fever in the pediatric patient: who to work up and how

1. Fever in the Pediatric Patient:Who to Work Up and How Valerie Wrede, MD, Capt, USAF, MC Medical Director, Emergency Services Misawa Air Base, Japan USAFP Conference, 14 Mar 2007

2. 28 d/o male infant, rectal temp 100.4 Healthy, term delivery Went home with mom No previous hospitalizations No chronic illnesses Never been on antibiotics Not treated for unexplained hyperbilirubinemia No intrapartum h/o mother for fever, HSV, GBS, nor antibiotic treatment Immunizations: Hep B Vaccine in nursery

3. 28 d/o male infant, rectal temp 100.4 ROS: negative eating well, normal urination, acting normal, no cough/congestion/emesis/diarrhea PE: non-toxic, alert, cooing VS: 130, 35, 100% RA, 100.4 No focal bacterial infection including: No purulent otitis media No skin or soft tissue infection No bone or joint infection

4. 28 d/o male infant, rectal temp 100.4 True fever? Yes Focal infection? No Toxic or high-risk? Infants < 28 or 30 days are high-risk

5. What is Fever? Physiology Response to Infection or Inflammation > 100.4 Rectal Not Necessarily Bad 100.4 – 101.9 Low grade 102 – 103.9 Moderate > 104 Discomfort > 106 Fever itself harmful

6. What MUST be done? RECOMMENDATION: Infants between 1 and 28 days old with a fever should be presumed to have a serious bacterial infection. Name of AAFP-approved source of systematic evidence review: National Guideline Clearinghouse Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence Class I" or overwhelming evidence from "strength of evidence Class II" studies that directly address all the issues)

7. Serious Bacterial Infections=SBI Bacterial Meningitis Sepsis/Bacteremia Bacterial Pneumonia UTI’s Bacterial Enteritis Soft Tissue Infections/Cellulitis Bone and Joint Infections

8. 28 d/o male infant, rectal temp = 100.4 Work-up CBC with diff Blood cultures Urinalysis Urine culture Lumbar Puncture

9. 28 d/o male infant, rectal temp = 100.4 CBC with Diff Abnormal WBC >15,000 or <5,000 WBC—no predictive value in determining risk of meningitis (Bonsu, 2003 [Q]) Band-to-Neutrophil ratio <0.2 improves negative predictive value for SBI to 98% (Baker, 1993 [A])

10. 28 d/o male infant, rectal temp = 100.4 Urine Culture Urinalysis Abnormal microscopy = spun urine > 10 wbc/hpf Gram stain more sensitive and specific than simple UA or dipstick Obtain catheterized specimen

11. 28 d/o male infant, rectal temp = 100.4 Lumbar Puncture If not obtained due to Failed procedure Traumatic LP Parental refusal Still start antibiotics

12. 28 d/o male infant, rectal temp = 100.4 Consider CXR, if respiratory symptoms Stool culture, if diarrhea Herpes Simplex Virus cultures Other viral cultures, if clinically indicated

13. 28 d/o male infant, rectal temp = 100.4 Management Hospitalize Ampicillin and 3rd Generation Cephalosporin or Gentamycin Follow cultures minimum of 36 hours Consider referral Discharge Criteria

14. 60 d/o female infant with rectal temp 100.4 Healthy, term delivery Went home with mom No previous hospitalizations No chronic illnesses Never been on antibiotics Not treated for unexplained hyperbilirubinemia No intrapartum h/o mother for fever, HSV, GBS, nor antibiotic treatment Immunizations: Hep B vaccine in nursery

15. 60 d/o female infant with rectal temp 100.4 ROS: negative eating well, normal urination, acting normal, no cough/congestion/emesis/diarrhea PE: no apparent distress, alert, interactive VS: 124, 38, 99% RA, 99.6 (Tylenol given at home) No focal bacterial infection including: No purulent otitis media No skin or soft tissue infection No bone or joint infection

16. 60 d/o female infant with h/o rectal temp 100.4 True Fever? Yes Focal Infection? No Toxic or high-risk? No

