The Febrile Child: Treat

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The Febrile ChildTreat em or Street em

• David Chaulk
• Pediatric EM Fellow
• January 2004

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Overview

• Cases
• Temperature Measurement
• Who Cares?
• Schools of Thought
• Scoring Systems
• Empiric Therapy

• Changes in Prevalence Changes in Management
• Recognizable Illnesses
• CPS Guidelines
• Cases Revisited

3
Case 1

• A 3 week old male infant is brought to your ED
  with a 2 day history of fever. He was born by
  uncomplicated vaginal delivery at 37 weeks
  gestation following a normal pregnancy. At his
  two week check-up he was noted to be gaining
  weight appropriately. His vital signs are T
  38.9?C (R), HR 140, RR 40, and BP 90/60. He is
  sleepy but easily rousable. Physical exam is
  normal apart from a slightly dull left tympanic
  membrane. His peripheral WBC is 16,000, his UA
  shows 3 WBC/hpf. BC and UC are sent. Your
  management at this point would consist of
• a. Discharge on antipyretics with close
  follow-up
• b. Discharge on oral amoxicillin with close
  follow-up
• c. LP and admission for parenteral antibiotics
• d. CXR to r/o pneumonia
• e. Stool for analysis and culture, and
  outpatient follow-up

4
Case 2

• A 7 week old girl is referred in to ED for
  evaluation of a rectal temperature of 39.2?C. Her
  PE is normal. Her UA is negative, her WBC is
  9,000 (70 neuts, 28 lymphs, 2 bands). BC, UC
  are sent. Acceptable management options for this
  child would include any one of the following
  except
• IM ceftriaxone in the ED
• Admission to the hospital for IV antibiotics
• Discharge with follow-up in 24 hours
• Admission to the hospital for observation
• Discharge on amoxicillin
• Any other investigations?

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Case 3

• A 19 month old boy comes to the ED with a 3 day
  history of fever. He appears well but his
  tympanic T is 39.8?C. His chest is clear, his
  abdomen is soft, and he is circumcised. No
  source can be found for his fever. A CBC reveals
  a WBC of 8200 (60 neuts, 27 bands). BCs are
  sent.
• Appropriate management at this point will be
  to
• a. Obtain a urine sample
• b. Administer IM ceftriaxone
• c. Perform an LP
• d. Obtain a CXR
• e. Discharge on antipyretics

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Temperature Measurement
Source Fever Problem
Rectal gt 38 Invasive, takes time
Oral 0.5 lower Technique dependent
Axillary 1.0 lower ? Reliability ? variability
Tympanic 0.5 lower Technique dependent
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Temperature Measurement

• Rectal is gold standard based on study from 1937!
• Controversial! Tympanic very accurate or very
  inaccurate
• Lanham 1999tympanic misses too many febrile
  children
• Shinozaki, 1998rectal inaccurate because of poor
  blood supply to rectum, T is slow to change
• Physiologically, T controlled by hypothalamus
• Hypothalamus and Tympanic Membrane have same
  blood supply (common carotid)

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Temperature MeasurementCPS Guidelines

• Age Recommended technique
• Birth to 2 years
• 1. Rectal (definitive)
• 2. Axillary (screening)
• Over 2 years to 5 years
• 1. Rectal2. Tympanic3. Axillary
• Older than 5 years
• 1. Oral2. Tympanic3. Axillary

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Who cares?

• 65 of children 0-2 will visit a physician for a
  febrile illness
• 10-20 of PED visits, 20-30 ped office visits
• 50 are fever without source
• Most represent self-limited illness
• Small precentage with Serious Bacterial
  Illnessbut who?

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A few Definitions

• Fever without Source
• An acute febrile illness in which the etiology
  of the fever is not apparent after a careful
  history and physical examination.
• Baraff et al, Pediatrics 1993 921-12
• Fever of Unknown Origin
• Fever gt 2 to 3 weeks
• Absence of localizing signs
• Failure of simple diagnostic efforts

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A few Definitions

• Occult Bacteremia
• a positive blood culture in the setting of well
  appearance and without focus (e.g. no pneumonia),
  BUT may be in the presence of URTI, otitis media,
  diarrhea, or wheezing
• Fleisher et al, J Pediatrics 1994
• Serious Bacterial Infections
• SBI include meningitis, sepsis, bone and joint
  infections, urinary tract infections, pneumonia
  and enteritis
• Baraff et al, Pediatrics 1993 921-12

