The Febrile Child:Treat âem or Street âem
David Chaulk
Pediatric EM Fellow
January 2004
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
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 38.9C (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-upb. Discharge on oral amoxicillin with close follow-upc. LP and admission for parenteral antibioticsd. CXR to r/o pneumoniae. Stool for analysis and culture, and outpatient follow-up
Case 2
⢠A 7 week old girl is referred in to ED for evaluation of a rectal temperature of 39.2C. 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:
a. IM ceftriaxone in the EDb. Admission to the hospital for IV antibioticsc. Discharge with follow-up in 24 hoursd. Admission to the hospital for observatione. Discharge on amoxicillin
⢠Any other investigations?
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 39.8C. 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). BCâs are sent.
Appropriate management at this point will be to:
a. Obtain a urine sampleb. Administer IM ceftriaxonec. Perform an LPd. Obtain a CXRe. Discharge on antipyretics
Temperature Measurement
Source Fever Problem
Rectal > 38 Invasive, takes time
Oral 0.5 lower Technique dependent
Axillary 1.0 lower ? Reliability
? variability
Tympanic 0.5 lower Technique dependent
⢠Rectal is gold standard based on study from 1937!⢠Controversial! Tympanic very accurate or very
inaccurate⢠Lanham 1999âŚtympanic misses too many febrile
children⢠Shinozaki, 1998âŚrectal 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)
Temperature Measurement
Age Recommended technique Birth to 2 years
1. Rectal (definitive)2. Axillary (screening)
Over 2 years to 5 years 1. Rectal
2. Tympanic3. Axillary
Older than 5 years1. Oral2. Tympanic3. Axillary
Temperature MeasurementCPS Guidelines
Who cares?
⢠65% of children 0-2 will visit a physician for a febrile illnessâ 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 IllnessâŚbut who?
A few DefinitionsâŚ
⢠Fever without Sourceâ ââŚAn acute febrile illness in which the
etiology of the fever is not apparent after a careful history and physical examination.â
⢠Baraff et al, Pediatrics 1993; 92:1-12
⢠Fever of Unknown Origin1. Fever > 2 to 3 weeks2. Absence of localizing signs3. Failure of simple diagnostic efforts
⢠Occult Bacteremiaâ ââŚa 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 wheezingâ
â Fleisher et al, J Pediatrics 1994
⢠Serious Bacterial Infectionsâ ââŚSBI include meningitis, sepsis, bone and joint
infections, urinary tract infections, pneumonia and enteritisââ Baraff et al, Pediatrics 1993; 92:1-12
A few DefinitionsâŚ
Occult Bacteremia
⢠Strep pneumo. >85%⢠N.meningitidis 3-5%⢠Others
â GASâ Staph aureusâ Salmonella sppâ HiB
⢠Now rare, previously was ~10%
Bacteremia
⢠< 2 mos, T > 38 incidence is 2-3%Avner and Baker, Emerg Med Clin NA 2002;20(1)
⢠3-36 mos, T < 39 incidence is <2%Klein, Ped Inf Dis J 2002;21(6):584-8
⢠2002 data, ie. Post HiB era
Untreated Bacteremia Outcomes
⢠Persitent fever 56%
⢠Persistent bacteremia 21%
⢠Meningitis 9%â S.pneumo 6%â HiB 26% (no longer seen)
Scoring Systems
⢠Demographic and Clinical Parametersâ Age, temperature, clinical appearance
⢠Lab Screens:â CBC, ESR, U/A
⢠Initially very promisingâŚultimately not so âhotâ
Scoring Systems
⢠Can we identify high risk kids?â Yale Observational Scoreâ 611 children, 192 bacteremicâ Median score was the same for both groupsâ A high score was a good marker
⢠Specificity and NPV ~97%⢠Sensitivity and PPV ~5%
â Not great screening tool (screens should be sensitive)
Scoring Systems
⢠Can we identify low risk kids?⢠Three main scoring systems
â Philadelphia, Rochester and Boston Criteriaâ All are similar but there are differences
⢠Main risk factors identifiedâ Age (3 groups. 0-28d, 28-90d, 3-36m)â Temperature T > 40.5 8-25% with OBâ Petechiae â 15-20% SBIâ WBC >15,000, bands>1000 â 5 fold in OBâ Toxic appearance
Lethargy/irritabilty Poor eye contactPoor perfusion Hypo/hyperventilationCyanosis
Philadelphia Rochester Boston
Age 1-2 months 0-2 months 1-3 months
Temperature 38.2C 38.0C 38.0C
History Not specified Term infant
Previously well
No recent vacc /abx
Not dehydrated
Physical examination Well-appearing (IOS < 10)
Well-appearing Well-appearing
Laboratory parameters (defines lower-risk patients)
Wbc < 15,000
BNR < 0.2
UA < 10 WBC/hpf
Urine gram stain âve
CSF <8 WBC
CSF gm stain âve
CXR clear
Stool: no blood, few or
no WBCâs on smear
WBC > 5,000; < 15,000
Abs band ct <1500
UA < 10 WBC/hpf
< 5 WBC/hpf stool smear
* No LP required!
