Febrile Child
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Transcript of Febrile Child
Febrile Child
Overview
Introduction
Occult bacteremia
Antibiotic prevention of SBI
Febrile seizure
Fever and petechiae
Fever in children with underlying illness
Rare syndromes
Introduction
Historical perspective Toxic looking child
Fever, menigeal signs, lethargic, limb, mottled Admit, septic work-up, parental antibiotics
Focal bacterial infection Any child with focal bacterial infection (excluding SBI)
such as OM, pharyngitis, sinusitis, etc. Oral antibiotics, outpatient care
Well looking child Risk for occult bacteremia and serious bacterial infection Previous decision analysis: pre-H. flu immunization Current decision analysis
Occult Bacteremia
Incidence of occult bacteremia Rosen: 3% to 5% EMR: 2.8% Fleisher et al Pediatrics 1994 Alpern et al AAP Sept 2000: 1.9% Baraff et at Ann Emerg Med 1993: 4.3%
Organism implicated in OB Rosen: 85% strep pneumo; 15% H. flu, N. men., Salmonella
and others EMR: strep pneumo and H. flu 99% Alpern et al: S. pneumo 82.9%, Salmonella 5.4%, Group A
strep 4.5%, Enterococcus 1.8%, M. cat 1.8%, and no H. flu Baraff et al Ann Emerg Med 1993: S. pneumo 85%, H. flu
10%, N. men 5%
Occult Bacteremia
Degree of temperature elevation Rosen: 39.5 to 39.9 degrees C 3%; 40 to 40.9 4%;
above 41 10% (Harper and Fleisher Pediatrics Ann 1993)
EMR: 39.0 to 39.9 1.9%; 40.0 to 40.9 3%; 41+ 9% Alpern et al Pediatrics Sept 2000: 40+ 2.9 times more
likely to have OB
Age of the child Rosen: children 24 to 36 months are less likely than
those under 24 months EMR: most OB between 6 to 18 months Alpern et at highest incidence 12-17 months
Occult Bacteremia
WBC Rosen: cases of H. flu one third of OB have WBC
under 15,000; meningococcemia who appear well 50% will have WBC under 15,000: cases of pneumococcal bacteremia one quarter will have WBC under 15,000
EMR: using 15,000 as cut-off will miss 35% of bcateremic children
Isaacman et al Pediatrics Nov 2000 ANC better predictor of OB
Kupperman et al Ann Emerg Med 1998 found that ANC greater than 10,000 better predictor of OB than WBC 15,000.
Occult Bacteremia
Blood cultures New blood culture techniques most blood culture
results are positive in less than 24 hrs; Alpern et al mean time 14.9 hrs
Most OB spontaneously resolves
Minor infections Fleisher et al J Pediatrics 1994: 12.8% OM Baraff et al Pediatrics 1993: 3-6% OM Children with focal minor infection have lower serum
bacterial concentrations; lower risk men and SBI (Fleisher et al J Ped 1994; Long J Ped 1994)
Occult Bacteremia
Assessment of observational scores: Bonadio Pediatric Clinics of NA 1998 Infants younger than 8 weeks
Retrospective studiesProspective studies
Infants and children older than 8 weeksProspective studies
Occult Bacteremia
Guidelines for managing OBGuidelines for febrile infants 0-3 months
Baker et al NEJM 1993: Philadelphia protocol Infants under 3 months Philadelphia protocol: low risk vs high risk 100% sensitive; 100% negative predictive value
Baker et al Pediatrics 1999: validation Validation of Philadelphia protocol Infants 29-60 days old; low risk vs high risk for SBI 100% sensitivity; 100% negative predictive value
Occult Bacteremia
Guidelines for managing OBGuidelines for febrile infants 0-3 months
Dagan et al J Pediatrics 1985: Rochester protocol
Jaskiewicz et al Pediatrics 1994: appraisal Rochester protocol
Avner et al Abstract: failure to validate Rochester protocol
Occult Bacteremia
Guidelines for managing OBGuidelines for febrile infants 0-3 months
Baraff et al Ann Emerg Med 1993 Meta-analysis febrile infants less than 90 days Febrile infants less than 28 days; low risk defined by
