Feverwithoutfocus

DrRafatMosalliQuestion1A3weekoldmaleinfantisbroughttoyourEDwitha2dayhistoryoffever.Hewasbornbyuncomplicatedvaginaldeliveryat37weeksgestationfollowinganormalpregnancy..Hisvitalsignsare:T38.9C(R),HR140,RR40,andBP90/60.Heissleepybuteasilyarousable.Physicalexamisnormalapartfromaslightlydulllefttympanicmembrane.WBCis16,000,hisUAshows3WBC/hpf.BCandUCaresent.Yourmanagementatthispointwouldconsistof:

a.Dischargeonantipyreticswithclosefollow-up b.Dischargeonoralamoxicillinwithclosefollow-up c.LPandadmissionforparenteralantibiotics d.CXRtor/opneumonia e.Stoolforanalysisandculture,andoutpatientfollow-upQuestion2A7weekoldgirlisreferredintoEDforevaluationofarectaltemperatureof39.2C.HerPEisnormal.HerUAisnegative,herWBCis9,000(70%neuts,28%lymphs,2%bands),andherLPrevealsaCSFWBCcountof8.BC,UC,andCSFculturesaresent.Acceptablemanagementoptionsforthischildwouldincludeanyoneofthefollowingexcept:IMceftriaxoneintheEDAdmissiontothehospitalforIVantibioticsDischargewithfollow-upin24hoursAdmissiontothehospitalforobservationDischargeonamoxicillinQuestion3A19montholdboycomestotheEDwitha3dayhistoryoffever.HeappearswellbuthistympanicTis39.8C.Hischestisclear,hisabdomenissoft,andheiscircumcised.Nosourcecanbefoundforhisfever.ACBCrevealsaWBCof8200(60%neuts,27%bands).BC’saresent.Appropriatemanagementatthispointwillbeto:

a.Obtainaurinesample b.AdministerIMceftriaxone c.PerformanLP d.ObtainaCXR e.DischargeonantipyreticsObjectivesDefinitionsWhichpatientsneedin-depthevaluationandtreatment?Whatlaboratorystudiesareindicatedforvariousageranges?Whichpatientsneedtreatmentwithantibiotics?Whichpatientsshouldbehospitalized?DefinitionsFeverFeverwithoutfocusFeverofunknownoriginOccultbacteremiaSeriousbacterialinfection(SBI)Whatisfever?Rectaltemperature>38C,eitheratphysician’soffice,ED,ordocumentedathomebyareliableparentorotheradultDifferentbodysitesRectal standardOral 0.5-0.6

lowerAxillary 0.8-1.0lowerTympanic0.5-0.6

lowerDocumented:IntheabsenceofantipyreticsInEDorofficeorbyhxfromreliableparents/adultsFrequencyoffebrileillness35%ofunscheduledambulatorycarevisits65%ofkidsseedocbeforeage2yMajority(75%)forT<39C13%T>39.5

FeverofUnknownOrigin1. Feverof38Corgreaterwhichhas continuedfora2to3weeks2. Absenceoflocalizingclinicalsigns3. NegativesimpleinvestigationsFeverwithoutfocus“Anacutefebrileillnessinwhichtheetiologyofthefeverisnotapparentafteracarefulhistoryandphysicalexamination.”20%ofchildhoodfevershavenoapparentcauseBaraffetal,Pediatrics1993;92:1-12Occultbacteremia“…apositivebloodcultureinthesettingofwellappearanceandwithoutfocus(e.g.nopneumonia)Fleisheretal,JPediatrics1994OccultbacteremiaorganismsStreptococcuspneumonia

>85%HaemophilusinfluenzaetypeB(nowrare–previously10%)Neisseriameningitidis

3-5%Others:S.aureusS.pyogenes(GAS)

SalmonellaspeciesOutcomesofoccultbacteremiawithoutantibioticsPersistentfever 56%Persistentbacteremia 21%Meningitis 9%S.pneumonia6%H.Influenzae26%(nowrare)Ageisquitematter>10%ofwell-appearingyounginfantswithatemperature>38°ChasaseriousbacterialinfectionormeningitisOnly<2%ofwell-appearingolderinfantsandyoungchildrenwithatemperature>39°C(manifestbacteremiaSeriousBacterialInfection“…Includemeningitis,sepsis,boneandjointinfections,urinarytractinfections,pneumoniaandenteritis”Baraffetal,Pediatrics1993;92:1-12