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Occult Bacteremia

• Strep pneumo. gt85
• N.meningitidis 3-5
• Others
• GAS
• Staph aureus
• Salmonella spp
• HiB
• Now rare, previously was 10

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Bacteremia

• lt 2 mos, T gt 38 incidence is 2-3
• Avner and Baker, Emerg Med Clin NA 200220(1)
• 3-36 mos, T lt 39 incidence is lt2
• Klein, Ped Inf Dis J 200221(6)584-8
• 2002 data, ie. Post HiB era

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Untreated Bacteremia Outcomes

• Persitent fever 56
• Persistent bacteremia 21
• Meningitis 9
• S.pneumo 6
• HiB 26 (no longer seen)

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Scoring Systems

• Demographic and Clinical Parameters
• Age, temperature, clinical appearance
• Lab Screens
• CBC, ESR, U/A
• Initially very promisingultimately not so hot

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Scoring Systems

• Can we identify high risk kids?
• Yale Observational Score
• 611 children, 192 bacteremic
• Median score was the same for both groups
• A high score was a good marker
• Specificity and NPV 97
• Sensitivity and PPV 5
• Not great screening tool (screens should be
  sensitive)

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Scoring Systems

• Can we identify low risk kids?
• Three main scoring systems
• Philadelphia, Rochester and Boston Criteria
• All are similar but there are differences
• Main risk factors identified
• Age (3 groups. 0-28d, 28-90d, 3-36m)
• Temperature T gt 40.5 8-25 with OB
• Petechiae 15-20 SBI
• WBC gt15,000, bandsgt1000 5 fold ? in OB
• Toxic appearance
• Lethargy/irritabilty Poor eye contact
• Poor perfusion Hypo/hyperventilation
• Cyanosis

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Philadelphia Rochester Boston
Age 1-2 months 0-2 months 1-3 months
Temperature 38.2?C 38.0?C 38.0?C
History Not specified Term infant Previously well No recent vacc /abx Not dehydrated
Physical examination Well-appearing (IOS lt 10) Well-appearing Well-appearing
Laboratory parameters (defines lower-risk patients) Wbc lt 15,000 BNR lt 0.2 UA lt 10 WBC/hpf Urine gram stain ve CSF lt8 WBC CSF gm stain ve CXR clear Stool no blood, few or no WBCs on smear WBC gt 5,000 lt 15,000 Abs band ct lt1500 UA lt 10 WBC/hpf lt 5 WBC/hpf stool smear No LP required! CSF lt 10 UA lt 10 WBC/hpf CXR clear WBC lt 20,000
Higher risk patients Hospitalize empiric abx Hospitalize empiric abx Hospitalize empiric abx
Lower risk patients Home No antibiotics Follow-up required Home No antibiotics Follow-up required Home Empiric abx (IM ceftriaxone) Follow-up required
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Statistics
Philadelphia Rochester Boston
SBI (low risk) 0 1.1 5.4
NPV 100 98.9 94.6
Sensitivity 100 92.4 ?
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Are neonates really different?

• Philadelphia criteria applied to 3-28 d
• 254 pts, 43 low risk (managed as OP)
• 32 (12.6) with SBI
• 17 UTIs, 8 OB, 4 BM
• 5 low risk infants has SBI
• Would miss 201000 of infants with SBI
• Empiric antibiotics standard of care in this age
  group

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Empiric Antibiotics28-90 d

• Lieu, 1992
• Decision analysis based on 6 management
  strategies for management of fever gt38 in 28-90 d
  infants
• Worst Strategy
• Clinical judgement
• Most Effective
• Full septic work up, IM ceftriaxone and
  outpatient management

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Empiric Antibiotics3-36 mos

• Couple of big studiesneither great
• Bass, 1993
• 519 children 3-36 mos, 11.6 with OB
• Compared clavulin to ceftriaxone in children with
  Tgt40 or Tgt39.5 and WBCgt15
• No difference between groups
• Fleisher, 1994
• 6733 patients, 2.9 with OB
• Compared amoxil to ceftriaxone
• ceftriaxone eradicated bacteremia, had fewer
  focal complications and less persitent fever

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Us Vs. Them

• Survey of AAP general pediatricians
• 610 (67) responded
• 40 indicated that parents frequently ask for abx
  when MD feels it is not warranted
• 48 stated parents pressure them to prescribe
• 30 stated they comply with that pressure
• Parental pressure viewed as leading cause for
  unnecessary abx

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Us Vs. Them
Should Fever be Treated?