CSF < 10
UA < 10 WBC/hpf
CXR clear
WBC < 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
Statistics
Philadelphia Rochester Boston
SBI (low risk) %
0 1.1 5.4
NPV % 100 98.9 94.6
Sensitivity
%
100 92.4 ?
Are neonates really different?
⢠Philadelphia criteria applied to 3-28 d⢠254 pts, 43% low risk (managed as OP)⢠32 (12.6%) with SBI
â 17 UTIâs, 8 OB, 4 BM
⢠5 low risk infants has SBI⢠Would miss 20:1000 of infants with SBI ⢠Empiric antibiotics standard of care in this
age group
Empiric Antibiotics28-90 d
⢠Lieu, 1992â Decision analysis based on 6 management strategies for
management of fever >38 in 28-90 d infants
⢠Worst Strategyâ Clinical judgement
⢠Most Effectiveâ Full septic work up, IM ceftriaxone and outpatient
management
Empiric Antibiotics3-36 mos
⢠Couple of big studiesâŚneither greatâ Bass, 1993
⢠519 children 3-36 mos, 11.6% with OB⢠Compared clavulin to ceftriaxone in children with T>40 or
T>39.5 and WBC>15⢠No difference between groups
â Fleisher, 1994⢠6733 patients, 2.9% with OB⢠Compared amoxil to ceftriaxone⢠ââŚceftriaxone eradicated bacteremia, had fewer focal
complications and less persitent feverâŚâ
Us Vs. Them
⢠Survey of AAP general pediatriciansâ 610 (67%) respondedâ 40% indicated that parents frequently ask for
abx when MD feels it is not warranted⢠48% stated parents pressure them to prescribe
â 30% stated they comply with that pressureâ Parental pressure viewed as leading cause for
unnecessary abx
Us Vs. Them
⢠Prosâ Decreases disomfort
â Dereases parental anxiety
â Extreme may cause brain damage (exceedingly rare)
â Limited/minimal evidence that it may reduce febrile seizures
⢠Consâ Harm of antipyretics
may outweigh benefits
â Fever is a normal physiologic response
â Fever is usually short lived and benign
â May obscure diagnostic/prognostic signs
Should Fever be Treated?
Us Vs. Them: Pyrexiophobia⢠91% of caregivers believed fever was harmful
â 21% listed brain damage and 14% listed death as effects of fever
⢠25% gave antipyretics for fever < 37.8
⢠85% awakened the child to treat feverâ 14% gave acetaminophen too frequentlyâ 44% gave ibuprofen too frequently
⢠65% of pediatricians believed fever in and of itself could be dangerous to the child
Changes and Controversies
⢠Eradication of HiB
⢠Decreasing Prevalence of Strep pneumo
⢠Increasing resistance of Strep pneumo
⢠Fever in infant with recognizable illness
HiB Vaccine (1987)
⢠Prior to vaccine:â 10-15% of OB and majority of SBIâ 12,000 cases/year(US) invasive HiB in <5yo
⢠1994-95â 300 cases/year (likely lower now)
⢠Invasive HiA/F are still uncommon but may emerge as serious pathogens
Prevnar/Pneumovax
⢠PCV7 (7 serotypes) studied in Northern California⢠Large herd effect noticed
â 34% of < 5 yo children immunizedâ 62% reduction in invasive PC seen
⢠Finnish otitis media studyâ Strep isolates from OM culturesâ Significant reduction in the 7 serotypesâ 33% increase in other serotypes
⢠PCV7 estimated to be 97% effectiveâ Excellent but will still see dz
⢠Will still see PC inâ Other serotypesâ Vaccine failuresâ Unimmunized childrenâ Immunocompromised children
⢠Bottom line:â Shouldnât change our respect for OB/SBI in young
childrenâŚyet
Prevnar/Pneumovax
Pneumococcal ResistanceKaplan, 1998
⢠Three year MC studyâ 1291 systemic pneumococcal infections
⢠Resistance increased annually over the study periodâ Penicillin resistance 21%â Ceftriaxone resistance 9%
⢠Resistance changes region to regionâ Ottawa has ~20% resistant Strep pneumo
Fever and Recognizable Illness
⢠Kupperman, 1997â Risk of bacteremia and UTI in febrile children with and
without bronchiolitis⢠432 children, 0-24 mos
â Children with bronchiolitis had significantly fewer positive cultures
⢠Blood 0% compared to 2.7%
⢠Urine 1.9% compared to 13.6%
