2. Approach to Acute Febrile Illness
• Definition: Rectal temperature ≥ 38.3°C, < 1 week
• History: Physical examination
• Pattern of fever and Length of illness
• Localizing symptoms
• Immunization status
• Prior use of medication
• Underlying disease
• Travel, contacts, animal and insect exposure
3. Management of Fever without source
• Infants 0 to 28 days of age
• Infants 29 to 90 days of age
• Infants 3 to 36 months of age
• Children aged 3 years to adulthood
4. Infants 0 to 28 days of age, Temp ≥ 38oC
• Infants 3 to 28 days old with temp. ≥ 38 oC 254 cases
• 32 (12.6%) had an Serious bacterial illness (SBI)
Arch Pediatr Adolesc Med. 1999 May;153(5):508-11.
5. Infants 0 to 28 days of age, Temp ≥ 38oC
• Sepsis work up:
• CBC, LFTs, Blood culture
• Urinalysis, Urine culture
• Lumbar puncture:
• HSV PCR if CSF pleocytosis
• Chest X Ray
• Viral study
6. Infants 0 to 28 days of age, Temp ≥ 38oC
Bacterial pathogens
• group B
streptococcus
• E.coli
• L.monocytogenes
Empirical antibiotics
• Ampicillin plus Gentamicin
• Ampicillin plus Cefotaxime
• Vancomycin
(gram positive on CSF gram
stain or risk for S.aureus)
Empirical acyclovir
• if risk factors for HSV disease
exist
7. Infants 29 to 90 days of age, Temp ≥ 38oC
Well – appearing Ill – appearing
8. Infants 29 to 90 days of age, Temp ≥ 38oC
Ill – appearing
Admit & Sepsis work up &
Parenteral antibiotic
Pathogens
• Neonatal pathogens
• H.influenzae, N.meningitides
• S.pneumoniae
Cefotaxime + Ampicillin
9. Infants 29 to 90 days of age, Temp ≥ 38oC
Well – appearing
Low – risk criteria
Outpatient management
YES
Clinical criteria
• Previously healthy
• No focal bacterial infection
Laboratory criteria
• WBC 5000 to 15000/mm3
• Band < 1500/mm3
• Normal UA
• Normal CSF, Stool exam
• (if obtained)
10. Infants 29 to 90 days of age, Temp ≥ 38oC
Low risk criteria Outpatient management
• Blood culture
• Urine culture
• Treat suspected influenza
Option 1
• Lumbar puncture
• Ceftriaxone 50 mg/kg IV/IM
• Reevaluation in 24 hours
Option 2
• No antibiotics
• Reevaluation in 24 hours
11. Infants 3 to 36 months of age, T ≥ 39oC
Well – appearing Ill – appearing
12. Infants 3 to 36 months of age, T ≥ 39oC
Ill – appearing
Sepsis work up
• Blood culture
• Urine culture
• Lumbar puncture (meningitis is suspected)
• Chest X Ray
(tachypnia & WBC > 20,000/mm3)
13. Infants 3 to 36 months of age, T ≥ 39oC
Ill – appearing
Sepsis work up
Parenteral antibiotic
Pathogens
• H.influenzae type B
• N.meningitides
• S.pneumoniae
• S.aureus
Ceftriaxone & Cefotaxime
14. Infants 3 to 36 months of age, T ≥ 39oC
Well – appearing
Complete
Incomplete
15. Occult Bacteremia
• Bacteria in the blood
• Well – appearing febrile child
• Absence of an identifiable focal bacterial source
17. Pathogenic bacteria cultured from patients with occult bacteremia
1. Arch Pediatr Adolesc Med.
1998;152:624-628.
2. Pediatrics. 2000 Sep;106(3):505-11.
18. Evaluation of febrile young infants
• Boston
• Philadelphia
• Rochester
• Lab-score
• Step by step
19. Boston protocol
• Prospectively evaluated 503 28- to 89-day-old infants with rectal
temperature greater than 38ºC (100.4ºF)
• Criteria:
• No immunizations or antimicrobials within the preceding 48 hours
• No evidence of dehydration, ear, soft tissue, or bone infection
• Overall well appearance
• Caretaker available by telephone
• The laboratory criteria defining low-risk patients included:
• Peripheral white blood cell (WBC) count less than 20,000/microL
• CSF with WBC <10/microL
• UA <10 WBC per high-powered field
• No infiltrate on chest radiograph if one was obtained
• Ceftriazone 50 mg/kg im, F/U 24 hr
• 27 (5.4%) had SBI
20. Philadelphia protocol
• 8-year experience with 747 infants 29- to 60-days of age with a rectal
temperature ≥38.2ºC (100.8ºF)
• Low-risk criteria included patients who were well-appearing with:
• WBC <15,000/microL
• Band-neutrophil ratio <0.2
• UA <10 WBC/hpf and a negative urine Gram stain
• CSF <8 WBC/microL and a negative CSF Gram stain
• Chest radiograph lacking an infiltrate if one was obtained
• Stool without blood and few or no WBCs on the smear in infants with
diarrhea
D/C and F/U 24 hr
Sensitivity 98 %(95% CI 92-100); specificity 42 %(95% CI 38-46);
PPV 14 %(95% CI 11-17); NPV 99.7 %(95% CI 98-100)
21. Rochester protocol
• Identify low-risk febrile infants (defined as a rectal temperature
greater than or equal to 38.0ºC or 100.4ºF) younger than 60 days
• Clinical criteria:
• ≥37 weeks gestation, and hospitalized no longer than the mother
• Infant was previously healthy
• Infant was well-appearing, with no ear, soft tissue, or bone infections
• LAB:
• WBC 5,000 to 15,000/microL with an absolute band count <1,500/microL
• Urinalysis with <10 WBC/hpf and no bacteria seen
• Stool with <5 WBC/hpf if obtained D/C with F/U
Five had SBI, NPV 98.9 %(95% CI 97-100)
24. • IBI 79.3% (22/26
sepsis, 9/10
meningitis)
• Non IBI 98.5%
25.