• Pros
• Decreases disomfort
• Dereases parental anxiety
• Extreme may cause brain damage (exceedingly rare)
• Limited/minimal evidence that it may reduce
  febrile seizures

• Cons
• Harm of antipyretics may outweigh benefits
• Fever is a normal physiologic response
• Fever is usually short lived and benign
• May obscure diagnostic/prognostic signs

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Us Vs. Them Pyrexiophobia

• 91 of caregivers believed fever was harmful
• 21 listed brain damage and 14 listed death as
  effects of fever
• 25 gave antipyretics for fever lt 37.8
• 85 awakened the child to treat fever
• 14 gave acetaminophen too frequently
• 44 gave ibuprofen too frequently
• 65 of pediatricians believed fever in and of
  itself could be dangerous to the child

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Changes and Controversies

• Eradication of HiB
• Decreasing Prevalence of Strep pneumo
• Increasing resistance of Strep pneumo
• Fever in infant with recognizable illness

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HiB Vaccine (1987)

• Prior to vaccine
• 10-15 of OB and majority of SBI
• 12,000 cases/year(US) invasive HiB in lt5yo
• 1994-95
• 300 cases/year (likely lower now)
• Invasive HiA/F are still uncommon but may emerge
  as serious pathogens

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Prevnar/Pneumovax

• PCV7 (7 serotypes) studied in Northern California
• Large herd effect noticed
• 34 of lt 5 yo children immunized
• 62 reduction in invasive PC seen
• Finnish otitis media study
• Strep isolates from OM cultures
• Significant reduction in the 7 serotypes
• 33 increase in other serotypes

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Prevnar/Pneumovax

• PCV7 estimated to be 97 effective
• Excellent but will still see dz
• Will still see PC in
• Other serotypes
• Vaccine failures
• Unimmunized children
• Immunocompromised children
• Bottom line
• Shouldnt change our respect for OB/SBI in young
  childrenyet

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Pneumococcal ResistanceKaplan, 1998

• Three year MC study
• 1291 systemic pneumococcal infections
• Resistance increased annually over the study
  period
• Penicillin resistance 21
• Ceftriaxone resistance 9
• Resistance changes region to region
• Ottawa has 20 resistant Strep pneumo

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Fever and Recognizable Illness

• Kupperman, 1997
• Risk of bacteremia and UTI in febrile children
  with and without bronchiolitis
• 432 children, 0-24 mos
• Children with bronchiolitis had significantly
  fewer positive cultures
• Blood 0 compared to 2.7
• Urine 1.9 compared to 13.6
• 0 children lt 2 mos with bronchiolitis had
  bacteremia or UTI

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Fever and Recognizable Illness

• Greene, 1999
• 5 year retrospective
• Children 3-36 mos with T gt39
• 1347 children with recognizable viral syndrome
• Croup, varicella, bronchiolitis, stomatitis
• Blood cultures in 65
• 2 of 876 (0.2) were culture positive

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Occult Pneumonia

• Bachur, 1999
• Prospective cohort study
• lt 5 yo children with T gt39 and WBC gt 20k
• CXR in 225/278
• CXR postive in
• 40 with suggestive clinical exam
• 26 of those without clinical evidence
• Recommends empiric cxr in fever without source

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UTIs in the Febrile Child

• Most frequent SBI and may present with fever only
• Prevalence 3.3 in febrile infants
• Gorelick, 2000
• Clinical Decision Rule
• T gt 39 fever gt 2 days
• White race age lt 1 year
• Absence of another potential source

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UTIs in the Febrile Child

• All with UTI had at least one risk factor
• Presence of any two factors
• Sensitivity 95
• Specificity 31

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Febrile Seizures

• Trainor, 1999
• Multi-centered analysis of ED management
• 455 children
• 1.3 bacteremic
• 5.9 UTI
• 12.5 abnormal CXR
• 135 had LPall normal
• In other words, manage like any other kid with
  fever

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Sonow youre completely lost!

