Management Of The Febrile Infant

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Management Of The Febrile Infant

  1. 1. Management of the Febrile Infant 2001 Theodore C. Sectish, MD Director, Residency Training Program in Pediatrics Assistant Professor in Pediatrics Stanford University School of Medicine
  2. 2. Fever in Infants
  3. 3. Learning Objectives: <ul><li>Fever in infants and outcomes of fever </li></ul><ul><li>Evaluation of the febrile infant </li></ul><ul><li>Modified Clinical Practice Guideline </li></ul><ul><li>Guidelines and Practice </li></ul><ul><li>New considerations </li></ul><ul><li>Management of Fever without Source - 2001 </li></ul>
  4. 4. Historical Perspective <ul><li>1967 Occult bacteremia </li></ul><ul><li>1970s Hospitalization of febrile infants </li></ul><ul><li>1980s Outpatient management </li></ul><ul><li>1985 HIB Vaccine </li></ul><ul><li>1993 Clinical Practice Guideline </li></ul><ul><li>2000 PCV7 Vaccine </li></ul>
  5. 5. Fever in Practice <ul><li>4% of 1341 infants <6 mos of age in a family practice clinic had temperatures >38.3 0 C 1 </li></ul><ul><li>10.5% of 1068 infants 3-24 mos of age in a pediatric practice in New York had temperatures >38.2 0 C 2 </li></ul><ul><li>Fever is a common problem in practice </li></ul>1-Pantell Clin Pediatr 1980;19:77 2-Hoekelman AJDC 1979;133:1017
  6. 6. Diagnoses: Febrile Infants < 3 months <ul><li>URI 35.0% </li></ul><ul><li>Otitis media 16.1% </li></ul><ul><li>Bronchiolitis 8.4% </li></ul><ul><li>Gastroenteritis 7.8% </li></ul><ul><li>Urinary tract infection 4.7% </li></ul><ul><li>Viral meningitis 2.7% </li></ul><ul><li>Bacteremia 1.5% </li></ul><ul><li>Bacterial meningitis 0.3% </li></ul><ul><li>Cellulitis 0.2% </li></ul><ul><li>Osteomyelitis 0.04% </li></ul>Pantell, personal communication, PROS study
  7. 7. Fever without Source (FWS) <ul><li>20% of all infants <3 years with fever have FWS </li></ul><ul><li>3% have occult pneumococcal bacteremia </li></ul><ul><ul><li>Of bacteremic infants, 3% have meningitis </li></ul></ul><ul><ul><li>1 out of 1000! </li></ul></ul><ul><li>Risks of pneumococcal bacteremia in a PCV7 immunized infant is unknown </li></ul><ul><li>Risk reduction estimate once immunized: 90% </li></ul>
  8. 8. Definition of Fever <ul><li>38.0 0 C </li></ul><ul><li>Rectal measurement </li></ul><ul><li>Unbundled infant </li></ul><ul><li>No recent antipyretics </li></ul><ul><li>No recent immunizations </li></ul>Baraff Pediatrics 1993;92:1
  9. 9. Bundling and Fever <ul><li>Experimental design with controls </li></ul><ul><li>Bundling = 5 blankets and a hat </li></ul><ul><li>20 bundled infants: mean change + 0.56 0 C </li></ul><ul><li>20 infant controls: mean change - 0.04 0 C </li></ul><ul><li>2 infants reached 38.0 C, not higher </li></ul>Cheng TL Pediatrics 1993;92(2):238
  10. 10. Febrile Infants: Outcomes of Interest <ul><li>Bacteremia 1.5 - 12% </li></ul><ul><li>Serious bacterial infection 1.4 - 17.3% </li></ul>Jaskiewicz Pediatrics 1994;94:390 Bass Pediatr Infect Dis J 1993:12:466 Fleisher J Pediatr 1994;124:504 Jaffe NEJM 1987;317:1175 Baraff Pediatr Infect Dis J 1992;11:257 Pantell, PROS Study, personal communication
  11. 11. Serious Bacterial Infection (SBI) <ul><li>Urinary tract infection </li></ul><ul><li>Sepsis or bacteremia </li></ul><ul><li>Meningitis </li></ul><ul><li>Bacterial enteritis </li></ul><ul><li>Bone and joint infections </li></ul><ul><li>Pneumonia </li></ul>
