia and enteritis”Baraff et al, Pediatrics 1993; 92:1-12
12Occult Bacteremia Strep pneumo. >85% N.meningitidis 3-5% Others GAS Staph aureusSalmonella sppHiBNow rare, previously was ~10%
13Bacteremia < 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):584-82002 data, ie. Post HiB eraShould quote the source & size of sample size.
14Untreated 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.
15Scoring Systems Demographic and Clinical Parameters Lab Screens: Age, temperature, clinical appearanceLab Screens:CBC, ESR, U/AInitially very promising…ultimately not so “hot”
16Scoring Systems Can we identify high risk kids? Yale Observational Score611 children, 192 bacteremicMedian score was the same for both groupsA high score was a good markerSpecificity 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.
17Scoring Systems Can we identify low risk kids? Three main scoring systemsPhiladelphia, Rochester and Boston CriteriaAll are similar but there are differencesMain risk factors identifiedAge (3 groups. 0-28d, 28-90d, 3-36m)Temperature T > % with OBPetechiae – 15-20% SBIWBC >15,000, bands>1000 – 5 fold in OBToxic appearanceLethargy/irritabilty Poor eye contactPoor perfusion Hypo/hyperventilationCyanosis
21Are neonates really different? Philadelphia criteria applied to 3-28 d254 pts, 43% low risk (managed as OP)32 (12.6%) with SBI17 UTI’s, 8 OB, 4 BM5 low risk infants has SBIWould miss 20:1000 of infants with SBIEmpiric antibiotics standard of care in this age group
22Empiric Antibiotics 28-90 d Lieu, 1992Decision analysis based on 6 management strategies for management of fever >38 in d infantsWorst StrategyClinical judgementMost EffectiveFull septic work up, IM ceftriaxone and outpatient managementIt’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.
23Empiric Antibiotics 3-36 mos Couple of big studies…neither greatBass, 1993519 children 3-36 mos, 11.6% with OBCompared clavulin to ceftriaxone in children with T>40 or T>39.5 and WBC>15No difference between groupsFleisher, 19946733 patients, 2.9% with OBCompared 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.
24Us Vs. Them Survey of AAP general pediatricians 610 (67%) responded 40% indicated that parents frequently ask for abx when MD feels it is not warranted48% stated parents pressure them to prescribe30% stated they comply with that pressureParental pressure viewed as leading cause for unnecessary abxMD versus parents
25Us Vs. Them Should Fever be Treated? Pros Cons Decreases disomfort Dereases parental anxietyExtreme may cause brain damage (exceedingly rare)Limited/minimal evidence that it may reduce febrile seizuresConsHarm of antipyretics may outweigh benefitsFever is a normal physiologic responseFever is usually short lived and benignMay obscure diagnostic/prognostic signs
26Us Vs. Them: Pyrexiophobia 91% of caregivers believed fever was harmful21% listed brain damage and 14% listed death as effects of fever25% gave antipyretics for fever < 37.885% awakened the child to treat fever14% gave acetaminophen too frequently44% gave ibuprofen too frequently65% of pediatricians believed fever in and of itself could be dangerous to the childRepeated by Anna Karwowska, similar results but less impressive…the way you ask the question
27Changes and Controversies Eradication of HiBDecreasing Prevalence of Strep pneumoIncreasing resistance of Strep pneumoFever in infant with recognizable illness
28HiB Vaccine (1987) Prior to vaccine: 1994-95 10-15% of OB and majority of SBI12,000 cases/year(US) invasive HiB in <5yo300 cases/year (likely lower now)Invasive HiA/F are still uncommon but may emerge as serious pathogens
29Prevnar/Pneumovax PCV7 (7 serotypes) studied in Northern California Large herd effect noticed34% of < 5 yo children immunized62% reduction in invasive PC seenFinnish otitis media studyStrep isolates from OM culturesSignificant reduction in the 7 serotypes33% increase in other serotypes