• What are the guidelines?
• What do you really need to know?

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CPS Guidelines (www.cps.ca)0-28 days

• No CPS guidelines documented for 0-28 d
• American Concensus Guidelines (Baraff, 1993)
• Full Septic Work up (all risk groups)
• LP (culture, cell counts and glucose/protein)
• Blood culture
• Urine (routine, microscopy and culture)
• If diarrhea, stool smear and culture
• If resp symptoms, CXR
• Admit, IV antibiotics

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CPS Guidelines29-90 days

• NOT low risk
• CPS toxic or unduly lethargic
• FSWU (BC,UC,LP)
• Admit
• Broad spectrum IV antibiotics

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CPS Guidelines29-90 days

• Low Risk
• No investigations
• Careful outpatient follow up, no treatment
• American Option
• FSWU
• Ceftriaxone
• RTED in 24h for re-assessment
• In reality, somewhere in between

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CPS Guidelines3-36 months

• Toxic Appearance
• FSWU
• Admit
• IV antibiotics

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CPS Guidelines3-36 months

• Non Toxic, T lt 39.5
• Observe only (if follow up assured)
• Non Toxic, T gt39.5
• CBC to decide if BC/UC and empiric therapy are
  needed
• If WBC lt 15k observe if follow up assured
• If follow up not assured a more aggressive
  approach may be indicated.

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CPS GuidelinesEmpiric Antibiotics

• If treating emprically
• Amoxicillin 60 mg/kg/day or
• Ceftriaxone 50 mg/kg
• ,and neither a substitute for for careful
  decision-making or follow-up. Long, 1994
• American guidelines are ceftriaxone

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Blood Culture () 3-36 mos

• Pneumococcus
• Persistent fever
• Admit, FSWU, IV abx
• Afebrile/well-looking
• Repeat culture, no treatment
• All other bacteria
• Admit, FSWU, IV abx

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Case 1

• A 3 week old male infant is brought to your ED
  with a 2 day history of fever. He was born by
  uncomplicated vaginal delivery at 37 weeks
  gestation following a normal pregnancy. At his
  two week check-up he was noted to be gaining
  weight appropriately. His vital signs are T
  38.9?C (R), HR 140, RR 40, and BP 90/60. He is
  sleepy but easily rousable. Physical exam is
  normal apart from a slightly dull left tympanic
  membrane. His peripheral WBC is 16,000, his UA
  shows 3 WBC/hpf. BC and UC are sent. Your
  management at this point would consist of
• a. Discharge on antipyretics with close
  follow-up
• b. Discharge on oral amoxicillin with close
  follow-up
• c. LP and admission for parenteral antibiotics
• d. CXR to r/o pneumonia
• e. Stool for analysis and culture, and
  outpatient follow-up

48
Case 2

• A 7 week old girl is referred in to ED for
  evaluation of a rectal temperature of 39.2?C. Her
  PE is normal. Her UA is negative, her WBC is
  9,000 (70 neuts, 28 lymphs, 2 bands), and her
  LP reveals a CSF WBC count of 8. BC, UC, and CSF
  cultures are sent. Acceptable management options
  for this child would include any one of the
  following except
• IM ceftriaxone in the ED
• Admission to the hospital for IV antibiotics
• Discharge with follow-up in 24 hours
• Admission to the hospital for observation
• Discharge on amoxicillin

49
Case 3

• A 19 month old boy comes to the ED with a 3 day
  history of fever. He appears well but his
  tympanic T is 39.8?C. His chest is clear, his
  abdomen is soft, and he is circumcised. No
  source can be found for his fever. A CBC reveals
  a WBC of 8200 (60 neuts, 27 bands). BCs are
  sent.
• Appropriate management at this point will be
  to
• a. Obtain a urine sample
• b. Administer IM ceftriaxone
• c. Perform an LP
• d. Obtain a CXR
• e. Discharge on antipyretics

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After all that.Heres what you need to know!

• hospitalize /- abx
• /- labs, home, /- abx
• home, no antibiotics
• /- labs, home, no antibiotics

• Infants lt 28 days
• Infants 1-3 months
• Infants and children 3 months to 3 yrs (T lt
  39?C)
• Infants and children 3 months to 3 years (T ?
  39?C)

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