neonatal fever bbc - tecp edu

6/9/14

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+

Neonatal Fever Benjamin B. Constance, MD, FAWM

+ Objectives

n  Define who is at risk for SBI

n  Clarify risk stratification

n  Provide treatment guidelines

n  Bust some myths

+Based on…

+ Case – what do you want to know?

n  20 day old male temp 38°C

+ History

n  Birth history

n  Past medical history

n  Symptom development

n  Immunization status

n  Nutrition source

n  Sick exposures

n  Medications used

n  Maternal HIV / HSV

Physical Exam

n  Rectal temperature

n  Full vital signs

n  Hydration status

n  Head to toe exam

n  Complete skin exam

n  Repeat exams

n  Observe behavior

n  Observe feeding

+ Case

n  20 day old male temp 38°C

n  X39 week NSVD

n  GBS and HSV negative mother

n  Feeding 3oz q4h, wet diapers

n  Normal physical exam

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+ Case Questions…

n  Why should this baby be admitted?

n  Is an LP really necessary?

n  What are the odds this patient has an SBI?

n  What if the patient had bronchiolitis?

+ Definitions

n  Young infant: < 90 days old

n  Neonate: 0-28 days old

n  Fever: >38°C

n  SBI: meningitis, bacteremia, UTI, pneumonia, enteritis, cellulitis, abscess, osteo, septic arthritis

+Definitions

n  Perinatally acquired: GBS, E coli, S pneumoniae, S aureus, L monocytogenes, HSV

n  Sepsis Evaluation: CBC, BCx, UA, UCx, CSF cell count, glucose, protein and culture, +/- CXR, stool cell count

+ CAUTION!!!

n  SBI can present with hypothermia (<36°C)

n  Difficulty with thermoregulation

n  Don’t miss low core temperature!

n  Consider this same as fever

+ Identifying Sick Patients n  Somnolent

n  Tachycardia

n  Hypotension

n  Capillary refill >3 seconds

n  Pale, cool skin

n  Diaphoresis

n  Respiratory distress

n  Decreased urine output

+ When to consider HSV

n  Mucous membranes, CNS or disseminated

n  Vesicles, conjunctivitis, seizures, CNS Sx, sepsis

n  CSF pleocytosis, elevated LFTs, DIC, acidosis

n  Dx with HS PCR from vesicles, CSF or blood

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+ Neonatal HSV and Status Pediatric Immunity

n  Little innate immunity n  Protection from maternal breast milk n  Unable to compartmentalize infections n  Present with vague symptoms n  Rapidly deteriorate into septic shock

0 - 28 days 29 - 56 days 57-89 days

Pediatric Immunity

n  First primary immunizations at 2 months n  Regain weight post birth n  Protection from maternal breast milk n  More resilient n  Still difficulty compartmentalizing infections

0 - 28 days 29 - 56 days 57-89 days

Pediatric Immunity

n  First primary immunizations at 2 months n  Protection from maternal breast milk n  More resilient n  Starting to develop innate immunity

0 - 28 days 29 - 56 days 57-89 days

+ General Resuscitation n  Assess airway, breathing,

circulation

n  IV / IO access

n  IV fluids 20-30 ml/kg

n  Fever control

n  Oxygen

n  Monitor (if available)

Criterion

Rochester Criteria (0-60 days of age)

Philadelphia Criteria (29-56 days of age)

Boston Criteria8 (28-89 days of age)

History and physical examination

Full-term • Normal prenatal and postnatal histories • No postnatal antibiotics • Well appearing • No focal infection

Well appearing • No focal infection

No antibiotics within preceding 48 h No immunizations within preceding 48 h Well appearing No focal infection

Laboratory parameters (defines low risk)

WBC: 5-15,000/mm3 • Band: count < 1500 • UA: < 10 WBC/ HPF • Stool:< 5 wbc /HPF on smear

WBC: < 15,000/mm3 • Band: total neutrophil (I:T) ratio < 0.2 • UA: < 10 WBC/ HPF • Urine: Gram stain negative • CSF: < 8 WBC/mm3 • CSF: Gram stain negative • Chest x-ray: no infiltrate* • Stool: no blood, few or no WBCs on smear*

WBC: < 20,000/mm3 • UA: <10 WBC/ HPF • CSF: < 10 WBC/mm3 • Chest radiograph: no infiltrate*

Treatment for high-risk patients Hospitalize + empiric antibiotics

Hospitalize + empiric antibiotics Hospitalize + empiric antibiotics

Treatment for low-risk patients Home 24-h follow-up required No empiric antibiotics

Home, if patient lives within 30 min of the hospital • 24-h follow-up required • No empiric antibiotics

Home, if caregiver available by telephone • Empiric IM ceftriaxone 50 mg/kg • Return for 24-h follow-up for second dose of IM/IV ceftriaxone

Performance of low-risk criteria

NPV: 98.9% (97.2-99.6) NPV: 100% (99-100) NPV: 94.6% (92.2-96.4)

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Criterion



Boston Criteria (28-89 days of age)