  12. 12. Probability of Bacterial Infection in Febrile Infants, <90 Days of Age Baraff J Peds 1993;92:1
  13. 13. Probability of Occult Bacteremia: Febrile Infants, 3 - 36 months Baraff Pediatrics 1993;92:1 Lee Arch Pediatr Adolesc Med 1998;152:624
  14. 14. Outcomes of Occult Bacteremia in the Age of Hemophilus Baraff PIDJ 1992;11:146
  15. 15. Occult Bacteremia in the Post-HIB Vaccine Era: 3-36 months <ul><li>Streptococcus pneumoniae 92% </li></ul><ul><li>Others: 8% </li></ul><ul><ul><li>Salmonella sp </li></ul></ul><ul><ul><li>N meningitidis </li></ul></ul><ul><ul><li>Group A Streptococcus </li></ul></ul><ul><ul><li>Group B Streptococcus </li></ul></ul>Lee Arch Pediatr Adolesc Med 1998;152:624
  16. 16. Outcomes of Outpatients with Pneumococcal Bacteremia <ul><li>548 episodes in an ER population </li></ul><ul><li>Treatment strategies varied: </li></ul><ul><ul><li>No antibiotics (N = 73) </li></ul></ul><ul><ul><li>Oral antibiotics (N = 239) </li></ul></ul><ul><ul><li>Parenteral antibiotics (N = 236) </li></ul></ul>Bachur Pediatrics 2000;105:502
  17. 17. Reevaluation of Outpatients with Pneumococcal Bacteremia Bachur Pediatrics 2000;105:502
  18. 18. Conclusions <ul><li>Data favor treatment </li></ul><ul><li>Declining prevalence of bacteremia demands a change in practice </li></ul>
  19. 19. How Do Clinicians Evaluate Febrile Infants?
  20. 20. Evaluation of the Febrile Infant <ul><li>Careful history </li></ul><ul><li>Physical examination </li></ul><ul><li>Selected laboratory tests </li></ul>
  21. 21. Evaluation of the Febrile Infant <ul><li>Age </li></ul><ul><li>Toxicity </li></ul><ul><li>Decisions to test, to treat, to admit </li></ul>
  22. 22. Evaluation of the Febrile Infant <ul><li>Evaluate: </li></ul><ul><ul><li>Vital signs </li></ul></ul><ul><ul><li>Skin color </li></ul></ul><ul><ul><li>Behavior </li></ul></ul><ul><ul><li>State of hydration </li></ul></ul><ul><li>Document carefully and convey a clear picture of the overall clinical appearance of the patient. </li></ul>
  23. 23. Evaluation of the Febrile Infant <ul><li>Perform a complete physical exam with particular attention to: </li></ul><ul><ul><li>Skin: for petechiae / purpura, rashes </li></ul></ul><ul><ul><li>Oropharynx: for signs of gingivostomatitis/herpangina </li></ul></ul><ul><ul><li>Pulmonary examination: for occult pneumonia </li></ul></ul><ul><ul><li>Bones, joints and soft tissues: for infection </li></ul></ul><ul><li>Consider the history of fever as correct in all reported measured temperatures </li></ul>
  24. 24. What is “Toxic”? It is a very difficult task to define “toxic”; the closest I can come to a definition is to say that if to an experienced physician he looks and acts damned sick, he’s toxic. Sidney Gellis Pediatric Notes , 1979
  25. 25. Definition: “Toxic” Infant <ul><li>Lethargy </li></ul><ul><ul><li>poor or absent eye contact </li></ul></ul><ul><ul><li>failure to recognize parents </li></ul></ul><ul><ul><li>poor interaction with persons / environment </li></ul></ul><ul><li>Signs of poor perfusion </li></ul><ul><li>Marked hypoventilation / apnea </li></ul><ul><li>Hyperventilation </li></ul><ul><li>Cyanosis </li></ul>
  26. 26. 1993 Clinical Practice Guideline <ul><li>Review of literature </li></ul><ul><li>Evidence based </li></ul><ul><li>Outcomes driven </li></ul><ul><li>Consensus opinion </li></ul>Baraff Pediatrics 1993;92:1
