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The Febrile Infant

The Febrile Infant. Steven Lanski, MD FAAP Emory University School of Medicine Children’s Healthcare of Atlanta @ Egleston. Objectives. Review the management options available when evaluating a febrile infant Review pertinent literature Management options Special cases .

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The Febrile Infant

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  1. The Febrile Infant Steven Lanski, MD FAAP Emory University School of Medicine Children’s Healthcare of Atlanta @ Egleston

  2. Objectives • Review the management options available when evaluating a febrile infant • Review pertinent literature • Management options • Special cases

  3. What Would You Do? • Well appearing 3 week infant fever 38 at home afebrile during evaluation 2) Well appearing 7 month circumcised male with diarrhea for 5 days and fever 3 days, temp 39.1 in office 3) Tired appearing 4 y.o. female, temp 40.5, no source

  4. Evaluation • History • Timeline and degree • Associated symptoms • Past medical conditions • Decreased defense • Hardware • Physical • Appearance • Other source • Skin involvement

  5. Guidelines • Expert consensus • Based on available evidence • Regional variation • Account for changing patterns and advances • Limit unnecessary evaluations • Invasive procedures • False positives • Maximize available resources

  6. Management Based on Age • Neonates • 28-90 days • 3 – 6 months • 6 – 24 months • >24 months

  7. Published Practice Guidelines • Baraff et al. Annuals Emerg Med and Pediatrics 1993 • Expert consensus based on literature • Fever > 38 (0-3 months) and > 39 (3-36 months) • Infants at greatest risk during 0-3 months • Rochester criteria selected as screening criteria

  8. Rochester Criteria • Dagan R, et al. Journal of Pediatrics 1985. • Well appearing term infants • Follow-up assured • Temp > 38 • WBC 5-15,000/mm3 • Band count < 1500 /mm3 • Urinalysis with < 10 WBC/hpf • No evidence of ear, soft tissue or bone infection • Modified (1988) if diarrhea present <5 WBC / hpf

  9. Management < 28 days • Neonates frequently do not show early signs of serious bacterial infections (SBI) • Rates of serious bacterial infection in febrile infants < 2 months is 8-14% • Poor immunity • Maternal pathogens (GBBS, E. coli) and Listeria • Infants less than 28 days of age should have full evaluation and hospitalization with IV antibiotics • Ampicillin and Cefotaxime or Gentamicin

  10. Management 29-60 Days • Work–up CBC/D, BCX, UA/UCX (consider CRP and LP) • Stool and CXR based on history / exam • Antibiotics and admission for patients with abnormal labs • Positive UA, WBC >15,000, Band >1500 • LP if not already done • Ceftriaxone or Cefotaxime

  11. Management 60-90 Days • At risk for occult bacteremia • Pneumococcus and HIB • Exam may still be unreliable • Beginning to develop immunity • Limited investigations (blood and urine) • Abnormal – management as previously described • Low risk – follow-up within 24 hours with or without antibiotics • Strongly consider LP if giving antibiotics

  12. Management 3-6 months • Occult Bacteremia remains a concern • Exam more reliable in identifying children at risk particularly those with meningitis • Pneumococcal vaccine begins to have protective effect to what extent ? • Fever cut-off raises to >39

  13. Management 3-6 month cont… • In patients without well defined source • ASOM, Bronchiolitis, Stomatitis, Croup, AGE… • Screen blood and urine • WBC >15,000 (send cultures) consider antibiotics (consensus recommendations) • WBC >20,000 or ANC > 10,000 give antibiotics • Follow-up within 24 hours

  14. Invasive Pneumococcal DiseaseCDC: Active Bacterial Core Surveillance, eight states, 1998-2005 • CDC: Active Bacterial Core Surveillance, eight states, 1998-2005

  15. Management 6-24 months • In a fully immunized infant with fever > 39 • Urine based on age and sex • Circumcised males >6 months unnecessary unless clinical condition dictates • Uncircumcised males until 1 year of age • Females until 2 years • Consensus recommends blood <36 months • Prior to pneumococcal vaccine

  16. Bronchiolitis and SBI • Kuppermann N. Arch Ped Adol Med 1997 • Compared rates of bacteremia and UTIs in febrile children w/o bronchiolitis • 432 children aged 0-24 months • Children with bronchiolitis had fewer positive cultures • Blood 0% vs 2.7% • Urine 1.9% vs 13.6% (Titus and Wright – Peds 2004) • No child < 2 months positive for bronchiolitis had a positive culture

  17. UTI - Clinical Decision Rule • Gorelick M. Arch Ped Adol Med 2000 • Risk factors • T > 39 • Fever > 2 days • White race • < 12 months • Absence of another source • All + UTI had at least 1 risk factor • Using 2 risk factors as the screening requirement • 0.8% probability of UTI in those screening negative • 6.4% probability of a UTI in those screening positive

  18. Special Cases • Prematurity • Immunocompromised • Patients with hardware

  19. Best Course of Action? • Regional epidemiology • Regional practice patterns • Consensus guidelines • Personal risk tolerance • Risk minimizer vs Test minimizer

  20. Children’s Healthcare of Atlanta Guidelines < 29 days

  21. CHOA Guidelines 29 – 60 days

  22. CHOA Guidelines 2-6 months

  23. CHOA Guidelines >6-24 months

  24. Questions ?

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