The febrile infant l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 24

The Febrile Infant PowerPoint PPT Presentation


  • 222 Views
  • Uploaded on
  • Presentation posted in: General

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 .

Download Presentation

The Febrile Infant

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 l.jpg

The Febrile Infant

Steven Lanski, MD FAAP

Emory University School of Medicine

Children’s Healthcare of Atlanta @ Egleston


Objectives l.jpg

Objectives

  • Review the management options available when evaluating a febrile infant

  • Review pertinent literature

  • Management options

  • Special cases


What would you do l.jpg

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 l.jpg

Evaluation

  • History

    • Timeline and degree

    • Associated symptoms

    • Past medical conditions

      • Decreased defense

      • Hardware

  • Physical

    • Appearance

    • Other source

    • Skin involvement


Guidelines l.jpg

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 l.jpg

Management Based on Age

  • Neonates

  • 28-90 days

  • 3 – 6 months

  • 6 – 24 months

  • >24 months


Published practice guidelines l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

Invasive Pneumococcal DiseaseCDC: Active Bacterial Core Surveillance, eight states, 1998-2005

  • CDC: Active Bacterial Core Surveillance, eight states, 1998-2005


Management 6 24 months l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

Special Cases

  • Prematurity

  • Immunocompromised

  • Patients with hardware


Best course of action l.jpg

Best Course of Action?

  • Regional epidemiology

  • Regional practice patterns

  • Consensus guidelines

  • Personal risk tolerance

    • Risk minimizer vs Test minimizer


Children s healthcare of atlanta guidelines 29 days l.jpg

Children’s Healthcare of Atlanta Guidelines < 29 days


Choa guidelines 29 60 days l.jpg

CHOA Guidelines 29 – 60 days


Choa guidelines 2 6 months l.jpg

CHOA Guidelines 2-6 months


Choa guidelines 6 24 months l.jpg

CHOA Guidelines >6-24 months


Questions l.jpg

Questions

?


  • Login