  27. 27. Clinical Practice Guideline
  28. 28. Clinical Practice Guideline
  29. 29. Important Clinical Questions <ul><li>Which young infants are at low risk for serious bacterial infection? </li></ul><ul><li>Which older infants deserve empiric antibiotic therapy? </li></ul>
  30. 30. Clinical Practice Guideline Low Risk Criteria: Clinical Appearance <ul><li>Nontoxic appearance </li></ul><ul><li>Previously healthy </li></ul><ul><li>No focal bacterial infection on exam </li></ul><ul><li>Otitis media is not considered a focal infection </li></ul>
  31. 31. Clinical Practice Guideline Low Risk Criteria: Laboratory Tests <ul><li>WBC: 5,000-15,000 / mm 3 </li></ul><ul><li>< 1500 bands </li></ul><ul><li>Normal urinalysis or Gram stained smear </li></ul><ul><li>If diarrhea is present: </li></ul><ul><li>< 5 WBCs per hpf on stool examination </li></ul>
  32. 32. Guideline: 0 - 28 days
  33. 33. Guideline: 0 - 28 days <ul><li>Sepsis Evaluation including: </li></ul><ul><ul><li>CBC, Blood Culture </li></ul></ul><ul><ul><li>Urinalysis, Urine Culture </li></ul></ul><ul><ul><li>CSF Exam and Culture </li></ul></ul><ul><li>Hospitalization </li></ul><ul><li>Options: </li></ul><ul><ul><li>#1 Parenteral antibiotics </li></ul></ul><ul><ul><li>#2 Observation </li></ul></ul>
  34. 34. Guideline: 29 - 90 days
  35. 35. Guideline: 29 - 90 days Follow-up <ul><li>Blood culture is positive: </li></ul><ul><ul><li>Admit </li></ul></ul><ul><ul><li>Sepsis work-up </li></ul></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><li>Urine culture is positive: </li></ul><ul><ul><li>Febrile: admit for sepsis work-up, treat </li></ul></ul><ul><ul><li>Afebrile: outpatient antibiotics </li></ul></ul>
  36. 36. Modified Guideline: 3 - 36 months
  37. 37. Modifications to the Guideline <ul><li>Higher temperature threshold in view of Pneumococcal bacteremia prevalance </li></ul><ul><ul><li>T > 39.5 0 C + WBC > 15,000: 10% </li></ul></ul><ul><ul><li>T > 39.5 0 C + WBC < 15,000: 1% </li></ul></ul><ul><li>Guideline applies to those 3-36 month olds who have not yet received 3 doses of PCV7 </li></ul>Baraff LJ Annals of Emerg Med 2000;36(6):602 Fleischer GR J Pediatrics 1994;124:504 Bass JW PIDJ 1993;12:466
  38. 38. Modified Guideline: 3 - 36 months Options <ul><li>Urinalysis or Urine leukocyte esterase + nitrite </li></ul><ul><li>Send urine culture: </li></ul><ul><ul><li>All males <6 months + uncircumcised males <1yr </li></ul></ul><ul><ul><li>Females <1 yr </li></ul></ul><ul><li>Send urine culture if positive urine screening </li></ul><ul><ul><li>Circumcised males 6-12 months </li></ul></ul><ul><ul><li>Females 1-2 yrs </li></ul></ul>Baraff LJ Annals of Emerg Med 2000;36(6):602
  39. 39. Modified Guideline: 3 - 36 months Options <ul><li>Infants and children who have not yet received 3 doses of PCV7 Vaccine </li></ul><ul><li>Temp > 39.5 0 C (103.1 0 F) </li></ul><ul><li>WBC and hold Blood Culture </li></ul><ul><ul><li>If WBC > 15,000 (ANC > 10,000) </li></ul></ul><ul><ul><ul><li>Send Blood Culture </li></ul></ul></ul><ul><ul><ul><li>Give Ceftriaxone 50 mg / kg </li></ul></ul></ul>Baraff LJ Annals of Emerg Med 2000;36(6):602
