Transcript Fevers In Infants - Stanford University

SCVMC Nighttime Curriculum
Fever
Erin Augustine, MD
Alan Schroeder, MD
• Previously healthy 3 week infant presents with fever to
100.5˚F. Well-appearing and no source of infection on
exam. Parents appropriate and able to follow up with
pediatrician when recommended. Next step?
A) Reassurance, Close Follow-Up
B) Urine Culture; Close Follow-Up
C) Urine & Blood Culture; Close Follow-Up
D) Urine, Blood, & CSF Culture; Close Follow-Up
E) Urine, Blood, & CSF Culture; Ceftriaxone; Close Follow-Up
F) Urine, Blood, & CSF Culture; Admit; IV Antibiotics
• Previously healthy 7 week infant presents with fever to
100.5˚F. Well-appearing and no source of infection on
exam. Parents appropriate and able to follow up with
pediatrician when recommended. Next step?
A) Reassurance, Close Follow-Up
B) Urine Culture; Close Follow-Up
C) Urine & Blood Culture; Close Follow-Up
D) Urine, Blood, & CSF Culture; Close Follow-Up
E) Urine, Blood, & CSF Culture; Ceftriaxone; Close Follow-Up
F) Urine, Blood, & CSF Culture; Admit; IV Antibiotics
• Previously healthy 11 week infant presents with fever
to 100.5˚F. Well-appearing and no source of infection
on exam. Parents appropriate and able to follow up
with pediatrician when recommended. Next step?
A) Reassurance, Close Follow-Up
B) Urine Culture; Close Follow-Up
C) Urine & Blood Culture; Close Follow-Up
D) Urine, Blood, & CSF Culture; Close Follow-Up
E) Urine, Blood, & CSF Culture; Ceftriaxone; Close Follow-Up
F) Urine, Blood, & CSF Culture; Admit; IV Antibiotics
Febrile Infants and Children
• Fever is Very Common
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Emergency Departments
Outpatient Clinics
• Appropriate Management of Fever
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Has Changed Over Last Few Decades
Is Debated
Differs Among Physicians
Serious Bacterial Infections (SBI)
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Bacteremia
Meningitis
Urinary Tract Infection (UTI)
Bacterial Diarrhea
Pneumonia
Bone & Joint Infections
Prior to 1985
• Management of febrile infants <2-3 mo
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Hospitalization
Sepsis Evaluation (Blood, Urine, CSF Cultures)
IV Antibiotics
Disadvantages to Hospitalization
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Nosocomial Infections
Adverse Effects of Antibiotics
Emergence of Resistant Bacteria
Stresses on Families
Cost
Rochester, Boston, & Philadelphia Criteria
Criteria established to predict infants <3 months
at low risk for SBI.
A = Rochester
B = Boston
C = Philadelphia
Rochester Criteria
• Prospective study to determine if a set of criteria
could accurately identify febrile infants <3 months at
low risk of SBI.
• Low Risk Rochester Criteria
 Previously Healthy
 No Soft Tissue, Skeletal, or Ear Infection
 WBC 5,000-15,000 (Bands <1,500)
 UA WBC <10/hpf
Dagan R, et al. J Pediatr. 1985.
Boston Criteria
• Prospective consecutive cohort study to determine
outcome of outpatient treatment of febrile infants 2889 days with Ceftriaxone IM.
• Low Risk Boston Criteria
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Looks Well
No Source of Infection
WBC <20,000
Urine WBC <10/hpf or Leukocyte Esterase Negative
CSF WBC <10
CXR Normal (If Obtained)
Baskin MN, et al. J Pediatr. 1992.
Philadelphia Criteria
• Randomized controlled study to evaluate efficacy of
managing febrile infants 29-56 days without
antibiotics or hospitalization.
• Low Risk Philadelphia Criteria
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Looks Well
No Source of Infection
WBC <15,000
Urine WBC <10/hpf
CSF WBC <8
CXR Normal (If Obtained)
Baker MD, et al. New Engl J Med. 1993.
Baraff Practice Guidelines
• Infants < 28 Days
Hospitalize
Blood, Urine, CSF Cultures
IV Antibiotics
• Infants 28-90 Days
Low Risk
Option 1
Blood, Urine, CSF Cultures
Ceftriaxone IM
Return 24 Hours
Option 2
Urine & Blood Culture
Return 24 Hours
High Risk
Hospitalize
Blood, Urine, CSF Cultures
IV Antibiotics
Baraff. Ann Emerg Med. 2000.
Baraff Practice Guideline
• Infants 3-36 Months
Toxic Appearing
Hospitalize
Blood, Urine, CSF Cultures
IV Antibiotics
Non-Toxic Appearing
Temp <39 C
Temp >39 C
No Diagnostic Tests
Return If Fever >48 Hours
Blood Culture if WBC >15,000 & No PCV
Urine Culture if M <6 mo, Uncirc <12 mo, F <2 yr, UA Pos
Ceftriaxone if WBC >15,000 & No PCV
Return if Febrile >48 Hours
Baraff. Ann Emerg Med. 2000.
