The Febrile Child: Treat ‘em or Street ‘em

1. The Febrile Child:Treat ‘em or Street ‘em David Chaulk Pediatric EM Fellow January 2004

2. Cases Temperature Measurement Who Cares? Schools of Thought Scoring Systems Empiric Therapy Changes in Prevalence & Changes in Management Recognizable Illnesses CPS Guidelines Cases Revisited Overview

3. Case 1 • A 3 week old male infant is brought to your ED with a 2 day history of fever. He was born by uncomplicated vaginal delivery at 37 weeks gestation following a normal pregnancy. At his two week check-up he was noted to be gaining weight appropriately. His vital signs are: T 38.9C (R), HR 140, RR 40, and BP 90/60. He is sleepy but easily rousable. Physical exam is normal apart from a slightly dull left tympanic membrane. His peripheral WBC is 16,000, his UA shows 3 WBC/hpf. BC and UC are sent. Your management at this point would consist of: a. Discharge on antipyretics with close follow-up b. Discharge on oral amoxicillin with close follow-up c. LP and admission for parenteral antibiotics d. CXR to r/o pneumonia e. Stool for analysis and culture, and outpatient follow-up

4. Case 2 • A 7 week old girl is referred in to ED for evaluation of a rectal temperature of 39.2C. Her PE is normal. Her UA is negative, her WBC is 9,000 (70% neuts, 28% lymphs, 2% bands). BC, UC are sent. Acceptable management options for this child would include any one of the following except: • IM ceftriaxone in the ED • Admission to the hospital for IV antibiotics • Discharge with follow-up in 24 hours • Admission to the hospital for observation • Discharge on amoxicillin • Any other investigations?

5. Case 3 • A 19 month old boy comes to the ED with a 3 day history of fever. He appears well but his tympanic T is 39.8C. His chest is clear, his abdomen is soft, and he is circumcised. No source can be found for his fever. A CBC reveals a WBC of 8200 (60% neuts, 27% bands). BC’s are sent. Appropriate management at this point will be to: a. Obtain a urine sample b. Administer IM ceftriaxone c. Perform an LP d. Obtain a CXR e. Discharge on antipyretics

6. Temperature Measurement

7. Temperature Measurement • Rectal is gold standard based on study from 1937! • Controversial! Tympanic very accurate or very inaccurate • Lanham 1999…tympanic misses too many febrile children • Shinozaki, 1998…rectal inaccurate because of poor blood supply to rectum, T is slow to change • Physiologically, T controlled by hypothalamus • Hypothalamus and Tympanic Membrane have same blood supply (common carotid)

8. Temperature MeasurementCPS Guidelines AgeRecommended technique Birth to 2 years 1. Rectal (definitive) 2. Axillary (screening) Over2 years to 5 years 1. Rectal2. Tympanic3. Axillary Older than 5 years 1. Oral2. Tympanic3. Axillary

9. Who cares? • 65% of children 0-2 will visit a physician for a febrile illness • 10-20% of PED visits, 20-30% ped office visits • 50% are fever without source • Most represent self-limited illness • Small precentage with Serious Bacterial Illness…but who?

10. A few Definitions… • Fever without Source • “…An acute febrile illness in which the etiology of the fever is not apparent after a careful history and physical examination.” • Baraff et al, Pediatrics 1993; 92:1-12 • Fever of Unknown Origin • Fever > 2 to 3 weeks • Absence of localizing signs • Failure of simple diagnostic efforts

11. A few Definitions… • Occult Bacteremia • “…a positive blood culture in the setting of well appearance and without focus (e.g. no pneumonia), BUT may be in the presence of URTI, otitis media, diarrhea, or wheezing” • Fleisher et al, J Pediatrics 1994 • Serious Bacterial Infections • “…SBI include meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia and enteritis” • Baraff et al, Pediatrics 1993; 92:1-12

12. Occult Bacteremia • Strep pneumo. >85% • N.meningitidis 3-5% • Others • GAS • Staph aureus • Salmonella spp • HiB • Now rare, previously was ~10%

13. Bacteremia • < 2 mos, T > 38 incidence is 2-3% Avner and Baker, Emerg Med Clin NA 2002;20(1) • 3-36 mos, T < 39 incidence is <2% Klein, Ped Inf Dis J 2002;21(6):584-8 • 2002 data, ie. Post HiB era

14. Untreated Bacteremia Outcomes • Persitent fever 56% • Persistent bacteremia 21% • Meningitis 9% • S.pneumo 6% • HiB 26% (no longer seen)

15. Scoring Systems • Demographic and Clinical Parameters • Age, temperature, clinical appearance • Lab Screens: • CBC, ESR, U/A • Initially very promising…ultimately not so “hot”

