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Febrile Child


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Febrile Child

  1. 1. Febrile Child
  2. 2. Overview <ul><li>Introduction </li></ul><ul><li>Occult bacteremia </li></ul><ul><li>Antibiotic prevention of SBI </li></ul><ul><li>Febrile seizure </li></ul><ul><li>Fever and petechiae </li></ul><ul><li>Fever in children with underlying illness </li></ul><ul><li>Rare syndromes </li></ul>
  3. 3. Introduction <ul><li>Historical perspective </li></ul><ul><ul><li>Toxic looking child </li></ul></ul><ul><ul><ul><li>Fever, menigeal signs, lethargic, limb, mottled </li></ul></ul></ul><ul><ul><ul><li>Admit, septic work-up, parental antibiotics </li></ul></ul></ul><ul><ul><li>Focal bacterial infection </li></ul></ul><ul><ul><ul><li>Any child with focal bacterial infection (excluding SBI) such as OM, pharyngitis, sinusitis, etc. </li></ul></ul></ul><ul><ul><ul><li>Oral antibiotics, outpatient care </li></ul></ul></ul><ul><ul><li>Well looking child </li></ul></ul><ul><ul><ul><li>Risk for occult bacteremia and serious bacterial infection </li></ul></ul></ul><ul><ul><ul><li>Previous decision analysis: pre-H. flu immunization </li></ul></ul></ul><ul><ul><ul><li>Current decision analysis </li></ul></ul></ul>
  4. 4. Occult Bacteremia <ul><li>Incidence of occult bacteremia </li></ul><ul><ul><li>Rosen: 3% to 5% </li></ul></ul><ul><ul><li>EMR: 2.8% Fleisher et al Pediatrics 1994 </li></ul></ul><ul><ul><li>Alpern et al AAP Sept 2000: 1.9% </li></ul></ul><ul><ul><li>Baraff et at Ann Emerg Med 1993: 4.3% </li></ul></ul><ul><li>Organism implicated in OB </li></ul><ul><ul><li>Rosen: 85% strep pneumo; 15% H. flu, N. men., Salmonella and others </li></ul></ul><ul><ul><li>EMR: strep pneumo and H. flu 99% </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Baraff et al Ann Emerg Med 1993: S. pneumo 85%, H. flu 10%, N. men 5% </li></ul></ul>
  5. 5. Occult Bacteremia <ul><li>Degree of temperature elevation </li></ul><ul><ul><li>Rosen: 39.5 to 39.9 degrees C 3%; 40 to 40.9 4%; above 41 10% (Harper and Fleisher Pediatrics Ann 1993) </li></ul></ul><ul><ul><li>EMR: 39.0 to 39.9 1.9%; 40.0 to 40.9 3%; 41+ 9% </li></ul></ul><ul><ul><li>Alpern et al Pediatrics Sept 2000: 40+ 2.9 times more likely to have OB </li></ul></ul><ul><li>Age of the child </li></ul><ul><ul><li>Rosen: children 24 to 36 months are less likely than those under 24 months </li></ul></ul><ul><ul><li>EMR: most OB between 6 to 18 months </li></ul></ul><ul><ul><li>Alpern et at highest incidence 12-17 months </li></ul></ul>
  6. 6. Occult Bacteremia <ul><li>WBC </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>EMR: using 15,000 as cut-off will miss 35% of bcateremic children </li></ul></ul><ul><ul><li>Isaacman et al Pediatrics Nov 2000 ANC better predictor of OB </li></ul></ul><ul><ul><li>Kupperman et al Ann Emerg Med 1998 found that ANC greater than 10,000 better predictor of OB than WBC 15,000. </li></ul></ul>
  7. 7. Occult Bacteremia <ul><li>Blood cultures </li></ul><ul><ul><li>New blood culture techniques most blood culture results are positive in less than 24 hrs; Alpern et al mean time 14.9 hrs </li></ul></ul><ul><ul><li>Most OB spontaneously resolves </li></ul></ul><ul><li>Minor infections </li></ul><ul><ul><li>Fleisher et al J Pediatrics 1994: 12.8% OM </li></ul></ul><ul><ul><li>Baraff et al Pediatrics 1993: 3-6% OM </li></ul></ul><ul><ul><li>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) </li></ul></ul>
  8. 8. Occult Bacteremia <ul><li>Assessment of observational scores: Bonadio Pediatric Clinics of NA 1998 </li></ul><ul><ul><li>Infants younger than 8 weeks </li></ul></ul><ul><ul><ul><li>Retrospective studies </li></ul></ul></ul><ul><ul><ul><li>Prospective studies </li></ul></ul></ul><ul><ul><li>Infants and children older than 8 weeks </li></ul></ul><ul><ul><ul><li>Prospective studies </li></ul></ul></ul>
  9. 9. Occult Bacteremia <ul><li>Guidelines for managing OB </li></ul><ul><ul><li>Guidelines for febrile infants 0-3 months </li></ul></ul><ul><ul><ul><li>Baker et al NEJM 1993: Philadelphia protocol </li></ul></ul></ul><ul><ul><ul><ul><li>Infants under 3 months </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Philadelphia protocol: low risk vs high risk </li></ul></ul></ul></ul><ul><ul><ul><ul><li>100% sensitive; 100% negative predictive value </li></ul></ul></ul></ul><ul><ul><ul><li>Baker et al Pediatrics 1999: validation </li></ul></ul></ul><ul><ul><ul><ul><li>Validation of Philadelphia protocol </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Infants 29-60 days old; low risk vs high risk for SBI </li></ul></ul></ul></ul><ul><ul><ul><ul><li>100% sensitivity; 100% negative predictive value </li></ul></ul></ul></ul>