NPV: 98.9% (97.2-99.6) NPV: 100% (99-100) NPV: 94.6% (92.2-96.4)

•  Must be term, no antibiotics, well appearing

•  Normal CBC, UA and stool •  Works 0-60 days •  No empiric antibiotics •  Good NPV

Criterion


















NPV: 98.9% (97.2-99.6) NPV: 100% (99-100) NPV: 94.6% (92.2-96.4)

•  Well appearing •  Includes CSF and CXR in addition •  Only 29-56 days •  No empiric antibiotics •  Must live close to hospital •  Best (100%) NPV

Criterion


















NPV: 98.9% (97.2-99.6) NPV: 100% (99-100) NPV: 94.6% (92.2-96.4)

•  No recent abx or immunizations •  Higher WBC cutoff, includes CSF

and CXR •  Workd 28-89 days •  Empiric ceftriaxone if sent home •  Lowest NPV

Criterion


















NPV: 98.9% (97.2-99.6) NPV: 100% (99-100) NPV: 94.6% (92.2-96.4)

Fever Management

n  Complete workup, even if known source n  Labs

n  CBC, blood culture n  Urinalysis, urine culture n  CXR if respiratory symptoms n  CSF gram stain and culture n  CRP n  Consider stool studies n  Consider HSV

0 - 28 days 29 - 56 days 57-89 days

Fever Management

n  Empiric therapy with broad antibiotics n  Ampicillin 200 mg/kg/day div q6h IV, AND n  Cefotaxime 150 mg/kg/day div q8h IV n  Acyclovir 20 mg/kg/dose n  Consider Vancomycin 15 mg/kg to cover resistant staph / strep n  Consider imipenem for GNR

n  Hospital admission n  Follow cultures n  Reassess patient

0 - 28 days 29 - 56 days 57-89 days

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Fever Management

n  Complete workup, even if known source n  Labs

n  CBC, blood culture n  Urinalysis, urine culture n  CXR if respiratory symptoms n  CSF gram stain and culture n  CRP n  Consider HSV

0 - 28 days 29 - 56 days 57-89 days

Fever Management 0 - 28 days 29 - 56 days 57-89 days

All Tests Normal

Yes

No

§  Follow-up in 24 hours §  Consider ceftriaxone if LP done §  Admit for poor social situation §  Only discharge if well appearing

§  Perform LP if not already §  Ceftriaxone 50 mg/kg §  Consider acyclovir §  Consider vancomycin §  Admit to hospital

Fever Management

n  Well appearing is low risk n  Typically 1 dose PCV (ê sepsis risk) n  Routine urine testing n  Consider blood and CSF (Boston) n  Discharge with 24h follow up if well appearing

0 - 28 days 29 - 56 days 57-89 days

Fever Management

n  Evaluate for source, or occult infection n  UTI à UA n  Bacteremia à CBC, blood cultures n  Pneumonia à chest x-ray n  Meningitis à consider CSF if elevated serum WBC

n  Treat specific sources of infection n  If normal workup, reassess in 48 hours n  Bronchiolitis? à still check UA and culture n  Ill appearing à admit + full sepsis workup + ceftriaxone

0 - 28 days 29 - 56 days 57-89 days

+Testing

n  Enterovirus PCR in summer months (dec hosp stay and antibiotic use)

n  CXR only if having resp sx <12wks (Crain et al 2 of 148 abnormal cxr)

n  Sool studies only based on Sx, not routinely helpful

+What about RSV?

n  Stud: <56 days 1,248 infants, 269 RSV pos

n  SBI in RSV+ 7% vs RSV- 12.5% (still large amount) [Lavine et al]

n  Given high risk of SBI in <28 days, full workup should be done despite flu or RSV

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+Biomarkers

n  Procalcitonin may increase risk of SBI but not rule out disease (Gomez et al)

n  Favorable diagnostic accuracy compared to Rochester (Woelker et al)

+ Disposition Patient Admit Abx

Well appearing 0-28 days + fever

Ill appearing 29-56 days + fever



✔ ✔ ?

✔ ✔ ?

Well appearing 29-56 days, consider discharge if 24 hour return and negative workup Consider empiric ceftriaxone if discharged

+ Common Myths

Well appearing = low risk for SBI

1/5 infants with a fever will have a severe infec;on

Normal WBC = low risk for meningi;s

Will be normal in 41% of infants with meningi;s

Nega;ve workup = low risk criteria in <29d

Low risk criteria performs poorly in febrile neonates

Myth Correc;on

+ Case Conclusion

n  20% incidence of SBI in febrile infants

n  UA neg, WBC 12,000, CSF 2 WBC

n  Admitted with amp + cefotax + acyclovir

n  Bronchiolitis would not change workup in this age group

+ Summary

< 3 months are at high risk for infec;on

<56 days should have full workup (serum, urine, CSF)

<28 days, even well appearing, should be admiQed with an;bio;cs (consider HSV)

29-‐56 days at low risk by criteria can be discharged with a safe follow up plan

neonatal fever bbc - tecp edu

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