16. Scoring Systems • Can we identify high risk kids? • Yale Observational Score • 611 children, 192 bacteremic • Median score was the same for both groups • A high score was a good marker • Specificity and NPV ~97% • Sensitivity and PPV ~5% • Not great screening tool (screens should be sensitive)

17. Scoring Systems • Can we identify low risk kids? • Three main scoring systems • Philadelphia, Rochester and Boston Criteria • All are similar but there are differences • Main risk factors identified • Age (3 groups. 0-28d, 28-90d, 3-36m) • Temperature T > 40.5 8-25% with OB • Petechiae – 15-20% SBI • WBC >15,000, bands>1000 – 5 fold  in OB • Toxic appearance Lethargy/irritabilty Poor eye contact Poor perfusion Hypo/hyperventilation Cyanosis

19. Statistics

21. Are neonates really different? • Philadelphia criteria applied to 3-28 d • 254 pts, 43% low risk (managed as OP) • 32 (12.6%) with SBI • 17 UTI’s, 8 OB, 4 BM • 5 low risk infants has SBI • Would miss 20:1000 of infants with SBI • Empiric antibiotics standard of care in this age group

22. Empiric Antibiotics28-90 d • Lieu, 1992 • Decision analysis based on 6 management strategies for management of fever >38 in 28-90 d infants • Worst Strategy • Clinical judgement • Most Effective • Full septic work up, IM ceftriaxone and outpatient management

23. Empiric Antibiotics3-36 mos • Couple of big studies…neither great • Bass, 1993 • 519 children 3-36 mos, 11.6% with OB • Compared clavulin to ceftriaxone in children with T>40 or T>39.5 and WBC>15 • No difference between groups • Fleisher, 1994 • 6733 patients, 2.9% with OB • Compared amoxil to ceftriaxone • “…ceftriaxone eradicated bacteremia, had fewer focal complications and less persitent fever…”

24. Us Vs. Them • Survey of AAP general pediatricians • 610 (67%) responded • 40% indicated that parents frequently ask for abx when MD feels it is not warranted • 48% stated parents pressure them to prescribe • 30% stated they comply with that pressure • Parental pressure viewed as leading cause for unnecessary abx

25. Pros Decreases disomfort Dereases parental anxiety Extreme may cause brain damage (exceedingly rare) Limited/minimal evidence that it may reduce febrile seizures Cons Harm of antipyretics may outweigh benefits Fever is a normal physiologic response Fever is usually short lived and benign May obscure diagnostic/prognostic signs Us Vs. Them Should Fever be Treated?

26. Us Vs. Them: Pyrexiophobia • 91% of caregivers believed fever was harmful • 21% listed brain damage and 14% listed death as effects of fever • 25% gave antipyretics for fever < 37.8 • 85% awakened the child to treat fever • 14% gave acetaminophen too frequently • 44% gave ibuprofen too frequently • 65% of pediatricians believed fever in and of itself could be dangerous to the child

27. Changes and Controversies • Eradication of HiB • Decreasing Prevalence of Strep pneumo • Increasing resistance of Strep pneumo • Fever in infant with recognizable illness

28. HiB Vaccine (1987) • Prior to vaccine: • 10-15% of OB and majority of SBI • 12,000 cases/year(US) invasive HiB in <5yo • 1994-95 • 300 cases/year (likely lower now) • Invasive HiA/F are still uncommon but may emerge as serious pathogens

29. Prevnar/Pneumovax • PCV7 (7 serotypes) studied in Northern California • Large herd effect noticed • 34% of < 5 yo children immunized • 62% reduction in invasive PC seen • Finnish otitis media study • Strep isolates from OM cultures • Significant reduction in the 7 serotypes • 33% increase in other serotypes

30. Prevnar/Pneumovax • PCV7 estimated to be 97% effective • Excellent but will still see dz • Will still see PC in • Other serotypes • Vaccine failures • Unimmunized children • Immunocompromised children • Bottom line: • Shouldn’t change our respect for OB/SBI in young children…yet

31. Pneumococcal ResistanceKaplan, 1998 • Three year MC study • 1291 systemic pneumococcal infections • Resistance increased annually over the study period • Penicillin resistance 21% • Ceftriaxone resistance 9% • Resistance changes region to region • Ottawa has ~20% resistant Strep pneumo

33. Fever and Recognizable Illness • Kupperman, 1997 • Risk of bacteremia and UTI in febrile children with and without bronchiolitis • 432 children, 0-24 mos • Children with bronchiolitis had significantly fewer positive cultures • Blood 0% compared to 2.7% • Urine 1.9% compared to 13.6% • 0 children < 2 mos with bronchiolitis had bacteremia or UTI

34. Fever and Recognizable Illness • Greene, 1999 • 5 year retrospective • Children 3-36 mos with T >39 • 1347 children with recognizable viral syndrome • Croup, varicella, bronchiolitis, stomatitis • Blood cultures in 65% • 2 of 876 (0.2%) were culture positive