Management of febrile Infants
Office Setting
• Prospective study of 3066 febrile infants ≤3 months seen by
practitioners from the Pediatric Research in Office Setting
(PROS) Network.
• Current guidelines followed in 42%
• Only 2/63 with bacteremia or meningitis were not initially
treated with antibiotics. Both well after treatment.
Clinicians use individualized judgment in treating febrile infants.
Using clinical guidelines would not have improved care, but
would have resulted in more hospitalizations and labs.
Pantell RH, et al. (PROS Study). JAMA. 2004.
Special Patient Populations
• Neonates
• Transplant recipients
– Bone marrow
– Solid organ
• Oncology patients
– Undergoing therapy, mucositis, central line
– Most chemotherapy: nadir ~ 10 days after rx
• Asplenic patients, including sickle cell
Treatment for neonates ≤ 2 months
• If < 28 days old
– Ampicillin AND cefotaxime OR
– Ampicillin AND gentamicin
• Consider acyclovir
• If 29-60 days old
– Ceftriaxone ± Ampicillin OR Vancomycin
– Until CSF results are known (cell count,
protein, glucose), initiate therapy with
meningitic dosing regimen
Urinary Tract Infection
• The prevalence of urinary tract infections in febrile
children ≤24 months is closest to
A) 2-4%
B) 6-8%
C) 10-12%
D) 14-16%
E) 18-20%
• The prevalence of urinary tract infections in febrile
uncircumcised males <3 months is closest to
A) 2-4%
B) 6-8%
C) 10-12%
D) 14-16%
E) 18-20%
UTI Prevalence
• Meta-Analysis (18 Articles; 22,919 Children)
• UTI Prevalence in Febrile Children ≤24 Months
7%
Shaikh N, et al. Pediatr Infect Dis J. 2008.
UTI Prevalence
• UTI Prevalence in Male Infants <3 months
2.4%
20%
Shaikh N, et al. Pediatr Infect Dis J. 2008.
UTI Prevalence
• Prevalence By Age (%)
Age
Overall
Females
Males
Circumcised
Uncircumcised
< 3 mo
7.2
7.5
8.7
2.4
20.1
3-6 mo
6.6
5.7
3.3
6-12 mo
5.4
8.3
1.7
12-24 mo
4.5
2.1
0.3
7.3
• Prevalence Highlights
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Decreases with Age
Highest in Females < 1 Year
Highest in Uncircumcised Males < 3 Months
Shaikh N, et al. Pediatr Infect Dis J. 2008.
• Previously healthy 3 month female presents with fever
to 101.7˚F. Well-appearing on exam. Urinalysis
positive. Parents appropriate and able to follow up
with pediatrician when recommended. Next step?
A) Urine Culture; Close Follow-Up
B) Urine Culture; Oral Antibiotics; Close Follow-Up
C) Urine & Blood Culture; Oral Antibiotics; Close Follow-Up
D) Urine, Blood, & CSF Culture; Oral Antibiotics; Close Follow-Up
E) Urine, Blood, & CSF Culture; IM Ceftriaxone; Close Follow-Up
F) Urine, Blood, & CSF Culture; Admit; IV Antibiotics
• Retrospective study of 354 children <2 years
discharged with diagnosis of UTI to characterize
patients with bactermia or meningitis.
• Bacteremia in 9% (33/354)
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Limited to age <6 months
 Inversely related to age
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0-1 Month = 21%
1-2 Months = 13%
2-3 Months = 4%
• Meningitis in 1% (4/354)
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Limited to age <1 month
Bachur R, et al. Pediatr Emerg Care. 1995.
Bronchiolitis
• Previously healthy 5 week infant presents with fever,
congestion, and cough. Exam consistent with
bronchiolitis. Parents appropriate and able to follow
up with pediatrician when recommended. Next step?
A) Reassurance, Close Follow-Up
B) Urine Culture; Close Follow-Up
C) Urine & Blood Culture; Close Follow-Up
D) Urine, Blood, & CSF Culture; Close Follow-Up
E) Urine, Blood, & CSF Culture; Ceftriaxone; Close Follow-Up
F) Urine, Blood, & CSF Culture; Admit; IV Antibiotics
Bronchiolitis & Serious Bacterial Infection (SBI)
Emergency Departments
• Multicenter prospective study of 1248 febrile
infants ≤ 60 days to evaluate frequency of
SBI in infants with and without RSV infection.
