Febrile Child

Dr. Steven Blyth

Dr. David Johnson

Overview

Introduction

Occult bacteremia

Antibiotic prevention of SBI

Febrile seizure

Fever and petechiae

Fever in children with underlying illness

Rare syndromes

Introduction

Historical 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

Occult Bacteremia

Incidence 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%

Occult Bacteremia

Degree 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 OB

Age 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

Occult Bacteremia

WBC 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.

Occult Bacteremia

Blood 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 resolves

Minor 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)

Occult Bacteremia

Assessment of observational scores: Bonadio Pediatric Clinics of NA 1998 Infants younger than 8 weeks

Retrospective studiesProspective studies

Infants and children older than 8 weeksProspective studies

Occult Bacteremia

Guidelines for managing OBGuidelines 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

Occult Bacteremia

Guidelines for managing OBGuidelines 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

Occult Bacteremia

Guidelines for managing OBGuidelines 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

Occult Bacteremia

Guidelines for managing OBGuidelines for febrile infants 3-36 months

Toxic children: no issueWell 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

Occult Bacteremia

Antibiotic use to prevent SBI in children at risk for OBBulloch et al Acad Emerg Med 1997Rothrock et al Pediatrics 1997

Febrile seizure

Synopsis of the American Academy of Pediatric practices parameters on the evaluation and treatment of children with febrile 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

Febrile seizure

EEG is not perform in a neurologically healthy child with simple febrile seizureThe following routine lab should not be performed in simple febrile seizure: CBC, lytes, Ca, phos, Mg, or glucoseNeuro-imaging should not be performed routinely on simple febrile seizureAnticonvulsant therapy is not recommended in simple febrile seizure

Fever and petechiae

Baker 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

Fever

Fever in children with underlying illnessOncology patients

At risk of overwhelming sepsisWhen febrile: CBC, CXR, blood culture, urine

culture, and LP when clinically indicatedNeutropenic patients at risk for Pseudomonas

and other gram negative; combination of tobramycin and ceftazidime

Indwelling IV devices add vancomycin to tobramycin and ceftazidime

Fever in children with underlying illness

Acquired 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

Fever in child with underlying illness

Sickle cell anemia Repeated splenic infarction leads to functional asplenia

susceptible to overwhelming infection esp. encapsulated organisms such as pneumococci and H. flu

Sickle cell patients with fever should have CBC and retic count infection esp Parovirus can cause aplastic crisis

Osteomyelitis should be suspected in fever and bone pain CBC, blood culture, stool culture, and urine culture

recommended At risk for Salmonella bacteremia; antibiotic choice should

include third gen ceph; hospitalization recommended

Fever in child with underlying illness

Congenital 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

Fever in child with underlying illness

Ventriculoperitoneal shuntsFever 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. epidermidisCT head also warranted

Febrile child

Other conditions to consider in febrile child Collagen vascular disease Malignancy Drug-induced fever Toxic ingestion Heat exhaustion and heatstroke Kawasaki syndrome Thyrotoxicosis