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 studies • Prospective studies • Infants and children older than 8 weeks • Prospective studies
Occult Bacteremia • Guidelines for managing OB • Guidelines 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 OB • Guidelines 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 OB • Guidelines 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 OB • Guidelines for febrile infants 3-36 months • Toxic children: no issue • Well 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 OB • Bulloch et al Acad Emerg Med 1997 • Rothrock 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 seizure • The following routine lab should not be performed in simple febrile seizure: CBC, lytes, Ca, phos, Mg, or glucose • Neuro-imaging should not be performed routinely on simple febrile seizure • Anticonvulsant 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 illness • Oncology patients • At risk of overwhelming sepsis • When febrile: CBC, CXR, blood culture, urine culture, and LP when clinically indicated • Neutropenic 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 shunts • Fever 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. epidermidis • CT 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