17. Is it a true fever? RECOMMENDATION: A response to antipyretic medication does not change the likelihood of a child having serious bacterial infection and should not be used for clinical decision making. Name of AAFP-approved source of systematic evidence review: National Guideline Clearinghouse Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence Class I" or overwhelming evidence from "strength of evidence Class II" studies that directly address all the issues)

18. Is it a true fever? Rectal temp preferred Center for Reviews and Dissemination Reviewers 2002 [M], Hooker 1993 [C], Reisinger 1979 [C] Parental report by touch Sensitivity 82-89%, specificity 76-86% Graneto 1996 [C], Hooker 1996 [C], Singht 1990 [C]

19. Low Risk for SBI “Rochester Criteria” Baker, 1993 [A] Prior history of being healthy Born at term (37 wks gestation) Not previously hospitalized No chronic illnesses Not hospitalized longer than mother Not treated for unexplained hyperbilirubinemia Not received antimicrobial agents No intrapartum history of mother for fever, GBS, nor antibiotics

20. Low Risk for SBI “Rochester Criteria” Baker, 1993 [A] No focal bacterial infection on physical exam No purulent otitis media No skin or soft tissue infection No bone or joint infection Negative laboratory screen

21. 60 d/o female infant with h/o rectal temp 100.4 Work-up CBC Blood culture UA Urine culture Consider LP if….

22. 60 d/o female infant with h/o rectal temp 100.4 Delay or omit LP if Low Risk using strict screening criteria Available, reliable f/u in 12-24 hours Provider confident parent will f/u Provider and family agree on plan Antibiotic therapy will not be started

23. 60 d/o female infant with h/o rectal temp 100.4 Consider CXR, if respiratory symptoms Stool culture, if diarrhea HSV cultures 95% present prior to 22 days of life Other viral cultures

24. 60 d/o female infant with h/o rectal temp 100.4 Management High-risk or toxic: Hospitalize, IV Antibiotics Low-risk, non-toxic: Consider outpatient management Follow-up in 12-24 hours Low-risk doesn’t equal no risk

25. 60 d/o infant Cough/congestion/rhinorrhea Rectal temp of 100.4 Older Sibling has URI Non-toxic and Not High-risk

26. 60 d/o infant True fever? Yes Focal Infection? Yes, URI Is temperature explained by physical exam findings? Yes Toxic or high-risk? No Controversy over age-cut offs: Cincinnati Children’s Hospital: 60 days UpToDate; Pantel, 2004: 90 days

27. 60 d/o infant with URI: w/o & Management CXR, since respiratory symptoms CXR: no infiltrate Nasal saline spray and suction Education: Warning Signs to Return Consider Tylenol (not Motrin) Follow-up at 24 hours (nurse call)

28. PROS Study Pantel, 2004 Pediatricians Office setting 3,066 febrile infants < 3 months of age Bacteremia 1.8 % Bacterial Meningitis 0.5%

29. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 PMH Healthy, term delivery Went home with mom No previous hospitalizations No chronic illnesses Never been on antibiotic therapy

30. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 No sick contacts Immunizations: up to date— Received 3 doses of Hib and PCV-7 ROS Eating well, Acting normal Normal urination No cough/congestion No emesis/diarrhea

31. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 PE: no apparent distress, alert, active VS: 124, 30, 99% RA, 102.2 No focal bacterial infection including: No purulent otitis media No skin or soft tissue infection No bone or joint infection

32. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 True Fever? Yes Focal Infection? No

33. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 Work-up Urinalysis Urine culture Catheterized specimen

34. Urine Collection Sterile urine collection in well-appearing, febrile child without focal source if: Female < 2 yrs of age Male, if circumcised < 6 months Male, if uncircumcised < 12 months Additional risk factors Emesis (without diarrhea) Fever > 102.2

