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Fever in Infants Under 3 MonFever in Infants Under 3 Mon.
Dr. Bob Wilson Golden BC
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What is the risk of serious bacterial infection in a febrile 2
month old infant ?month old infant ?• A. 5%• B. 10%• C. 25%• D. 50%• E 100%• E. 100%
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What is the most commonWhat is the most common congenital viral infection ?
• A. Herpes simplex• B RubellaB. Rubella• C. Varicella
D R bi• D. Rabies• E. CMV
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A 3 week old infant presents withA 3 week old infant presents with fever > 38 degrees C. You will -
• A. Give acetaminophen and reassure the parentsp
• B. Take a blood culture and commence IM ceftriaxone as OPceftriaxone as OP
• C. LP, urine and blood culture, chest x-ray, initiate ampicillin and gentamycin IV as IPinitiate ampicillin and gentamycin IV as IP
• D. Ask Dr. Blondel-Hill
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I have no financial interests or other relationship with any pharmaceutical companypharmaceutical companyI have no other conflict of
interest to reportUnfortunatelyUnfortunately
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Learning Objectives
• Infants < 3 mon represent a special group for assessing possible causes of fever due to g ptheir intrinsic susceptibility to serious bacterial infection and particular risks of pexposure
• Infants < 1 mon are the high risk groupInfants < 1 mon are the high risk group within the high risk group
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Definition
• Rectal temp > 38 0Rectal temp > 38.0• Tympanic, temporal, axillary may be
inaccurateinaccurate• ? Excessively bundled – remeasure 20 min.
f b dliafter unbundling
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Conditions Beyond Scope of MyConditions Beyond Scope of My Talk
• Infection in VLBW infants• Neonates in nurseryNeonates in nursery
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What me worry?
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Why are Infants at Risk ?
• Hold over from neonatal period• Infections acquired in nursery but expressedInfections acquired in nursery but expressed
later• Increased susceptibility (poor ability to• Increased susceptibility (poor ability to
localize infection)C i l i f i• Congenital infections
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How Concerned Should We Be
• Avner, Baker Emerg Med Clin NA 2002;20: 49-67;
• infants < 2 mon with documented fever• 10% serious bacterial infection• 10% serious bacterial infection• 3% bacteremia or bacterial
i i imeningitis
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Difficulty in “Reading” Infants
• Non specific physiologic responseselevations in HR and RR dependant on p
fever• History dependant on caregivers – someHistory dependant on caregivers some
may not be present• Localizing signs of inflammation may not• Localizing signs of inflammation may not
be present (eg meningismus)
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Fever in Infants < 3 months
• Infection• Infection• Infection• Other:
– Neurosurgical – CNS bleed, tumor– Abdominal – NEC, intussusception – Inflammatory – variants of Kawasaki’s lupusInflammatory variants of Kawasaki s, lupus – Metabolic – hyperthyroidism, volume depletion,
electrolyte etc– Drug related
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Types of Infection to Consider
• Bacterial• ViralViral• Protozoan
F l ( i l VLBW i f i h l• Fungal (mainly VLBW infants with central lines and/or TPN)
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Congenital InfectionsCongenital InfectionsStorch
• Syphilis• ToxoplasmosisToxoplasmosis• “Others” (influenza, varicella, et cetella)
R b ll• Rubella• Cytomegalovirus• Herpes Simplex
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Incidence in USA
Agent Per 100,000 births
Annual
CMV 1000 40,000
T l i 100 4000Toxoplasmosis 100 4000
HSV 20 800HSV 20 800
Syphilis 10 400
Rubella <1 5
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Number of Neonates WithNumber of Neonates With Symptoms At Birth Is Small
Agent Total Cases Symptomatic
CMV 40,000 4,000
Toxoplasmosis 4 000 1 000Toxoplasmosis 4,000 1,000
HSV 800 800
Syphilis 400 130