  10. 10. Occult Bacteremia <ul><li>Guidelines for managing OB </li></ul><ul><ul><li>Guidelines for febrile infants 0-3 months </li></ul></ul><ul><ul><ul><li>Dagan et al J Pediatrics 1985: Rochester protocol </li></ul></ul></ul><ul><ul><ul><li>Jaskiewicz et al Pediatrics 1994: appraisal Rochester protocol </li></ul></ul></ul><ul><ul><ul><li>Avner et al Abstract: failure to validate Rochester protocol </li></ul></ul></ul>
  11. 11. Occult Bacteremia <ul><li>Guidelines for managing OB </li></ul><ul><ul><li>Guidelines for febrile infants 0-3 months </li></ul></ul><ul><ul><ul><li>Baraff et al Ann Emerg Med 1993 </li></ul></ul></ul><ul><ul><ul><ul><li>Meta-analysis febrile infants less than 90 days </li></ul></ul></ul></ul><ul><ul><ul><ul><li>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 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Febrile infants 28-90 days low risk outpatient care with IM ceftriaxone, septic work up, and 24 hr f/u </li></ul></ul></ul></ul>
  12. 12. Occult Bacteremia <ul><li>Guidelines for managing OB </li></ul><ul><ul><li>Guidelines for febrile infants 3-36 months </li></ul></ul><ul><ul><ul><li>Toxic children: no issue </li></ul></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><ul><li>Recent studies challenge these recommendations; selective approach </li></ul></ul></ul>
  13. 13. Occult Bacteremia <ul><li>Antibiotic use to prevent SBI in children at risk for OB </li></ul><ul><ul><li>Bulloch et al Acad Emerg Med 1997 </li></ul></ul><ul><ul><li>Rothrock et al Pediatrics 1997 </li></ul></ul>
  14. 14. Febrile seizure <ul><li>Synopsis of the American Academy of Pediatric practices parameters on the evaluation and treatment of children with febrile seizures (Peditrics 1999) </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>12-18 months LP strongly suggested because sign of meningitis may be subtle in this age group </li></ul></ul><ul><ul><li>18+ months LP only if signs and symptoms of meningitis </li></ul></ul>
  15. 15. Febrile seizure <ul><li>EEG is not perform in a neurologically healthy child with simple febrile seizure </li></ul><ul><li>The following routine lab should not be performed in simple febrile seizure: CBC, lytes, Ca, phos, Mg, or glucose </li></ul><ul><li>Neuro-imaging should not be performed routinely on simple febrile seizure </li></ul><ul><li>Anticonvulsant therapy is not recommended in simple febrile seizure </li></ul>
  16. 16. Fever and petechiae <ul><li>Baker et al Pediatrics Dec 1989 </li></ul><ul><ul><li>7% incidence of meningococcal disease </li></ul></ul><ul><ul><li>Petechiae below nipple line associated with invasive bacterial disease </li></ul></ul><ul><ul><li>Generalized rash more associated with invasive bacterial disease </li></ul></ul><ul><ul><li>WBC greater than 15,000, ABC greater than 500 cell/ul, CSF abnormality 93% sensitive and 62% specific for invasive bacterial disease </li></ul></ul><ul><ul><li>Recommend hospitalization, septic work up, and parenteral antibiotic </li></ul></ul>
  17. 17. Fever <ul><li>Fever in children with underlying illness </li></ul><ul><ul><li>Oncology patients </li></ul></ul><ul><ul><ul><li>At risk of overwhelming sepsis </li></ul></ul></ul><ul><ul><ul><li>When febrile: CBC, CXR, blood culture, urine culture, and LP when clinically indicated </li></ul></ul></ul><ul><ul><ul><li>Neutropenic patients at risk for Pseudomonas and other gram negative; combination of tobramycin and ceftazidime </li></ul></ul></ul><ul><ul><ul><li>Indwelling IV devices add vancomycin to tobramycin and ceftazidime </li></ul></ul></ul>
  18. 18. Fever in children with underlying illness <ul><li>Acquired Immunodeficiency Syndrome </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Low CD4 similar approach to neutropenic cancer patient; septic work up and broad spectrum antibiotic </li></ul></ul>
  19. 19. Fever in child with underlying illness <ul><li>Congenital heart disease </li></ul><ul><ul><li>Children with valvular heart disease are at risk for endocarditis </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Suggested antibiotics include Vancomycin and Gentamycin until cultures are positive </li></ul></ul>
  20. 20. Fever in child with underlying illness <ul><li>Ventriculoperitoneal shunts </li></ul><ul><ul><li>Fever in this group must be evaluated for shunt infection esp if patient displays headache, stiff neck, vomiting, or irritability </li></ul></ul><ul><ul><li>Shunt reservoir should be aspirated and examined for pleocytosis and bacteria </li></ul></ul><ul><ul><li>Most common pathogen is S. epidermidis </li></ul></ul><ul><ul><li>CT head also warranted </li></ul></ul>
  21. 21. Febrile child <ul><li>Other conditions to consider in febrile child </li></ul><ul><ul><li>Collagen vascular disease </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Drug-induced fever </li></ul></ul><ul><ul><li>Toxic ingestion </li></ul></ul><ul><ul><li>Heat exhaustion and heatstroke </li></ul></ul><ul><ul><li>Kawasaki syndrome </li></ul></ul><ul><ul><li>Thyrotoxicosis </li></ul></ul>