Fever In The Neonate 2003


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  • 38 = 2 SD>mean temp for infants <3mo old
  • If fitting these criteria – then infant considered Low Risk for SBI
  • Ampicillin Covers Listeria Gentamicin Fine prior to d/c, ie in NICU or NBN, but misses community acquired H. flu Ceftriaxone Great coverage for GBBS, E. coli, H. flu ? Biliary Sludging in the <6 week old Cefotaxime Use in place of Ceftriaxone until 6 weeks
  • Fever In The Neonate 2003

    1. 1. Fever in the Neonate June 2003
    2. 2. QOD <ul><li>A 2 week old infant who was born at term has fever, poor feeding, lethargy, and a bulging fontanelle. The CSF is cloudy and contains 2,000 WBCs/mm 3 </li></ul><ul><li>The organism MOST likely to be causing this infant’s problem is: </li></ul><ul><ul><ul><li>GBBS </li></ul></ul></ul><ul><ul><ul><li>H. flu </li></ul></ul></ul><ul><ul><ul><li>Listeria </li></ul></ul></ul><ul><ul><ul><li>Neisseria </li></ul></ul></ul><ul><ul><ul><li>Strep pneumo </li></ul></ul></ul>
    3. 3. Learning Objectives <ul><li>Define fever </li></ul><ul><li>Know which age group with fever is of highest concern </li></ul><ul><li>Know the mortality of neonatal sepsis </li></ul><ul><li>Be able to explain the “rule out sepsis” work up </li></ul><ul><li>Identify the most common troublesome bacteria </li></ul>
    4. 4. What is a Fever? <ul><li>Fever </li></ul><ul><ul><li>Temperature > or = 38.0C (100.4F) </li></ul></ul><ul><li>How is it taken? </li></ul><ul><ul><li>Rectal </li></ul></ul><ul><ul><ul><li>Until old enough to keep thermometer under the tongue </li></ul></ul></ul><ul><ul><li>Tympanic and axillary temps </li></ul></ul><ul><ul><ul><li>may miss 20-30% of fevers </li></ul></ul></ul><ul><li>Does time of fever recognition matter? </li></ul><ul><ul><li>If fever discovered at home, but not present in office or ER, then MUST act on history </li></ul></ul>
    5. 5. Who is a Neonate? <ul><li>Neonate = <30 days old </li></ul><ul><li>In this context of Neonatal Fever (Fever of Neonates and Young Infants?) </li></ul><ul><ul><li>Birth – 2 months </li></ul></ul><ul><ul><li>Debate on 2-3 months old </li></ul></ul>
    6. 6. Why Worry about these Infants? <ul><li>Most appear WELL </li></ul><ul><li>No test is 100% sensitive/specific for serious bacterial infection (SBI) </li></ul><ul><li>Can have rapid decline in face of SBI </li></ul><ul><li>Fever may be the only indicator of SBI </li></ul>SBI = bacterial meningitis, bacteremia, septic arthritis, osteomyelitis, UTI, bacterial enteritis, pneumonia
    7. 7. Epidemiology <ul><li>Incidence of SBI in febrile infants </li></ul><ul><ul><li><1 month old – 13% </li></ul></ul><ul><ul><li>1-2 months old – 10% </li></ul></ul><ul><li>So… younger age means higher risk </li></ul><ul><ul><li>0-1mo>1-3mo>3-36mo </li></ul></ul><ul><li>Highly morbid condition </li></ul><ul><ul><li>Mortality of neonatal sepsis is 10-40% with significant morbidity </li></ul></ul>
    8. 8. Why the Higher Risk? <ul><li>Lower level of immunocompetence </li></ul><ul><ul><li>Decreased opsonin activity </li></ul></ul><ul><ul><li>Decreased macrophage function </li></ul></ul><ul><ul><li>Decreased neutrophil activity </li></ul></ul><ul><li>Poor IgG response to encapsulated bacteria </li></ul><ul><ul><li>Until >24 months old </li></ul></ul>
    9. 9. So…What Do We Do? <ul><li>An excellent HISTORY </li></ul><ul><ul><li>Especially with well-appearing infant, diagnosis and level of concern likely determined by history </li></ul></ul><ul><ul><li>Birth hx, PNC, recent Abx use, perinatal exposures, h/o hyperbilirubinemia </li></ul></ul><ul><li>Problems with the history </li></ul><ul><ul><li>Inconsistent presentation amongst febrile infants </li></ul></ul><ul><ul><li>Several clinical parameters have been studied as predictors of SBI </li></ul></ul><ul><ul><ul><li>None have been found to be 100% sensitive and specific for infants <2months old </li></ul></ul></ul>
    10. 10. The Physical Exam <ul><li>Again…. </li></ul><ul><ul><li>Most are well-appearing </li></ul></ul><ul><li>2 large studies: </li></ul><ul><ul><li>747 febrile 1-2months old infants – 66% appeared well to the MD despite having SBI </li></ul></ul><ul><ul><li>Similar study of 1-3 months old infants – those with SBI could not be weeded out from those without by appearance alone </li></ul></ul>Well-Appearance DOES NOT rule out SBI
