the febrile infant
DESCRIPTION
The Febrile Infant. BY: DRA.Fatma .s.al zahrani. The Febrile Infant. Definition: Temperature >/= 38 C (100.4 F ) Rectal temp closely correlates with core body temperature Ear/Axillary/Sticker temps are unreliable. Temps vary depending upon time of day. The Febrile Infant. - PowerPoint PPT PresentationTRANSCRIPT
The Febrile Infant
BY:
DRA.Fatma .s.al zahrani
The Febrile Infant
Definition: Temperature >/= 38 C (100.4 F ) Rectal temp closely correlates with core body
temperature Ear/Axillary/Sticker temps are unreliable. Temps vary depending upon time of day
The Febrile Infant
Fever Without A Source
(FWLF)
Acute febrile illness in which the etiology of the fever is not localized after the history and physical examination.
The Febrile Infant
Pathogenesisof fever:
Pathogens → cytokine release →resets thermoregulation of hypothalamus→ maintains a higher body temperatur
Infants < 3 months less likely to have fever
The Febrile Infant
What to do?
Obtaining detailed History Age Parents report of wellbeing Parents report of specific symptoms Height and presence of fever Risk Factors (Prematurity,Immunocompromised) Epidemiologic Factors (Sick contacts)
The Febrile Infant
Physical Exam Give anti pyretic to relax the child if irritable
or in pain Perform throughu physical examination. Look for evidence of serious illness Meningeal signs may not be apparent < 18mo
The Febrile Infant
Approach
1)The high risk age is:
0 – 28 days 28 – 90 days 3 – 36 months
The Febrile Infant
2)Toxic Appearing A clinical picture consistent with the sepsis
syndrome: Lethargy Poor Perfusion Hypoventilation Hyperventilation Cyanosis
The Febrile Infant
3)Lethargy:
Poor eye contact &poor interaction with parents and people arround
The Febrile Infant
Assessing Risk
Rochester Fever Criteria
Yale Observation Scale (Clinical)
The Febrile Infant
Rochester Criteria for Febrile Infants Ages 60 – 90 Days
Criteria Well appearing/Full term No skeletal, soft tissue, skin, or ear infections Previously healthy WBC 5000 – 15,000 Bands <1500 UA: WBC’s < 10/hpf If diarrhea: fecal Leukocytes <5/hpf Interpretation Well appearing febrile infant risk: 7-9% All Rochester Criteria present: < 1%
The Febrile Infant
Yale Observation Scale 3 - 36 Months Quantifies “Toxic Appearance” Quality of Cry Reaction to parents Arousability Color Hydration Social Response Interpretation: Risk increases with higher scores
The Febrile Infant
Low Risk Infants Previously Healthy/Full term No focal Bacterial Infection on PE Good social situation Nontoxic clinical appearance Negative lab screening: WBC 5000 – 15,000 < 1500 Bands Normal UA < 5 WBCs/hpf in stool if diarrhea present
The Febrile Infant
Management: Infants 0 – 28 Days ALL infants should be admitted , with full
sepsis workup (Blood, Urine, CSF) Empiric parenteral antibiotic therapy pending
negative cultures.
The Febrile Infant
Management:
Infants 0 – 28 Days
Most common bacterial organisms
(Group B Strep,E. Coli,Listeria)
Antibiotic coverage Ampicillin and Gentamicin OR Ampicillin and Cefotaxime
The Febrile Infant
Management:
Infants 28 – 90 Days Febrile Infant Toxic OR Nontoxic High Risk OR Low Risk Inpatient OR outpatient
The Febrile Infant
Management:a)Infants 28 – 90 Days Low Risk Outpatient Full sepsis work up and empiric parenteral antibiotic coverage (Ceftriaxone IV/IM)
Follow up within 24 hours If CSF cx (+), admit for IV Abx treatment If Blood cx (+) i) febrile/ill for IV Abx ii) afebrile/well, may consider oral Abx outpt Rx
If Urine cx (+), i)febrile/ill for IV Abx, ii) afebrile/well, consider oral Abx outpt Rx
The Febrile Infant
Management:
Infants 28 – 90 Days
Admit Low Risk if: Immature/Unreliable Parents Unsure of follow up No home telephone Lack of Transportation
The Febrile Infant
Management:
Infants 28 – 90 Days
Nontoxic High Risk Admit Full sepsis work up +/- empiric parenteral antibiotics
Most Common Organisms Late onset Group B Strep Strep. Pneumoniae H. Flu N. Meningitidis
The Febrile Infant
Management:
Children 3 – 36 Months Fever without source accounts for 14% of
outpatient visits Mean probability of occult bacteremia 4% Higher risk of bacteremia with temps >39C Sensitivity of clinical evaluation greater
(89-92%) in this age group
The Febrile Infant
Management:
Children 3 – 36 Months
Nontoxic, Temp > 39 C (102.2 F)
Lab work not indicated if presumptive diagnosis is URI, or sick contacts with URI
- CBC w Diff, Blood Cx
-CXR indicated if signs of LRI, WBC > 15, Temp > 104- urine culture (catheter or suprapubic) is gold standard
UA/Urine cx if males < 6 months and females < 2years
The Febrile InfantManagement:Children 3 – 36 Months Most Common Organisms Strep. Pneumoniae H. Flu N. Meningitidis Strep. Pyogenes Staph Salmonella
The Febrile Infant
AntibioticTreatment:
-Children 3 – 36 Months
Nontoxic, Temp > 39 C (102.2 F) WBC > 15,000 UA (+) Can treat with Abx without LP in this age Group optional)
The Febrile Infant
Treatment:Children 3 – 36 Months Ensure follow up If Blood cx (+) i) febrile/ill f0r admission & IV Abx
ii) a febrile/well, consider outpt oral Abx
Most studies indicate that treatment with parenteral
Abx associated with least risk of further sequelae If Urine cx (+) i) admit if febrile/ill for IV Abx
ii) a febrile/well, consider outpt oral Abx
The Febrile Infant
Summary
Guidelines is one way to assist physicians in managing infants and children with fever without a source .They are flexible and management may be individualized according to the case.