Febrile Child

1
Febrile Child

• Dr. Steven Blyth
• Dr. David Johnson

2
Overview

• Introduction
• Occult bacteremia
• Antibiotic prevention of SBI
• Febrile seizure
• Fever and petechiae
• Fever in children with underlying illness
• Rare syndromes

3
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

4
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

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

6
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.

7
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)

8
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

9
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

10
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

11
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

12
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

13
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

14
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

15
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

16
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

17
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

18
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

19
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

20
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

21
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

22
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