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Fever without source

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  • 1. Dr. Saptharishi L G Junior Resident
  • 2. LEARNING OBJECTIVES   Approach to a < 36 month old child with acute fever (fever< 5 days)  Concept of ‘Fever Without Source’ and the related practical issues  Clinical practice protocols for Fever Without Source (FWS) in <3 year olds
  • 3. INDEX CASE  B/o S 4 month old male infant Resident of Sec 38, Chandigarh Brought with complaints of  Fever  3 days
  • 4. History Of Presenting illness  FEVER :  Moderate to high grade, intermittent  Documented up to a max of 102 F (by a local doctor)  h/o excessive crying a/w poor feeding – with fever spike  At other times, infant is playful, active and feeding well.  No h/o rigors, No diurnal variation  No h/o rapid breathing/ retractions/ nasal flaring  No h/o neck retractions/ bulging fontanelle/ vomiting  No h/o loose stools/ altered bowel habits
  • 5. Other aspects of History  PAST HISTORY:  Born by FTNVD at PGI; Birth weight – 3.1 Kg  Uneventful antenatal and perinatal period  No h/s/o birth asphyxia/ NNJ FAMILY HISTORY:  First born; No significant family history Exclusively Breastfed since birth Immunized appropriately for age (including Hib)
  • 6. Examination  Anthropometry:  Weight – 6.1 kg (3rd to 15th percentile – WHO charts)  Length – 64 cm (50th centile – WHO charts)  OFC – 42 cm ( 0 to 1 Z score – WHO charts) Vitals:  Temp - 39° C  HR – 122/min  RR – 42/min  BP – 78/50 mm Hg  CFT – 2 s  SpO2 – 98%
  • 7. Examination  No pallor/icterus/ cyanosis/ clubbing/ LAP/ edema General impression  Active, alert but crying  ‘NOT- TOXIC/ SICK ‘ looking Head to toe examination  No obvious focus of sepsis (cellulitis/ abscess/ furuncle)  AF – at level, soft; Perianal region – WNL  Ear – No e/o ASOM, Nose & Throat – mild congestion Systemic examination  CVS/ RS – NAD  P/A – Liver: palpable 2 cm under RCM, soft, non-tender  CNS – Irritable but No e/o FND; Normal examination
  • 8. So what would you like to do for this child??  Child with “just fever”, Sounds familiar? BecauseAlmost all of us have „BURNT‟ our fingers !!!
  • 9. FEVERIdentified FWS / FWF focus Serious Benign Bacterial causes Infections
  • 10. NORMAL TEMPERATURE RANGES Definition of fever Axillary  34.7° to 37.3° C (94.5 to 99.1 F) Oral  35.5° to 37.5° C (95.9 to 99.5 F) Rectal  36.6° to 37.9° C (97.9 to 100.2 F)  Core body temperature > 38° C or 100.4 F Accurate temperature measurement – a must. Fever reported by parent, but now afebrile… Then ?  Fever documented by axillary/ tympanic membrane  Fever documented by rectal thermometry
  • 11. Should doctors be worried as well?  Risk of bacteremia in children with FWS  Up to 10 % (old US data)  7% (BMJ 2010) Complications of Occult Bacteremia  Delayed onset meningitis  Pneumonia  Septic arthritis  Osteomyelitis  Mortality
  • 12. FEVER Can I somehow PICK-UP this group atIdentified presentation?? FWS / FWF focus Serious Benign Bacterial causes Infections Occult Occult UTI Bacteremia Pneumonia
  • 13. Height of fever  No direct correlation with etiology Neonates  Afebrile/hypothermic response despite SBI Older infants & children < 3 years old  EXAGGERATED febrile response  Temp > 40° C  38% risk of SBI High grade fever – unusual in older children/adolescents – SERIOUS Increasing prevalence of pneumococcal bacteremia with increasing temperatures
  • 14. Pattern Of Fever  DOES NOT reliably distinguish between etiologies Response to Anti-pyretic – Bacterial Vs. Viral
  • 15. Observational Assessment  Clinical appearance has good predictive value All children with toxic appearance must be hospitalized, evaluated and started on IV antibiotics
  • 16. What constitutes ‘TOXIC’ look?  Alertness – child looking at the observer, looking around the room, with eyes that are shiny & bright, etc. Normal motor ability – sitting without support, moving arms & legs on table or lap, etc. Playfulness – vocalizing spontaneously, playing with objects, reaching for objects, smiling & crying with noxious stimuli, etc. Irritability- consolability of cry Infant’s smile has a very high negative predictive value for meningitis
  • 17. Interpretation Score – 10  2.7% SBI Yale Observation Score Score 11-15  26% SBI Score > 16  92.3% SBI  1 3 5Quality of cry Strong or No cry Whimper or sob Weak cry / moan/ high pitched cryReaction to Brief cry / content Cries off and on Persistent cryParentsState variation Awakens quickly Difficult to awaken No arousal/ falls asleepColor Pink Acrocyanotic Pale/ cyanotic /mottledHydration Eyes, skin and Mouth slightly dry Mucosa , eyes – mucosa – moist dry/ sunken eyesSocial Response Alert or smiles Alert/ brief smile No smile/ anxious/ dull
  • 18.
