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Febrile child


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Febrile child

  1. 1. Febrile Child
  2. 2. OverviewIntroductionOccult bacteremiaAntibiotic prevention of SBIFebrile seizureFever and petechiaeFever in children with underlying illnessRare syndromes
  3. 3. IntroductionHistorical 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
  4. 4. Occult BacteremiaIncidence 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%
  5. 5. Occult BacteremiaDegree 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 OBAge 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
  6. 6. Occult BacteremiaWBC 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.
  7. 7. Occult BacteremiaBlood 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 resolvesMinor 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)
  8. 8. Occult BacteremiaAssessment of observational scores:Bonadio Pediatric Clinics of NA 1998 Infants younger than 8 weeks  Retrospective studies  Prospective studies Infants and children older than 8 weeks  Prospective studies
  9. 9. Occult BacteremiaGuidelines for managing OB Guidelines 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
  10. 10. Occult BacteremiaGuidelines for managing OB Guidelines 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
  11. 11. Occult BacteremiaGuidelines for managing OB Guidelines 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
  12. 12. Occult BacteremiaGuidelines for managing OB Guidelines for febrile infants 3-36 months  Toxic children: no issue  Well 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
  13. 13. Occult BacteremiaAntibiotic use to prevent SBI in childrenat risk for OB Bulloch et al Acad Emerg Med 1997 Rothrock et al Pediatrics 1997
  14. 14. Febrile seizureSynopsis of the American Academy ofPediatric practices parameters on theevaluation and treatment of children withfebrile 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
  15. 15. Febrile seizureEEG is not perform in a neurologically healthychild with simple febrile seizureThe following routine lab should not beperformed in simple febrile seizure: CBC,lytes, Ca, phos, Mg, or glucoseNeuro-imaging should not be performedroutinely on simple febrile seizureAnticonvulsant therapy is not recommendedin simple febrile seizure
  16. 16. Fever and petechiaeBaker 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
  17. 17. FeverFever in children with underlying illness Oncology patients  At risk of overwhelming sepsis  When febrile: CBC, CXR, blood culture, urine culture, and LP when clinically indicated  Neutropenic patients at risk for Pseudomonas and other gram negative; combination of tobramycin and ceftazidime  Indwelling IV devices add vancomycin to tobramycin and ceftazidime
  18. 18. Fever in children with underlying illnessAcquired 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
  19. 19. Fever in child with underlying illnessCongenital 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
  20. 20. Fever in child with underlying illnessVentriculoperitoneal shunts Fever 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. epidermidis CT head also warranted
  21. 21. Febrile childOther conditions to consider in febrile child Collagen vascular disease Malignancy Drug-induced fever Toxic ingestion Heat exhaustion and heatstroke Kawasaki syndrome Thyrotoxicosis