    11. 11. Deciding on Management <ul><li>What does the literature say? </li></ul><ul><ul><li>Rochester criteria </li></ul></ul><ul><ul><li>Philadelphia criteria </li></ul></ul><ul><ul><li>Boston criteria </li></ul></ul>More widely accepted Rochester Criteria No source for fever Previously healthy Full term No prior or current Abx Nontoxic WBC 5,000-15,000 <1,500 bands UA <10 WBC/HPF Stool <5 WBC/HPF (if diarrhea) Philadelphia Criteria Observation Score WBC<15,000 Band:Seg <0.2 UA <10 WBC/HPF CSF analysis <8 WBC Normal CXR Boston Criteria WBC<20,000 UA <10 WBC/HPF CSF analysis < 10WBC Normal CXR All criteria missed diagnosis of SBI in <1 month olds
    12. 12. Well-Established Management <ul><li>< 1 month old </li></ul><ul><ul><li>Automatic “rule out sepsis” work up </li></ul></ul><ul><ul><ul><li>CBC with differential </li></ul></ul></ul><ul><ul><ul><li>Blood culture </li></ul></ul></ul><ul><ul><ul><li>Urine culture </li></ul></ul></ul><ul><ul><ul><ul><li>Via straight cath or suprapubic tap </li></ul></ul></ul></ul><ul><ul><ul><li>CSF analysis and culture </li></ul></ul></ul><ul><ul><ul><ul><li>Glucose, protein, gram stain, cell count, and culture </li></ul></ul></ul></ul><ul><ul><li>If clinically indicated </li></ul></ul><ul><ul><ul><li>CXR </li></ul></ul></ul><ul><ul><ul><li>NP aspirate </li></ul></ul></ul><ul><ul><ul><ul><li>RSV/ Influenza A screen as indicated </li></ul></ul></ul></ul><ul><ul><li>Admit </li></ul></ul><ul><ul><li>Empiric antibiotics until cultures negative for 48hrs </li></ul></ul>
    13. 13. 1-3 Month Olds – Tougher Decision <ul><li>1-2 months old – usual practice </li></ul><ul><ul><li>Blood culture, CBC with diff </li></ul></ul><ul><ul><li>CSF evaluation </li></ul></ul><ul><ul><li>Urine culture </li></ul></ul><ul><ul><li>CXR </li></ul></ul><ul><ul><ul><li>clinically indicated </li></ul></ul></ul><ul><ul><li>NP aspirate </li></ul></ul><ul><ul><ul><li>RSV/ Influenza A screen as indicated </li></ul></ul></ul><ul><ul><li>Hospitalize, treat with empiric antibiotics, and observe for 48 hours </li></ul></ul><ul><li>2-3 months old </li></ul><ul><ul><li>“ gray-zone” </li></ul></ul><ul><ul><li>No consensus on management </li></ul></ul>
    14. 14. Bad Bugs <ul><li>GBBS, GBBS, GBBS! (Streptococcus agalactiae) </li></ul><ul><li>E.Coli </li></ul><ul><li>Listeria </li></ul><ul><li>After d/c home, think </li></ul><ul><ul><li>Strep pneumo </li></ul></ul><ul><ul><li>H. flu </li></ul></ul>GBBS and E. coli account for 50-70% of all neonatal infections
    15. 15. Antibiotic Regimen <ul><li>Before discharge from Nursery or NICU </li></ul><ul><ul><li>Ampicillin and gentamicin </li></ul></ul><ul><ul><ul><li>No H. flu coverage </li></ul></ul></ul><ul><li>After discharge home </li></ul><ul><ul><li>Ampicillin and </li></ul></ul><ul><ul><li>Cefotaxime if <3mo </li></ul></ul><ul><ul><li>Ceftriaxone if >3mo </li></ul></ul><ul><ul><ul><li>Risk of ceftriaxone causing bilirubin displacement and theoretical risk of biliary sludging in <3month old </li></ul></ul></ul><ul><li>After 6-9 weeks old, ampicillin for listeria coverage is not necessary </li></ul>
    16. 17. The Daily QUIZ Continues!! <ul><li>Define Fever </li></ul><ul><li>38.0C or 100.4F or higher </li></ul><ul><li>Why not tympanic or axillary temps? </li></ul><ul><li>Miss 20-30% of fevers </li></ul><ul><li>Who is at greatest risk of SBI? </li></ul><ul><li>0-1mo>1-2mo>3-36month </li></ul>
    17. 18. Oh, No! There’s More!! <ul><li>Describe the “rule out sepsis” work up </li></ul><ul><li>CBC with diff </li></ul><ul><li>Blood culture </li></ul><ul><li>Urine culture </li></ul><ul><li>CSF analysis and culture </li></ul><ul><li>Labs are drawn – now what? </li></ul><ul><li>Admit </li></ul><ul><li>Empiric antibiotics </li></ul>
    18. 19. <ul><li>Name the “Bad Bugs” </li></ul><ul><li>GBBS! GBBS! GBBS! </li></ul><ul><li>E.coli </li></ul><ul><li>Listeria </li></ul><ul><li>Strep pneumo </li></ul><ul><li>H. flu </li></ul>
    19. 20. <ul><li>Choose your antibiotics </li></ul><ul><li>In the nursery? </li></ul><ul><li>Ampicillin and gentamicin </li></ul><ul><li>6 week old at home? </li></ul><ul><li>Ampiciliin and cefotaxime </li></ul><ul><li>9 week old at home? </li></ul><ul><li>Ampicillin (?) and ceftriaxone </li></ul>
    20. 21. QOD <ul><li>A 2 week old infant who was born at term has fever, poor feeding, lethargy, and a bulging fontanelle. The CSF is cloudy and contains 2,000 WBCs/mm 3 </li></ul><ul><li>The organism MOST likely to be causing this infant’s problem is: </li></ul><ul><ul><ul><li>GBBS </li></ul></ul></ul><ul><ul><ul><li>H. flu </li></ul></ul></ul><ul><ul><ul><li>Listeria </li></ul></ul></ul><ul><ul><ul><li>Neisseria </li></ul></ul></ul><ul><ul><ul><li>Strep pneumo </li></ul></ul></ul>GBBS Higher risk in older infants Accounts for 5% of neonatal infections GBBS and E. coli account for 50-70%% of all neonatal infections
    21. 22. Summer is Finally Here! Enjoy!!