35. Urine Collection Catheterization if not toilet trained Clean catch if toilet trained Bag specimens not recommended

36. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 Consider Bacteremia and obtain CBC, blood cultures if: PCV-7 or Hib not up to date for age What to do for < 6 mo of age? Appears ill Fever > 40 degrees C Meningococcal contact

37. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 CBC, blood cultures not recommended since: well-appearing child unremarkable history PCV-7 and Hib up to date Pre PCV-7 pneumococcal bacteremia was 1.7 percent Now risk < 1%

38. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 Consider other SBI, but should have s/s of focal infection: Viral, culture Meningits, LP Bacterial Enteritis, stool cx Pneumonia, CXR Have low threshold for ordering CXR if cough/congestion since children often don’t take in deep enough breath to get good lung exam

39. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 Management UA results Positive if Nit+, LE+, > 5 wbc/hpf If UA positive, treat with oral antibiotics F/u urine culture results

40. 8 m/o well-appearing female infant with 2 day h/o rectal temp 102.2 Education Conversation with the parent: Low-Risk is not No-Risk Document risk of bacteremia in this patient <1% since PCV-7 and Hib UTD, parent agreed with above plan Return for continued fevers for 48 hours, irritability, lethargy, or any other concerns

41. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 PMH Healthy, term delivery Went home with mom No previous hospitalizations No chronic illnesses Has never been on antibiotic therapy Circumcised in nursery

42. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 No sick contacts Immunizations: up to date Received 2 doses of Hib and PCV-7 ROS Eating well, acting normal Normal urination No cough/congestion No emesis/diarrhea

43. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 PE: no apparent distress, reaching for objects, interactive VS: 128, 32, 99% RA, 102.2 No focal bacterial infection including No purulent otitis media No skin or soft tissue infection No bone or joint infection

44. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 True fever? Yes Focal Infection? No

45. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 Work-up MUST DO: Urinalysis, urine culture CONSIDER: CBC, blood cultures because hasn’t received 3 doses of PCV-7 and Hib vaccine

46. 5 m/o well-appearing male infant with 2 day h/o rectal temp of 102.2 Discuss with parent about amount of risk willing to tolerate Risk of bacteremia approximately 1-2% Exact unknown since not rec’d all doses of PCV-7 Pre-PCV 7 bacteremia 2% Pre-PCV 7 risk of bacteremia progressing to meningitis 5% Post-PCV 7 reduction in invasive pneumococcal disease 40% Post-PCV 7 risk for developing meningitis 0.04%

47. Things to NOT forget It might not be an infection 3 yo male w/5 day h/o fevers to 103 Started on Amox 2 days ago for sinus infection, but fevers continued PMH: unremarkable

48. 3 yo male with 5 days of fever to 103 ROS Decreased oral intake Decreased activity Rash present Red eyes

49. 3 yo male with 5 days of fever to 103 PE: uncomfortable appearing 3 yo male sitting still in mom’s lap VS: 140, 90/50, 50, 98% RA, 103.6 Bilateral conjunctival swelling Dry, fissured lips Cervical adenopathy Rash over trunk (scarlatiniform) Skin changes of limbs (edema, desquamation)

50. 3 yo male with 5 days of fever to 103, Differential Diagnosis: Scarlet Fever Stevens-Johnson Syndrome Drug Eruption Henoch-Schonlein Purpura Toxic Shock Syndrome Measles Rocky Mountain spotted fever Infectious mononucleiosis Kawasaki Disease

51. 3 yo male 5 day h/o fevers to 103 Work-up CBC, Blood cultures CMP UA, urine culture ESR or CRP CXR EKG, echocardiogram, cath (looking for coronary artery aneyrusm

52. Kawasaki Disease Fever for at least five days Four of the Five: Bilateral bulbar conjunctival infection Mucosal changes Erythema, Edema of Ext, Periungual Desquamation Rash, polymorphous, nonvesicular Cervical adenopathy >1.5 cm, often unilateral Treatment: O2, IVIG, Aspirin

53. Bibliography Available on request valerie.wrede@misawa.af.mil DSN 315-226-6647