Fever in infants less than 3 months of age

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Fever in infants less than 3 months of age

• Madesa Espana, MD, FAAP
• Pediatric Emergency Medicine
• St. Josephs Regional Medical Center
• Paterson, New Jersey

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Introduction

• Objectives
• To identify infants with fever
• To identify the febrile infants who are at risk
  for serious bacterial infection
• To present the different approaches in the
  evaluation and management of fever in infants
  less than 3 month old

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Definition of Fever

• Rectal temperature of 100.4 degrees F or higher
• Documented at home by caretakers or in the ED
• Axillary and tympanic temperatures are unreliable

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Traditional Strategies

• Boston Criteria
• Rochester Criteria
• Philadelphia Criteria

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Boston Protocol

• Age 28 89 days old
• Out patient management
• No immunizations or antimicrobials in the past 48
  hours
• No evidence of dehydration, ear, soft tissue or
  bone infection
• Overall well appearance
• Caretaker available by telephone

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Boston Protocol

• Laboratory criteria defining low-risk patients
• WBC count less than 20,000/mL
• CSF WBC lt10/microL
• UA lt10 WBC/hpf
• No infiltrate if CXR was done

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Boston Protocol

• Treatment
• Ceftriaxone 50 mg/kg IM
• Follow up
• 24 hour return visit

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Philadelphia Protocol

• Age 29 - 60 days
• Temperature 38.2 or higher
• Well appearing

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Philadelphia Protocol

• Laboratory criteria defining low-risk patients
• WBC lt 15,000/microL
• Band-neutrophil ratio lt0.2
• CSF lt 8 WBC/microL, negative gram stain
• No infiltrate on CXR
• Stool negative for blood or WBC

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Philadelphia Protocol

• Treatment
• No antibiotics
• Follow up
• 24 hour follow up visit

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Rochester Protocol

• Age 60 days or younger
• Out-patient management
• gt37 weeks gestation, uncomplicated perinatal
  course
• Previously healthy
• Well appearing, no ear soft tissue or bone
  infections

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Rochester Protocol

• Laboratory criteria for low-risk infants
• WBC 5,000 15,000/ microL, band count lt1,500/
  microL
• UA with lt10 WBC/ hpf with no bacteria
• Stool lt 5 WBC/ hpf if obtained

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Rochester Protocol

• Treatment
• No antibiotics
• Follow up
• Reliable follow up with 24 hours

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Fever in Neonates (0 28 days)

• Higher incidence of serious bacterial illness in
  this age group
• Serious bacterial illness
• UTI
• Bacteremia
• Meningitis
• Bacterial gastroenteritis

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Serious bacterial infections

• Group B strep
• Escherichia coli
• Strep pneumoniae
• H. influenza type b
• Non-typable H. flu
• Listeria monocytogenes
• Staphylococcus aureus

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Recent developments

• Universal immunizations
• Hib
• Pneumococcal
• Point of care testing
• RSV
• Influenza A and B

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Evaluation of the febrile infant

• History
• Associated symptoms and behavior
• Respiratory
• Gastrointestinal
• Feeding
• Activity
• Irritability

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Evaluation of the febrile infant

• Exposure to sick contacts
• Siblings, babysitter and daycare
• Any previous illness or antibiotic use

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Evaluation of the febrile infant

• Birth history
• Maternal fever, PROM
• Maternal GBS status and prophylaxis
• Maternal history of STDs
• Infants nursery/NICU course

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Evaluation of the febrile infant

• Physical Examination
• Abnormal vital signs, including pulse oximetry
• Toxic appearance
• Irritability
• Inconsolability
• Poor perfusion
• Poor tone
• Decreased activity or lethargy

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Evaluation of the febrile infant

• Physical Examination
• Signs of local infection
• Omphalitis
• Septic arthritis
• Limb swelling and inflammation
• Skin or mucus membrane lesions

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Evaluation of the febrile infant

• Physical Examination
• Signs of bacterial meningitis
• Altered sleep patterns
• Decreased oral intake
• Paradoxical irritability
• Hyper/hypothermia
• Bulging fontanel
• Nuchal rigidity

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Evaluation of the febrile infant

• Laboratory Tests
• WBC count
• 5,000 15,000 or 20,000/microL
• Band count lt1,500/microL
• Poor sensitivity/specificity

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Evaluation of the febrile infant