26.
27. Infants 3 to 36 months of age, T ≥ 39oC Well – appearing
Immunization incomplete
WBC ≥ 15,000/mm3 H/C
WBC > 20,000/mm3 CXR
CBC, UA, Urine culture
28. Infants 3 to 36 months of age, T ≥ 39oC Well – appearing
Immunization incomplete
WBC ≥ 15,000/mm3
CBC, UA, Urine culture
• Ceftriaxone (50 mg/kg/dose) IM
• Outpatient follow up within 24 hrs
• Admit for parenteral antibiotic
29. Antimicrobial treatment of occult bacteremia: a
multicenter cooperative study.
Children 3 to 36 months, T ≥ 39.5oC without focus of infection
WBC < 15,000/mm3 WBC ≥ 15,000/mm3 WBC ≥ 30,000/mm3
H/C positive 5 of
182, 2.7%
H/C positive 55 of
331, 16.6%
H/C positive 9 of 21,
42.9%
Pediatr Infect Dis J. 1993 Jun;12(6):466-73.
30. Occult pneumonias: empiric chest radiographs in
febrile children with leukocytosis
CXR were obtained in 225 cases
With respiratory
symptom, 79 case
With leukocytosis ≥
20,000/mm3, 149 cases
Pneumonia, 32 of 79 (40%) Pneumonia, 38 of 146 (26%)
Ann Emerg Med. 1999 Feb;33(2):166-73.
31. Infants 3 to 36 months of age, T ≥ 39oC Well – appearing
Immunization complete
Sign & Symptoms of UTI
• Girls < 24 mo of age
• Uncircumcised boys < 12 months of age
• Circumcised boys < 6 months of age
UA, Urine culture
NO YES
34. Managment
• ATB
• Upper UTI or fever 7-14 d
• Cystitis 3-7 d
• 1st UTI U/S KUB, not recommend routine VCUG if U/S normal
• Recurrent UTI U/S KUB, VCUG if not done before
35.
36. Antibiotics prophylaxis
• Not recommend routine ATB prophylaxis in 1st UTI
• Consider in patient that has to do VCUG
• High-grade reflux and underlying obstructive/complex uropathies
37. Renal abscess • Pyelonephrosis
• accumulation of purulent debris and
sediment in the renal pelvis and urinary
collecting system
• Symptoms: severe pyelonephritis,
persistent + signs of hydronephrosis
• ATB + drainage
• Acute focal bacterial nephritis (acute lobar
nephronia)
• intermediate stage between pyelonephritis
and intrarenal abscess
• CT: lobar or wedge-shaped, distribution of
hypointensity lesions
• ATB 14-21 days
38. • Perinephric or renal abscess
• Hematogenous seeding especially
Staphylococcus aureus BSI or renal
extension of ascending UTIs
• Severe pyelonephritis – fever, flank pain,
leukocytosis, and sometimes BSI
• CT: perirenal fluid or gas, renal distortion
• S. aureus, gram-negative bacilli (GNB)
(especially Escherichia coli and other
enteric GNB)
• Previous abdominal surgery, renal
transplantation, malignancy, and oral or
dental infection anaerobe
• ATB 2-3 wks + drainage
• Xanthogranulomatous pyelonephritis
• chronic bacterial pyelonephritis and
obstruction
• Age < 8 years, > 40 years
• DDx renal tumor
• Flank pain, fever, chills, and chronic
bacteriuria; vague symptoms such as
malaise, malnutrition, weight loss, and
failure to thrive, usually > 1 mo
• Proteus species, E. coli
• Obstruction is present in 70% to 80% of
children ( congenital genitourinary
anormality, renal calculi)
39. Children aged 3 years to Adulthood
• The incidence of occult bacteremia decreases after 3 years of
age