⢠0 children < 2 mos with bronchiolitis had bacteremia or UTI
⢠Greene, 1999â 5 year retrospective â Children 3-36 mos with T >39â 1347 children with recognizable viral syndrome
⢠Croup, varicella, bronchiolitis, stomatitis
â Blood cultures in 65%â 2 of 876 (0.2%) were culture positive
Fever and Recognizable Illness
Occult Pneumonia
⢠Bachur, 1999⢠Prospective cohort study
â < 5 yo children with T >39 and WBC > 20k
â CXR in 225/278
⢠CXR postive inâ 40% with suggestive clinical exam
â 26% of those without clinical evidence
⢠Recommends empiric cxr in fever without source
UTIâs in the Febrile Child
⢠Most frequent SBI and may present with fever only
⢠Prevalence 3.3% in febrile infants
⢠Gorelick, 2000â Clinical Decision Rule
T > 39 fever > 2 days
White race age < 1 year
Absence of another potential source
⢠All with UTI had at least one risk factor
⢠Presence of any two factorsâ Sensitivity 95%â Specificity 31%
UTIâs in the Febrile Child
Febrile Seizures
⢠Trainor, 1999⢠Multi-centered analysis of ED management
â 455 childrenâ 1.3% bacteremicâ 5.9% UTIâ 12.5% abnormal CXRâ 135 had LPâŚall normal
⢠In other words, manage like any other kid with fever
SoâŚnow youâre completely lost!
What are the guidelines?
What do you really need to know?
CPS Guidelines (www.cps.ca)
0-28 days⢠No CPS guidelines documented for 0-28 d
⢠American Concensus Guidelines (Baraff, 1993)
â 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
â Admit, + IV antibiotics
CPS Guidelines29-90 days
⢠NOT low risk
⢠CPS â âtoxic or unduly lethargicââ FSWU (BC,UC,LP)â Admitâ Broad spectrum IV antibiotics
⢠Low Riskâ No investigationsâ Careful outpatient follow up, no treatment
⢠American Optionâ FSWUâ Ceftriaxoneâ RTED in 24h for re-assessment
⢠In reality, somewhere in between
CPS Guidelines29-90 days
⢠Toxic Appearanceâ FSWUâ Admitâ IV antibiotics
CPS Guidelines3-36 months
⢠Non Toxic, T < 39.5â Observe only (if follow up assured)
⢠Non Toxic, T >39.5â CBC to decide if BC/UC and empiric therapy are neededâ If WBC < 15k observe if follow up assured
⢠If follow up not assured a more aggressive approach may be indicated.
CPS Guidelines3-36 months
⢠If treating emprically:â Amoxicillin 60 mg/kg/day orâ Ceftriaxone 50 mg/kgâ ââŚ,and neither a substitute for for careful
decision-making or follow-up.â Long, 1994
⢠American guidelines are ceftriaxone
CPS GuidelinesEmpiric Antibiotics
Blood Culture (+) 3-36 mos
⢠Pneumococcusâ Persistent fever
⢠Admit, FSWU, IV abx
â Afebrile/well-looking⢠Repeat culture, no treatment
⢠All other bacteria⢠Admit, FSWU, IV abx
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 38.9C (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-upb. Discharge on oral amoxicillin with close follow-upc. LP and admission for parenteral antibioticsd. CXR to r/o pneumoniae. Stool for analysis and culture, and outpatient follow-up
Case 2
⢠A 7 week old girl is referred in to ED for evaluation of a rectal temperature of 39.2C. 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:
a. IM ceftriaxone in the EDb. Admission to the hospital for IV antibioticsc. Discharge with follow-up in 24 hoursd. Admission to the hospital for observatione. Discharge on amoxicillin
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 39.8C. 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). BCâs are sent.
Appropriate management at this point will be to:
a. Obtain a urine sampleb. Administer IM ceftriaxonec. Perform an LPd. Obtain a CXRe. Discharge on antipyretics
After all thatâŚ.Hereâs what you need to know!
⢠Infants < 28 days:
⢠Infants 1-3 months
⢠Infants and children 3 months to 3 yrs (T < 39C):
⢠Infants and children 3 months to 3 years (T 39C):
hospitalize +/- abx
+/- labs, home, +/- abx
home, no antibiotics
+/- labs, home, no antibiotics