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Serious Bacterial Infections inSerious Bacterial Infections in Febrile Infants
• Bacteremia• MeningitisMeningitis• Osteomyelitis/Suppurative Arthritis
Ski /S f Ti I f i• Skin/Soft Tissue Infection• Urinary Tract Infection• Gastroenteritis• PneumoniaPneumonia
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Common Bacterial Pathogens inCommon Bacterial Pathogens in Febrile Infants
• Gp B streptococcus• E. coli• Salmonella sp.• Streptococcus pneumoniae• Staphlococcus sp – esp MRSA• Hemophilus influenzae type b, non typeable • Enterococcus• Listeria monocytogenes
N i i i itidi• Neisseria meningitidis
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Less Common Pathogens
• TB• PertussisPertussis• Chlamydia
S hili• Syphilis• Malaria
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History
• Pregnancy, birth wt and maturity, neonatal illness or prolonged stay in nursery ? ICN
h i f di i i di h bl d i• Change in feeding, vomiting, diarrhea, blood in stools
• Respiratory Sx : rhinorrhea cough distress• Respiratory Sx : rhinorrhea, cough, distress• Measured temp?• Parental intuition• Parental intuition• Intercurrent illness in family, sibs in daycare,
immunization, family coccooned?, y
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Physical Exam
• Rectal temp, vital signs, O2 sat• Volume status• CNS – interaction, fontanel, meningeal irritation• Respiratory: URI?, flaring alae, retractions, work p y , g , ,
of breathing, lobar consolidation, wheeze, cyanosis
• Cardiac: peripheral circulation, pallor, hyperdynamic precordium
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Exam cont’d
• Abdomen: distension, tenderness, organomegally, bowel soundsg g y,
• Skin and soft tissues: rash, petechae, purpura jaundice arthropathypurpura, jaundice, arthropathy
• Trial feed
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Infants under 1 Month
• Sepsis workup – must include LP due to late onset gp B strep meningitis
(CBC, urine R/M, culture blood, urine, other, chest x-ray, pos. stool WBC and culture)id h i l if i l i• Consider herpes simplex esp. if seizure or lesions
• Consider Chlamydia if pneumonia• Consider S. aureus if nursery stay, family member
colonized
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Infants 30-90 Days
• Ill appearing, signs of possible localizing infection or decompensation
sepsis workup including LPanticipatory treatmentll i i h ibl b i l i• Well appearing with possible benign explanationlimited workup+/ anticipatory treatment+/- anticipatory treatment
• Follow up
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Group B Strep Sepsis
Year Early Onset Late Onset< 7 days 7-89 days
1992 1.7/1000 births 0.3/1000 births99 .7/ b s . / b s
1997 0.7 0.3
2009 0.26 0.3
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Herpes SimplexHerpes Simplex Dr. Sara Long’s way
• Age < 21 d fever/hypothermia without focus or vesicles/oral lesions and CSF pleocytosis
• Virus culture conjunctiva, throat, rectum• PCR CSF for herpes virus, antigen detection for
bacterial pathogens (and gm stain)• Bacterial culture CSF, blood, urine + other• Acyclovir 60 mg/kg/d div Q8H x 21 d IV +
antibiotics (amp and genta)
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Treatment of SuspectedTreatment of Suspected Bacteremia or Meningitis
• Ampicillin 200-400 mg/kg/d IV div Q6H (max 12 gm/d) some adjustment for age and premis
i /k l• Gentamycin 2.5 mg/kg IV Q8H – alternate 6.5 mg/kg/d once daily (5 mg/kg 8-30 d) many adjustments for age and maturity adjust based onadjustments for age and maturity adjust based on levels
• If staph or resistant S. pneumo suspected add vancomycin 15-20 mg/kg Q8H (age > 1 mon 10-15 mg/kg Q6-8 H) adjust in neonatesOld th 2 ft i• Older than 2 mon may use ceftriaxone or cefotaxime +/- vanco (remember Ca with ceftriaxone restriction)
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:
Incidence rate : cases per 100 000
Changes in Pneumococcal Disease100,000
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Etiology of Pneumonia inEtiology of Pneumonia in Neonates
• Gp B Strep• Staph aureusp• Gm –ve enteric organisms• Strep. pyogenesp py g• Listeria• Chlamydia trachomatisChlamydia trachomatis• CMV• RSV• RSV
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Etiology of Pneumonia in Infants