• Laboratory tests
• Urinalysis
• Normal U/A
• Urine culture
• Catheterized or suprapubic aspiration

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Evaluation of the febrile infant

• Laboratory test
• Stool examination in infants with diarrhea
• Stool WBC count
• Stool culture
• Stool for rotavirus

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Evaluation of the febrile infant

• Laboratory test
• Lumbar puncture
• Optional
• Infants over 28 days
• Well-appearing child
• Low grade fever
• No antibiotics

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Evaluation of the febrile infant

• Blood Culture
• All infants less than 28 days old
• Older infants receiving empiric antibiotics
• Viral cultures/PCR studies
• Skin/mucus membrane lesions
• CSF
• Stool

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Evaluation of the febrile infant

• Chest radiographs
• Indicated in infants with respiratory symptoms
  tachypnea, rales, rhonchi, wheezing, grunting,
  rhinorrhea, stridor, nasal flaring

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Low risk for SBI 2009

• Well appearing
• No medical problems, uncomplicated birth history
• No focus of infection

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Low risk for SBI 2009

• Laboratory findings
• WBC count lt15,000/microL
• UA lt 10 WBC/hpf, no bacteria
• CSF lt8 WBC/hpf, neg gram stain
• CXR with no infiltrates
• Stool without blood or few WBCs

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Out-patient management of Low risk group

• Option 1
• Cultures blood, urine, CSF
• Ceftriaxone 50 mg/kg
• 24 hour follow up
• Option 2
• Cultures blood and urine
• No antibiotics
• 24 hour follow up

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In-patient management

• Neonates
• Presence of local infection
• Toxic appearance
• Abnormal vital signs

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In-patient management

• Laboratory tests
• WBC count lt5,000 or gt15,000
• UA gt 10 WBC/hpf, bacteria
• CSF gt8 WBC/hpf, gram stain
• Stool with blood or high WBC
• CXR with infiltrates

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In-patient management

• Lumbar tap
• Dry or bloody tap
• Previous antibiotic treatment

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Management of the febrile infant

• Antibiotic therapy
• Ampicillin
• Gentamicin
• Cefotaxime
• Vancomycin

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Management of the febrile infant

• Acyclovir
• Ill-appearing neonates
• Skin or mucus membrane lesions
• Seizures

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Recommendations

• Neonates
• Blood, urine CSF cultures
• CXR
• In-patient management
• Empiric treatment
• Ampicillin gentamicin/cefotaxime
• Acyclovir

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Recommendations

• Ill appearing 29 60 days old infant or temp gt
  38.5 F
• CBC
• Blood, urine, CSF and (/-) stool cultures
• CXR
• In-patient management
• Ceftriaxone or Cefotaxime
• Vancomycin

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Recommendations

• Well appearing 29 60 days old infants
• CBC
• Blood, urine (/-) stool cultures
• Lumbar puncture/CSF culture
• Empiric antibiotics
• Out-patient management of low risk group
• /- Ceftriaxone
• 24 hour follow up

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Recommendations

• Ill appearing 61 90 days old infants
• CBC
• Blood, urine, CSF (/-) stool cultures
• CXR
• In-patient management
• Ceftriaxone or Cefotaxime
• Vancomycin

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Recommendations

• Well appearing 61 90 days old infants
• CBC
• Blood, urine (/-) stool culture
• CXR
• Lumbar tap/CSF culture
• Empiric antibiotics
• Out patient management
• 24 hour follow up

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Concomitant viral infections

• Influenza
• Bronchiolitis
• Croup
• Varicella
• Stomatitis
• Low incidence of bacteremia
• Lower incidence of UTI

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Limitations of the guidelines

• Neonates
• Poor specificity
• Extensive testing
• Most studies are ED based
• Poor adherence to the guidelines in office
  settings

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Espanas management of febrile infants

• Admit all infants who are ill appearing
• Full sepsis work up and in-patient management of
  all infants 6 8 weeks of age
• Avoid empiric antibiotics for well appearing
  patients
• Ensure follow up within 24 hours for discharged
  patient

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• Thank you!

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ACEP guidelines 2003

• Febrile neonates
• CXR in less than 3 months old with respiratory
  symptoms
• UTI in both males and females lt 1 year, girls lt2
  years
• Normal dipstick does not rule out UTI, send urine
  culture