35. Occult Pneumonia • Bachur, 1999 • Prospective cohort study • < 5 yo children with T >39 and WBC > 20k • CXR in 225/278 • CXR postive in • 40% with suggestive clinical exam • 26% of those without clinical evidence • Recommends empiric cxr in fever without source

36. UTI’s in the Febrile Child • Most frequent SBI and may present with fever only • Prevalence 3.3% in febrile infants • Gorelick, 2000 • Clinical Decision Rule T > 39 fever > 2 days White race age < 1 year Absence of another potential source

37. UTI’s in the Febrile Child • All with UTI had at least one risk factor • Presence of any two factors • Sensitivity 95% • Specificity 31%

38. Febrile Seizures • Trainor, 1999 • Multi-centered analysis of ED management • 455 children • 1.3% bacteremic • 5.9% UTI • 12.5% abnormal CXR • 135 had LP…all normal • In other words, manage like any other kid with fever

39. So…now you’re completely lost! What are the guidelines? What do you really need to know?

40. CPS Guidelines (www.cps.ca)0-28 days • No CPS guidelines documented for 0-28 d • American Concensus Guidelines (Baraff, 1993) • Full Septic Work up (all risk groups) • LP (culture, cell counts and glucose/protein) • Blood culture • Urine (routine, microscopy and culture) • If diarrhea, stool smear and culture • If resp symptoms, CXR • Admit, + IV antibiotics

41. CPS Guidelines29-90 days • NOT low risk • CPS – “toxic or unduly lethargic” • FSWU (BC,UC,LP) • Admit • Broad spectrum IV antibiotics

42. CPS Guidelines29-90 days • Low Risk • No investigations • Careful outpatient follow up, no treatment • American Option • FSWU • Ceftriaxone • RTED in 24h for re-assessment • In reality, somewhere in between

43. CPS Guidelines3-36 months • Toxic Appearance • FSWU • Admit • IV antibiotics

44. CPS Guidelines3-36 months • Non Toxic, T < 39.5 • Observe only (if follow up assured) • Non Toxic, T >39.5 • CBC to decide if BC/UC and empiric therapy are needed • If WBC < 15k observe if follow up assured • If follow up not assured a more aggressive approach may be indicated.

45. CPS GuidelinesEmpiric Antibiotics • If treating emprically: • Amoxicillin 60 mg/kg/day or • Ceftriaxone 50 mg/kg • “…,and neither a substitute for for careful decision-making or follow-up.” Long, 1994 • American guidelines are ceftriaxone

46. Blood Culture (+) 3-36 mos • Pneumococcus • Persistent fever • Admit, FSWU, IV abx • Afebrile/well-looking • Repeat culture, no treatment • All other bacteria • Admit, FSWU, IV abx

47. Case 1 • A 3 week old male infant is brought to your ED with a 2 day history of fever. He was born by uncomplicated vaginal delivery at 37 weeks gestation following a normal pregnancy. At his two week check-up he was noted to be gaining weight appropriately. His vital signs are: T 38.9C (R), HR 140, RR 40, and BP 90/60. He is sleepy but easily rousable. Physical exam is normal apart from a slightly dull left tympanic membrane. His peripheral WBC is 16,000, his UA shows 3 WBC/hpf. BC and UC are sent. Your management at this point would consist of: a. Discharge on antipyretics with close follow-up b. Discharge on oral amoxicillin with close follow-up c. LP and admission for parenteral antibiotics d. CXR to r/o pneumonia e. Stool for analysis and culture, and outpatient follow-up

48. Case 2 • A 7 week old girl is referred in to ED for evaluation of a rectal temperature of 39.2C. Her PE is normal. Her UA is negative, her WBC is 9,000 (70% neuts, 28% lymphs, 2% bands), and her LP reveals a CSF WBC count of 8. BC, UC, and CSF cultures are sent. Acceptable management options for this child would include any one of the following except: • IM ceftriaxone in the ED • Admission to the hospital for IV antibiotics • Discharge with follow-up in 24 hours • Admission to the hospital for observation • Discharge on amoxicillin

49. Case 3 • A 19 month old boy comes to the ED with a 3 day history of fever. He appears well but his tympanic T is 39.8C. His chest is clear, his abdomen is soft, and he is circumcised. No source can be found for his fever. A CBC reveals a WBC of 8200 (60% neuts, 27% bands). BC’s are sent. Appropriate management at this point will be to: a. Obtain a urine sample b. Administer IM ceftriaxone c. Perform an LP d. Obtain a CXR e. Discharge on antipyretics

50. After all that….Here’s what you need to know! • hospitalize +/- abx • +/- labs, home, +/- abx • home, no antibiotics • +/- labs, home, no antibiotics • Infants < 28 days: • Infants 1-3 months • Infants and children 3 months to 3 yrs (T < 39C): • Infants and children 3 months to 3 years (T  39C):