30Prevnar/Pneumovax PCV7 estimated to be 97% effective Excellent but will still see dzWill still see PC inOther serotypesVaccine failuresUnimmunized childrenImmunocompromised childrenBottom line:Shouldn’t change our respect for OB/SBI in young children…yet
31Pneumococcal Resistance Kaplan, 1998 Three year MC study1291 systemic pneumococcal infectionsResistance increased annually over the study periodPenicillin resistance 21%Ceftriaxone resistance 9%Resistance changes region to regionOttawa has ~20% resistant Strep pneumo
33Fever and Recognizable Illness Kupperman, 1997Risk of bacteremia and UTI in febrile children with and without bronchiolitis432 children, 0-24 mosChildren with bronchiolitis had significantly fewer positive culturesBlood 0% compared to 2.7%Urine 1.9% compared to 13.6%0 children < 2 mos with bronchiolitis had bacteremia or UTI
34Fever and Recognizable Illness Greene, 19995 year retrospectiveChildren 3-36 mos with T >391347 children with recognizable viral syndromeCroup, varicella, bronchiolitis, stomatitisBlood cultures in 65%2 of 876 (0.2%) were culture positive
35Occult Pneumonia Bachur, 1999 Prospective cohort study CXR postive in < 5 yo children with T >39 and WBC > 20kCXR in 225/278CXR postive in40% with suggestive clinical exam26% of those without clinical evidenceRecommends empiric cxr in fever without source
36UTI’s in the Febrile Child Most frequent SBI and may present with fever onlyPrevalence 3.3% in febrile infantsGorelick, 2000Clinical Decision RuleT > 39 fever > 2 daysWhite race age < 1 yearAbsence of another potential source
37UTI’s in the Febrile Child All with UTI had at least one risk factorPresence of any two factorsSensitivity 95%Specificity 31%Not a uti talk, but studies have shown that under 2 years bag specimen inadequate
38Febrile Seizures Trainor, 1999 Multi-centered analysis of ED management455 children1.3% bacteremic5.9% UTI12.5% abnormal CXR135 had LP…all normalIn other words, manage like any other kid with fever
39So…now you’re completely lost! What are the guidelines?What do you really need to know?
40CPS Guidelines (www.cps.ca) 0-28 days No CPS guidelines documented for 0-28 dAmerican Concensus Guidelines (Baraff, 1993)Full Septic Work up (all risk groups)LP (culture, cell counts and glucose/protein)Blood cultureUrine (routine, microscopy and culture)If diarrhea, stool smear and cultureIf resp symptoms, CXRAdmit, + IV antibiotics
41CPS Guidelines 29-90 days NOT low risk CPS – “toxic or unduly lethargic”FSWU (BC,UC,LP)AdmitBroad spectrum IV antibiotics
42CPS Guidelines 29-90 days Low Risk American Option No investigationsCareful outpatient follow up, no treatmentAmerican OptionFSWUCeftriaxoneRTED in 24h for re-assessmentIn reality, somewhere in between
44CPS Guidelines 3-36 months Non Toxic, T < 39.5Observe only (if follow up assured)Non Toxic, T >39.5CBC to decide if BC/UC and empiric therapy are neededIf WBC < 15k observe if follow up assuredIf follow up not assured a more aggressive approach may be indicated.
45CPS Guidelines Empiric Antibiotics If treating emprically:Amoxicillin 60 mg/kg/day orCeftriaxone 50 mg/kg“…,and neither a substitute for for careful decision-making or follow-up.” Long, 1994American guidelines are ceftriaxone
46Blood Culture (+) 3-36 mos Pneumococcus All other bacteria Persistent feverAdmit, FSWU, IV abxAfebrile/well-lookingRepeat culture, no treatmentAll other bacteria
47Case 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. At his two week check-up he was noted to be gaining weight appropriately. His vital signs are: T 38.9C (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-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
48Case 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
49Case 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
50After all that…. Here’s what you need to know! hospitalize +/- abx+/- labs, home, +/- abxhome, no antibiotics+/- labs, home, no antibioticsInfants < 28 days:Infants 1-3 monthsInfants and children 3 months to 3 yrs (T < 39C):Infants and children 3 months to 3 years (T 39C):