• RSV, parainfluenza, influenza, adenovirus• Streptococcus pneumoniaeStreptococcus pneumoniae• Haemophilus influenza (non-typable)
M l i• Mycoplasma pneumoniae• Pertussis• Chlamydia sp• TBTB
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Pneumonia TreatmentMcIntosh, NEJM 2002;346:429-437, Pediatr Rev
2008;29:147if staph aureus suspected add Clox or Vancoif staph aureus suspected add Clox or Vanco
Age OP IP – no lobar infiltrate or effusion
IP - severe
effusion
Birth – 20 d Admit Amp + Genta+/- Cefotaxime
Amp + Genta+/- Cefotaxime
3wk–3mon (afebrile)
Erythro orAzithro
Erythro orAzithro
N/A(afebrile)
3wk-3mon(f b il )
Admit Cefotaxime Cefotaxime orAmp (high dose)
(febrile)p ( g )
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Protecting Infants AgainstProtecting Infants Against Pertussis
• Immunize• Cocoon (immunize sibs and caregivers)Cocoon (immunize sibs and caregivers)• Treatment is only effective for shortening
symptoms when started in catarrhal phasesymptoms when started in catarrhal phase • Treatment does shorten period of infectivity
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Patient 1
• 2 ½ month male infant with one day of fever to 38.0 (axilla), rhinorrhea, decreased ( ), ,breast feeding duration but increased frequency q y
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Patient 1
• No problems in pregnancy, delivery or neonatal periodp
• Breast feeding has progressed normally• Intercurrent respiratory illness in mom and• Intercurrent respiratory illness in mom and
one older sibling
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Patient 1
• Appears well hydrated, interacts normally with parent and examiner, demonstrates ability to feed on breast
• No markers of CNS disease (not full fontanelle, meningeal irritation, lethargy or hyperirritability)
• Mild rhinorrhea and pharyngeal injection, otherwise NAD on examination
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Patient 1Patient 1
• Does this patient need more evaluation• Can we just send them home?Can we just send them home?• What other factors might we consider?
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Rochester Criteria (variants YaleRochester Criteria (variants Yale, Harvard)
• Ill or well appearing, previously healthy?• Term (> 37 wk)( )• WBC > 20 x 109/l , bands > 1.5 • Urine bag dip/ cath – positive leuk esteraseUrine bag dip/ cath positive leuk esterase,
greater than 10 WBC/hpf spun urine• If diarrhea > 5 WBC/hpfIf diarrhea, > 5 WBC/hpf• Telephone, transportation, reliable, able to
follow in 24 hrfollow in 24 hr
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Patient 2
• 4 week old infant female with two days of reduced feeding, now fever of 38 and has g,vomited last two feeds
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Patient 2
• Babe is lethargic in mom’s arms, fails to feed
• “looks ill”• Normally hydratedy y• Fontanelle fails to depress when held
uprightp g• Babe emits high pitched cry with diaper
changeg
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Patient 2
• What further investigations does this babe need?
• What treatment would you initiate?• Admit?• Admit?• Transfer?• Escort?
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Conclusions
• Fever in infants < 3 mon represents a higher than usual risk of serious infection
• Fever in infants < 1 mon is especially concerning and always warrants full work up, admission for close observation and anticipatory treatment
• The expression “a high index of suspicion” particularly applies to assessing sick infants
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What is the risk of serious bacterial infection in a febrile 2
month old infant ?month old infant ?• A. 5%• B. 10%• C. 25%• D. 50%• E 100%• E. 100%
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What is the most commonWhat is the most common congenital viral infection ?
• A. Herpes simplex• B RubellaB. Rubella• C. Varicella
D R bi• D. Rabies• E. CMV
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A 3 week old infant presents withA 3 week old infant presents with fever > 38 degrees C. You will -
• A. Give acetaminophen and reassure the parentsp
• B. Take a blood culture and commence IM ceftriaxone as OPceftriaxone as OP
• C. LP, urine and blood culture, chest x-ray, initiate ampicillin and gentamycin IV as IPinitiate ampicillin and gentamycin IV as IP
• D. Ask Dr. Blondel-Hill