  40. 40. Modified Guideline: 3 - 36 months Options <ul><li>CXR to rule out pneumonia if: </li></ul><ul><ul><li>SaO 2 < 95% </li></ul></ul><ul><ul><li>Tachypnea, rales, respiratory distress </li></ul></ul><ul><ul><li>T > 39.5 0 C and WBC > 20,000 </li></ul></ul>Baraff LJ Annals of Emerg Med 2000;36(6):602
  41. 41. Guideline: 3 - 36 months Follow-up <ul><li>Blood culture is positive: </li></ul><ul><ul><li>S. pneumo : if febrile, admit for sepsis work-up and antibiotics; if afebrile, treat as outpatient </li></ul></ul><ul><ul><li>All other pathogens: admit for sepsis work-up and antibiotics </li></ul></ul><ul><li>Urine culture is positive: </li></ul><ul><ul><li>Febrile / ill: inpatient antibiotics </li></ul></ul><ul><ul><li>Afebrile / well: outpatient antibiotics </li></ul></ul>
  42. 42. Guidelines and Practice
  43. 43. Quotable Quote: “I don’t consider these ‘rules.’ They are kind of…..like….‘guidelines’” John Prober, speaking about tournament rules at the 50th Birthday Golf Tournament for brother Charles. August 1999
  44. 44. Data Support Departures from the Guideline <ul><li>Jaskiewicz Pediatrics 1994;94:390 </li></ul><ul><ul><li>437 low risk febrile infants < 60 days </li></ul></ul><ul><ul><li>< 1% risk of bacteremia </li></ul></ul><ul><ul><li>1% risk of SBI </li></ul></ul><ul><li>Chiu Pediatr Infect Dis J 1994;13:946 </li></ul><ul><ul><li>254 low risk febrile infants < 31 days </li></ul></ul><ul><ul><li>0.7% risk of bacteremia </li></ul></ul><ul><ul><li>5.3% had UTI, no other SBI </li></ul></ul>
  45. 45. Adherence Rates with Guideline <ul><li>194 Utah primary care pediatricians’ adherence with the practice guideline </li></ul><ul><ul><li>0 - 28 days: 39% </li></ul></ul><ul><ul><li>29 - 90 days: 9.6% </li></ul></ul><ul><ul><li>3 - 36 months: 75% </li></ul></ul><ul><ul><li>all three ages: 0% </li></ul></ul>Young, Pediatrics 1995;95:623
  46. 46. Otitis Media Influences Management <ul><li>194 Utah pediatricians surveyed in 1994 </li></ul><ul><li>Scenario of a 2 month old with a temp of 38.7 0 C and otitis media </li></ul><ul><li>82% would treat with oral antibiotics if screening tests were negative </li></ul>Young Pediatrics 1995;95:623
  47. 47. Data from Pediatric Practice: the PROS Fever Study <ul><li>White 73.7% </li></ul><ul><li>Hispanic 13.8% </li></ul><ul><li>African-Amer 7.2% </li></ul><ul><li>Asian/PacIsle 2.5% </li></ul><ul><li>Other 2.8% </li></ul>Personal communication, Pantell, PROS Study <ul><li>Medicaid 37% </li></ul><ul><li>HMO 35% </li></ul><ul><li>Private 22% </li></ul><ul><li>Self Pay 3% </li></ul><ul><li>Other 3% </li></ul>3093 infants, < 3 months of age
  48. 48. PROS Fever Study: Laboratory Tests Personal communication, Pantell, PROS Study
  49. 49. PROS Fever Study: Management Personal communication, Pantell, PROS Study
  50. 50. Outcomes in PROS Fever Study Observed rates of: Bacteremia 1.5 % Bacterial meningitis 0.3% Of these: Treated at initial contact 96% Hospitalized at initial contact 84% Preventable bad outcomes 0% Personal communication, Pantell, PROS Study
  51. 51. PROS Fever Study: Adherence Rates to Guideline <ul><li>Age Rate </li></ul><ul><li>0-1 month 44% </li></ul><ul><li>1-3 months </li></ul><ul><ul><li>Appears sick 32% </li></ul></ul><ul><ul><li>Appears well 44% </li></ul></ul>Personal communication, Pantell, PROS Study
  52. 52. New Considerations <ul><li>Automated Blood Culture Systems </li></ul><ul><li>Band counts - out? </li></ul><ul><li>Importance of UTI </li></ul><ul><li>Fever with Source </li></ul><ul><ul><li>Recognizable Viral Syndromes </li></ul></ul>