FeverPracticeGuidelinesCPSguidelines:Managementofthefebrileone-to36-month-oldchildwithnofocusofinfection.PaediatrChildHealth1996;1:41-45*re-affirmedApril2002“American”consensusguidelines:Practiceguidelineforthemanagementofinfantsandchildren0-36monthsofagewithfeverwithoutsource.Baraffetal,Pediatrics1993;92:1-12Casescenarios-feverByagegroup:<1monthofage1–3months3–36monthsWhyaccordingtoageBecauseinyounginfantsthere'sagreaterprobabilityofseriousbacterialinfectionsomoreaggressiveapproachtotheevaluationandmanagementoffeveriswarranted.Febrileinfant<1month“American”consensusrecommendationsAllshouldhave:Fullsepticw/uCSFcultures,gmstain,cellcount/diff,gluc/protBloodculturesUrineroutine,micro,cultureIfdiarrhea,stoolexam(smearandculture)Ifrespsx:CXRADMIT,IVantibiotics,orADMIT,observewithoutantibioticsFebrileinfants1-3mofageAccordingtovalidatedcriteriaE.g.RochesterscoreLowandhighriskFebrileinfants<3months

riskofbacteremiaIfmeetslowriskRochester 0.2%(1:500)criteriaIfmeetslowriskcriteria 0.7-1%but<1monthFebrileinfants1-3mofage

HiRisk:“American”andCanadianConsensusrecommendationsADMITtohospitalwithfullsepticw/uBC,UC,LPBroad-spectrumparentalantibioticsFebrileinfants1-3mofagelowrisk

Option1(“American”):BloodcultureUrinecultureLPCeftriaxone50mg/kgIMReturnforre-evaluationw/i24hoursOption2(“American”andCPS)Noinvestigation(orurinecultureonly)Carefuloutpatientobservation,withouttreatment,closefollow-upFollow-upofInfants1-3moldWithin24hoursRepeatexamforsource,sequelaeReview,repeatlabsArrangeongoingfollow-upFollow-upof1-3mIfbloodculturepositiveADMITforsepsisevaluationParenteralantibioticspendingresultsIfurineculturepositivePersistentfever:ADMITforsepsisevaluationandparenteralabxtxpendingresultsAfebrileandwell:outpatientantibioticsFeverWithoutSource

Age3–36MonthsFeverWithoutSource

Age3–36MonthsRiskofoccultbacteremia3-11%,mean4.3%forT>39CRiskgreaterwithHighertemperaturesWBC>15,000(13%vs2.6%)Riskofpneumococcalmeningitis(w/oabxtx)0.21%(1:500)HowshouldachildwithFWFbeevaluated?Detailedhistoryandthoroughphysicalexaminationavoidindiscriminatelyorderingalargebatteryoftests.Physicalexamination:

“Toxicappearance”Lethargy/irritabilityPoor/absenteyecontactPoorperfusionHypo/hyperventilationCyanosisFWS–age3-36months:

ConsensusRecommendationsCHILDNON-TOXIC,T<39CNodiagnostictestsorantibioticsAcetaminophen15mg/kgprnforfeverReturniffeverpersists>48hoursorthefollowingshappened:ReturntotheEmergencyDepartmentifyourchildmorefussyorwon’tstopcryingtoosleepyordrowsystiffneckWon’tstopvomitingnewrashHasaseizureGetsanyotherneworworseningsymptom(s)thatconcernsyouFWS–age3-36months:

RecommendationsCHILDNON-TOXIC,T

39CUrineculture(forM<6month,F<2yrsage)BC–2optionsOption1:obtainforallchildrenwithT39COption2:obtainifT39CandWBC>15,000CXR,stoolcultureifindicatedclinicallyAcetaminophen15mg/kgq4hforT39CFollow-upin24-48hours*noantibioticsFWS–age3-36months:

ConsensusRecommendationsCHILDAPPEARSTOXIC:ADMITtohospitalSepsisw/uParenteralabxInvestigationoptions[]CBC[]bloodculture[]urinalysis[]urineculture[]CXR[]LP[]NothingChoiceofantibioticIfdecidetotreatempiricallyceftriaxoneorpoAmoxicillin/clavulanateFWS–age3-36months:

BCreturnspositivePneumococcus:Persistentfever:ADMITforsepsisw/uandparenteralabxpendingsensitvityFWS–age3-36months:

BCreturnspositiveAllOtherBacteria:ADMITforsepsisw/uandparenteralabxpendingsensitivityresultsFWS–age3-36months:

UrineculturereturnspositiveAllorganisms:ADMITiffebrileorill-appearingOutpatientabxifafebrileandwellSummary:FWSInfants<28days:Infants1-3monthsNontoxicchildren3m-3yrs(T<

39

C)Nontoxicchildren3m-3y

(T39C):Hospitalize+/-abx-AccordingtoriskscorehospitalVshome,+/-abxHome,noantibiotics+/-labs,home,noantibioticsclosefollow-upinall!41ToxichighlyFebrileChildAged3-36mosWithoutApparentFocusBeManaged?RegardlessofPCVstatusHospital/AntibioticRxYes"ill","toxic","lethargic"?>20,000WBC/mm3No?riskforbacteremiaWBCfevermaleage7-11mosYes?YesConsiderAge3-36mosTemp.>390CAMOXorspecifywhy