the febrile infant
Download
Skip this Video
Download Presentation
The Febrile Infant

Loading in 2 Seconds...

play fullscreen
1 / 24

The Febrile Infant - PowerPoint PPT Presentation


  • 425 Views
  • Uploaded on

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 .

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'The Febrile Infant' - ilori


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
the febrile infant

The Febrile Infant

Steven Lanski, MD FAAP

Emory University School of Medicine

Children’s Healthcare of Atlanta @ Egleston

objectives
Objectives
  • Review the management options available when evaluating a febrile infant
  • Review pertinent literature
  • Management options
  • Special cases
what would you do
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

evaluation
Evaluation
  • History
    • Timeline and degree
    • Associated symptoms
    • Past medical conditions
      • Decreased defense
      • Hardware
  • Physical
    • Appearance
    • Other source
    • Skin involvement
guidelines
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
management based on age
Management Based on Age
  • Neonates
  • 28-90 days
  • 3 – 6 months
  • 6 – 24 months
  • >24 months
published practice guidelines
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
rochester criteria
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
management 28 days
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
management 29 60 days
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
management 60 90 days
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
management 3 6 months
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
management 3 6 month cont
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
invasive pneumococcal disease cdc active bacterial core surveillance eight states 1998 2005
Invasive Pneumococcal DiseaseCDC: Active Bacterial Core Surveillance, eight states, 1998-2005
  • CDC: Active Bacterial Core Surveillance, eight states, 1998-2005
management 6 24 months
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
bronchiolitis and sbi
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
uti clinical decision rule
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
special cases
Special Cases
  • Prematurity
  • Immunocompromised
  • Patients with hardware
best course of action
Best Course of Action?
  • Regional epidemiology
  • Regional practice patterns
  • Consensus guidelines
  • Personal risk tolerance
    • Risk minimizer vs Test minimizer
ad