  • 19. BUT, Remember…. No combination of clinicalhistory-taking & examination is good-enough 
  • 20. Age-based ClinicalPractice Protocols  < 28 days old 1-3 months old 3 – 36 months old
  • 21. Neonates with FWS   Highest risk group – 12% SBI – UTI/ Occult bacteremia  Strep B, E coli, Listeria  Highest sequelaeSigns of viral illness – does not negate need for full diagnostic evaluationRSV infected neonates – same risk of SBI as RSV negative neonates All neonates with FWS should undergo • Blood c/s, Urinalysis, Urine c/s, CSF study, WBC count • CXR if respiratory symptoms/ Stool testing for WBC count if diarrhea present • IV antibiotics initiated as early as possible • Hospitalization and follow up
  • 22. 1 – 3 month old with FWS  ROCHESTER Criteria – LOW RISK group Appearing well Previously healthy No e/o skin/ soft tissue/ bone/ joint/ ear infections WBC count – 5000 to 15000/mm3 ANC < 1500/mm3 Urine WBC < 10 WBCs/HPF of centrifuged sample Fecal leucocyte count < 5/ HPF in children with diarrhea Boston criteria  included routine CSF also (<10 WBC/HPF) Philadelphia criteria Criteria by Baker et al
  • 23. 1 -3 month old with FWS  Must Dos  WBC counts / Urine dipstick / Urine & Blood c/s CSF  Optional (depending on local protocol) LOW RISK Not LOW RISK F/u in 24 hrs Hospitalize No antibiotics IV antibioticsCollect cultures Collect cultures
  • 24. 3 – 36 month old with FWS  Fever definition stays… But for evaluation purpose,  Temperature > 39° C  CUT-OFF for further work-up  Rationale:  Risk of bacteremia – 0.8 % till 39° C  Jumps to 8% beyond 39° C  No significant further rise beyond 40 or 41° C
  • 25. OCCULT OCCULTOCCULT UTI Pneumonia Bacteremia • IV Antibiotics • Hospitalize • CSF ( if not done already) • Blood c/s • Urine c/s • Urinalysis
  • 26. American Family Physician 2007
  • 27.
  • 28. Rules of the Game  Never do Lumbar Puncture in a child with FWS with suspected bacteremia, if you are not planning to give at least one dose of IV Antibiotic… Never start IV antibiotics to a <3 year-old child with FWS without CSF analysis*…
  • 29. Emerging trends  Effect of Pneumococcal and Hib vaccines  Decrease in bacteremia in 3 – 36 months age group  NEWER Recommendations  Urinalysis more useful than CBC in this group Lee GM et al. Management of febrile children in the age of the conjugate pneumococcal vaccine: a cost-effectiveness analysis. Pediatrics 2001; 108: 835-44 Improving pneumococcal vaccine coverage Bacteremia rates < 0.5% STOP empirical testing and treatment
  • 30. Caveats / Pitfalls  Emphasis on detection of bacterial diseases… Useful for large tertiary care centers… Exclusion of certain sub-groups of children… Artificial chronological age distinctions… Majority assumed to be infectious… Useless unless based on local epidemiological data…
  • 31. Role of newer markers  C-Reactive protein  Lacour et al  sensitivity – 89%, specificity – 75%  Andreola et al  sensitivity – 88%, specificity – 61% Procalcitonin  Lacour et al  sensitivity – 93%, specificity – 78%  Lopez et al  CRP Vs. Pc – similar ROC AUC values
  • 32. ‘TAKE- HOME’ MESSAGES  Significant subset of febrile, 0 to 36 month old children  ‘AT-RISK’ for Serious Bacterial Infections  MORE So in Indian setting/ developing countries  Higher bacteremia/ occult bacterial infections Even ‘ADEQUATE’ history & physical examination falls short…Misses SBI & over-treats benign illnesses Development of an INDIGENOUS data-based protocol – a necessity for every major tertiary care centre
  • 33. ‘TAKE- HOME’ Practice points  Febrile Neonate (0 to 28 days old)  CBC, Blood c/s, urinalysis & urine c/s, CSF analysis, CXR*/Stool*  Empiric IV antibiotic  Hospitalize Febrile Young Infant (1-3 months)  CBC, Blood c/s, Urinalysis and c/s, CXR*/Stool*  Optional CSF# + IV/IM Ceftriaxone  Hospitalize  Follow-up as detailed  OPD Vs. Admission
  • 34. ‘TAKE- HOME’ Practice points  Febrile child 3 – 36 months:  Temp cut-off > 39° C  Evaluate for occult infections (UTI/Bacteremia/Pneumonia)  CBC with differential  in children with fever > 39° C  Indications for Urine c/s  Boys Vs. girls  CXR indications  clinical / WBC > 20,000/mm3  Decision reg antibiotics & hospitalization
  • 35. Primary Reference 
  • 36. Pediatrics 2011 
  • 37. THANK YOU !Would be pleased to respond to queries… If any

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