Total Infants (n=1248)
SBI in 11.4%
RSV Pos (n=269)
RSV Neg (n=979)
SBI in 7%
UTI in 5.4%
Bacteremia in 1.1%
Bacterial Meningitis in 0%
SBI in 12.5%
UTI in 10.1%
Bacteremia in 2.3%
Bacterial Meningitis in 0.9%
Levine DA, et al. Pediatrics. 2004.
Bronchiolitis & Serious Bacterial Infection (SBI)
Primary Care Offices
• Prospective cohort study of 3066 febrile infants
<3 months to evaluate frequency of SBI in infants
with and without clinically diagnosed bronchiolitis.
• Infants with bronchiolitis, SBI in 0%.
• Infants without bronchiolitis, SBI in 8%.
In office setting, SBI is uncommon in febrile infants
<3 months with clinically diagnosed bronchiolitis.
Luginbuhl LM, et al. Pediatrics. 2008.
Conclusion
• To identify febrile infants and children at
risk of serious bacterial infections,
clinicians should use a combination of
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Clinical Judgement
 Published Guidelines
 Clinical and Laboratory Indices
 Immunization status
References
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Baker MD, Bell L, Avner JR. Outpatient Management Without Antibiotics of Fever in
Selected Infants. New Engl J Med. 1993. 329(20): 1437-41.
Baraff LJ. Management of Fever Without Source in Infants and Children. Ann Emerg
Med. 2000. 36:602-14.
Baraff LJ, Bass JW, Fleisher GR, Klein JO, McCracken Jr GH, Powell KR, Schriger DL.
Practice Guideline for the Management of Infants and Children 0-36 Months of Age with
Fever Without Source. Ann Emerg Med. 1993. 22:108-20.
Baskin MN, O’Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28-89 days
of age with intramuscular administration of ceftriaxone. J Pediatr. 1992. 120:22-7.
Bachur R, Caputo GL. Bacteremia and meningitis among infants with urinary tract
infections. Pediatr Emerg Care. 1995. 11:280-4.
Carstairs KL, Tanen DA, Johnson AS, Kailes SB, Riffenburgh RH. Pneumococcal
Bacteremia in Febrile Infants Presenting to the Emergency Department Before and After
the Introduction of the Heptavalent Pneumococcal Vaccine. Ann Emerg Med. 2007.
49:772-7.
CDC. www.cdc.gov. 2002 & 2008.
Dagan R, Powell KR, Hall CB, Menegus MA. Identification of infants unlikely to have
serious bacterial infection although hospitalized for suspected sepsis. J Pediatr. 1985.
107:855-60.
Dagan R, Sofer S, Phillip M, Shachak E. Ambulatory care of febrile infants younger than 2
months of age classified as being at low risk for having serious bacterial infections. J
Pediatr. 1998. 112:355-60.
References
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Garra G, Cunningham SJ, Crain EF. Reappraisal of Criteria Used to Predict Serious
Bacterial Illness in Febrile Infants Less than 8 Weeks of Age. Acad Emerg Med. 2005.
12:921-5.
Herz AM, Greenhow TL, Alcantara J, Hansen J, Baxter RP, Black SB, Shinefield HR.
Changing Epidemiology of Outpatient Bacteremia in 3- to 36-Month-Old Children After the
Introduction of the Hepatavalent-Conjugated Pneumococcal Vaccine. Pediatr Infect Dis J.
2006. 25:293-300.
Huppler AR, Eickhoff JC, Wald ER. Performance of Low-Risk Criteria in the Evaluation of
Young Infants with Fever: Review of the Literature. Pediatrics. 2010. 125:228-33.
Jaskiewicz JA, McCarthy CA, Richardson AC, White KC, Fisher DJ, Powell KR, Dagan R.
Febrile Infants at Low Risk for Serious Bacterial Infections – An Appraisal of the Rochester
Criteria and Implications for Management. Pediatrics. 1994. 94:390-6.
Kadish HA, Loveridge B, Tobey J, Bolte RG, Corneli HM. Applying Outpatient Protocols in
Febrile Infants 1-28 Days of Age: Can the Threshold Be Lowered? Clin Pediatr. 2000.
39:81-8.
Levine DA, Platt SL, Dayan PS, Macias CG, Zorc JJ, Krief W, Schor J, Bank D, Fefferman
N, Shaw KN, Kuppermann N. Risk of Serious Bacterial Infection in Young Febrile Infants
With Respiratory Syncytial Virus Infections. Pediatrics. 2004. 113:1728-34.
Luginbuhl LM, Newman TB, Pantell RH, Finch SA, Wasserman RC. Office-Based
Treatment and Outcomes for Febrile Infants With Clinically Diagnosed Bronchiolitis.
Pediatrics. 2008. 122:947-54.
Pantell RH, Newman TB, Bernzweig J. Management and Outcomes of Care of Fever in
Early Infancy. JAMA. 2004. 291:1203-12.
Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of Urinary Tract Infection in
Childhood. Pediatr Infect Dis J. 2008. 27:302-8.