  53. 53. Automated Blood Culture Systems <ul><li>More rapid detection of bacterial pathogens </li></ul><ul><ul><li>Direct plating techniques: 36 hours </li></ul></ul><ul><ul><li>Automated systems: < 24 hours </li></ul></ul><ul><li>Facilitates outpatient management </li></ul>McGowan KL Pediatrics 2000;106(2):251 Alpern ER Pediatrics 106(3):505
  54. 54. Band Count: Not Discriminatory <ul><li>100 infants less than 2 years of age </li></ul><ul><ul><li>31 with bacterial infections </li></ul></ul><ul><ul><li>69 with respiratory viral infections </li></ul></ul><ul><li>No difference in: </li></ul><ul><ul><li>Absolute band count </li></ul></ul><ul><ul><li>Percentage band count </li></ul></ul><ul><ul><li>Band-to-neutrophil ratio </li></ul></ul>Kuppermann Arch Pediatr Adolesc Med 1999;153:261
  55. 55. Importance of UTI <ul><li>UTI is the most common SBI </li></ul><ul><li>Prevalence varies by age and gender: </li></ul><ul><ul><li>Females < 1: 6.5% 1-2: 8.1% </li></ul></ul><ul><ul><li>Males < 1: 3.3% 1-2: 1.9% </li></ul></ul><ul><li>Uncircumcised boys under 1 year have a rate of UTI 5-20 times greater than circumcised boys </li></ul><ul><li>Infants are at greater risk for renal injury: </li></ul><ul><ul><li>Reflux is more likely and more severe </li></ul></ul>AAP Committee on Quality Improvement Pediatrics 1999;103:843
  56. 56. Recognizable Viral Syndromes <ul><li>21,216 patients, 3-36 months of age </li></ul><ul><li>6% had a recognizable viral syndrome (RVS) </li></ul>Greenes Pediatr Infect Dis 1999;18:258
  57. 57. Why Do Clinicians not Adhere to the Clinical Practice Guideline? <ul><li>Many clinicians disagree with: </li></ul><ul><li>Definition of fever </li></ul><ul><li>Age thresholds </li></ul><ul><li>Applying study data to their practices in which there is better compliance and follow-up </li></ul>
  58. 58. Why Do Clinicians not Adhere to the Clinical Practice Guideline? <ul><li>Clinical decisions are driven by: </li></ul><ul><li>Desire to detect serious bacterial infection early rather than to treat “occult” bacteremia </li></ul><ul><li>Low probability of bacteremia and SBI </li></ul><ul><li>Preferences of parents </li></ul><ul><li>Personal experience </li></ul>
  59. 59. Caveat <ul><li>Experience is worth any amount of evidence... ...clinical experience….can be defined as “making the same mistakes with increasing confidence over an impressive number of years” </li></ul>BMJ 1999;319:18
  60. 60. Management of Fever Without Source <ul><li>Guideline is a place to start </li></ul><ul><li>Need to know IZ status </li></ul><ul><li>UTI: most frequent infection </li></ul><ul><li>Recognize the “toxic” infant </li></ul><ul><li>If you treat, obtain cultures </li></ul><ul><li>Document carefully </li></ul><ul><li>Arrange follow-up </li></ul>
  61. 61. Charles Prober’s Golden Rules <ul><li>The younger the infant, the greater the uncertainty </li></ul><ul><li>A toxic appearance demands immediate action </li></ul><ul><li>A non-toxic appearance fuels controversy </li></ul><ul><li>Careful follow-up must be assured </li></ul><ul><li>Recommendations continue to evolve </li></ul><ul><li>No rules are golden </li></ul>
  62. 62. Keep up with the literature.. ..managing febrile infants is an ever changing topic

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