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Febrile Child
Overview
Introduction
Occult bacteremia
Antibiotic prevention of SBI
Febrile seizure
Fever and petechiae
Fever in children with underlying illness
Rare syndromes
Introduction
Historical perspective
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Toxic looking child
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Focal bacterial infection
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Fever, menigeal signs, lethargic, limb, mottled
Admit, septic work-up, parental antibiotics
Any child with focal bacterial infection (excluding SBI)
such as OM, pharyngitis, sinusitis, etc.
Oral antibiotics, outpatient care
Well looking child
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Risk for occult bacteremia and serious bacterial infection
Previous decision analysis: pre-H. flu immunization
Current decision analysis
Occult Bacteremia
Incidence of occult bacteremia
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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
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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%
Occult Bacteremia
Degree of temperature elevation
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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
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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
Occult Bacteremia
WBC
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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.
Occult Bacteremia
Blood cultures
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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
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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)
Occult Bacteremia
Assessment of observational scores:
Bonadio Pediatric Clinics of NA 1998
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Infants younger than 8 weeks
Retrospective studies
 Prospective studies
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Infants and children older than 8 weeks
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Prospective studies
Occult Bacteremia
Guidelines for managing OB
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Guidelines for febrile infants 0-3 months
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Baker et al NEJM 1993: Philadelphia protocol
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Infants under 3 months
Philadelphia protocol: low risk vs high risk
100% sensitive; 100% negative predictive value
Baker et al Pediatrics 1999: validation
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Validation of Philadelphia protocol
Infants 29-60 days old; low risk vs high risk for SBI
100% sensitivity; 100% negative predictive value
Occult Bacteremia
Guidelines for managing OB
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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
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Occult Bacteremia
Guidelines for managing OB
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Guidelines for febrile infants 0-3 months
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Baraff et al Ann Emerg Med 1993
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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
Occult Bacteremia
Guidelines for managing OB
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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
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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
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Febrile seizure
Synopsis of the American Academy of
Pediatric practices parameters on the
evaluation and treatment of children with
febrile seizures (Peditrics 1999)
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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
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
Fever and petechiae
Baker et al Pediatrics Dec 1989
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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
Fever
Fever in children with underlying illness
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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
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Fever in children with
underlying illness
Acquired Immunodeficiency Syndrome
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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
Fever in child with
underlying illness
Congenital heart disease
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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
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
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Febrile child
Other conditions to consider in febrile child
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Collagen vascular disease
Malignancy
Drug-induced fever
Toxic ingestion
Heat exhaustion and heatstroke
Kawasaki syndrome
Thyrotoxicosis