Rochester protocol; despite 99.3% neg predictive value they recommend hospitalization, septic work up, and parenteral antibiotics
Febrile infants 28-90 days low risk outpatient care with IM ceftriaxone, septic work up, and 24 hr f/u
Occult Bacteremia
Guidelines for managing OBGuidelines for febrile infants 3-36 months
Toxic children: no issueWell looking child: current recommendations,
temp greater than 39 and WBC greater than 15,000 get blood culture, IM cetriaxone, and f/u 24hrs; urine culture boys less than 6 months and girls less than 2 years
Recent studies challenge these recommendations; selective approach
Occult Bacteremia
Antibiotic use to prevent SBI in children at risk for OBBulloch et al Acad Emerg Med 1997Rothrock et al Pediatrics 1997
Febrile seizure
Synopsis of the American Academy of Pediatric practices parameters on the evaluation and treatment of children with febrile seizures (Peditrics 1999) LP strongly suggested in the first seizure in infants
less than 12 month because signs and symptoms of meningitis may be absent in this age group
12-18 months LP strongly suggested because sign of meningitis may be subtle in this age group
18+ months LP only if signs and symptoms of meningitis
Febrile seizure
EEG is not perform in a neurologically healthy child with simple febrile seizureThe following routine lab should not be performed in simple febrile seizure: CBC, lytes, Ca, phos, Mg, or glucoseNeuro-imaging should not be performed routinely on simple febrile seizureAnticonvulsant therapy is not recommended in simple febrile seizure
Fever and petechiae
Baker et al Pediatrics Dec 1989 7% incidence of meningococcal disease Petechiae below nipple line associated with
invasive bacterial disease Generalized rash more associated with invasive
bacterial disease WBC greater than 15,000, ABC greater than 500
cell/ul, CSF abnormality 93% sensitive and 62% specific for invasive bacterial disease
Recommend hospitalization, septic work up, and parenteral antibiotic
Fever
Fever in children with underlying illnessOncology patients
At risk of overwhelming sepsisWhen febrile: CBC, CXR, blood culture, urine
culture, and LP when clinically indicatedNeutropenic patients at risk for Pseudomonas
and other gram negative; combination of tobramycin and ceftazidime
Indwelling IV devices add vancomycin to tobramycin and ceftazidime
Fever in children with underlying illness
Acquired Immunodeficiency Syndrome Repeated risk of infection with common bacterial
pathogens, risk of Pneumocytsis carinii, mycobacterial infections (TB, AI), cryptococcosis, cytomegalovirus, Ebstein-Barr virus, lymphoma and other malignancies
Low CD4 similar approach to neutropenic cancer patient; septic work up and broad spectrum antibiotic
Fever in child with underlying illness
Congenital heart disease Children with valvular heart disease are at risk for
endocarditis Fever without obvious source with a new or
changing murmur; hospitalization, serial blood cultures, echo, antibiotics against: S.viridans, S aureus, S. fecalis, S. pneumo, enterococci, H. flu, and other gram neg rods
Suggested antibiotics include Vancomycin and Gentamycin until cultures are positive
Fever in child with underlying illness
Ventriculoperitoneal shuntsFever in this group must be evaluated for
shunt infection esp if patient displays headache, stiff neck, vomiting, or irritability
Shunt reservoir should be aspirated and examined for pleocytosis and bacteria
Most common pathogen is S. epidermidisCT head also warranted
Febrile child
Other conditions to consider in febrile child Collagen vascular disease Malignancy Drug-induced fever Toxic ingestion Heat exhaustion and heatstroke Kawasaki syndrome Thyrotoxicosis