The Febrile Child: Treat ‘em or Street ‘em David Chaulk Pediatric EM Fellow January 2004
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
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 38.9C (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-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
Case 2 A 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 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.
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 39.8C. 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 sample b. Administer IM ceftriaxone c. Perform an LP d. Obtain a CXR e. Discharge on antipyretics
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.
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)
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
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?
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
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
Occult Bacteremia Strep pneumo. >85% N.meningitidis 3-5% Others GAS Staph aureus Salmonella spp HiB Now rare, previously was ~10%
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.
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.
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”
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.
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 > 40.5 8-25% 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
Philadelphia Rochester Boston Age 1-2 months 0-2 months 1-3 months Temperature 38.2C 38.0C 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)
Statistics Philadelphia Rochester Boston SBI (low risk) % 1.1 5.4 1.1 5.4 NPV % 100 98.9 94.6 Sensitivity % 92.4 ?
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
Empiric Antibiotics 28-90 d Lieu, 1992 Decision analysis based on 6 management strategies for management of fever >38 in 28-90 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.
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 3 -36 months of age.
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
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
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
Changes and Controversies Eradication of HiB Decreasing Prevalence of Strep pneumo Increasing resistance of Strep pneumo Fever in infant with recognizable illness
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 1994-95 300 cases/year (likely lower now) Invasive HiA/F are still uncommon but may emerge as serious pathogens
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
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
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
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
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
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
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
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
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
So…now you’re completely lost! What are the guidelines? What do you really need to know?
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
CPS Guidelines 29-90 days NOT low risk CPS – “toxic or unduly lethargic” FSWU (BC,UC,LP) Admit Broad spectrum IV antibiotics
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
CPS Guidelines 3-36 months Toxic Appearance FSWU Admit IV antibiotics
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.
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
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
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 38.9C (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-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
Case 2 A 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 ED Admission to the hospital for IV antibiotics Discharge with follow-up in 24 hours Admission to the hospital for observation Discharge on amoxicillin
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 39.8C. 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 sample b. Administer IM ceftriaxone c. Perform an LP d. Obtain a CXR e. Discharge on antipyretics
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 < 39C): Infants and children 3 months to 3 years (T 39C):