Morning Report August 9, 2010

Fever in Young Infants Neonates and young infants may manifest fever as the only significant sign of underlying infection. The incidence of serious bacterial infection (SBI) is higher in infants < 3mo, especially those children < 28 days. Not everyone has stridor, depends on functional or anatomic susceptibility to upper airway narrowing and variations in immune response

Definition of Fever Rectal temperatures are standard for detection of fever in <3mo Rectal temp > 100.4 F is considered a fever If the caregiver reports a measured temp of 100.4 or greater but the baby is afebrile in the ER…he/she should still receive full evaluation If the caregiver reports a subjective fever, has given NO antipyretics, and the baby is afebrile in the ER…a full workup may not be necessary. Not everyone has stridor, depends on functional or anatomic susceptibility to upper airway narrowing and variations in immune response 3

Differential Diagnosis Viral infection is the most common cause of fever. RSV Influenza Varicella Herpes simplex virus (HSV) Adenoviruses Enteroviruses Metapneumovirus In infants <28 days, the presence of an SBI with a confirmed viral illness still exists…UTI mainly 4

Differential Diagnosis Serious bacterial infections Urinary tract infection (most common) Sepsis/bacteremia Meningitis Pneumonia Bone and joint infection Skin and soft tissue infections Bacterial gastroenteritis The incidence of SBI in neonates (0-28 days) is 5.4-13.1% of febrile infants. The patient already has a fixed obstruction. When the patient becomes agitated it causes a worsening dynamic obstruction.

Evaluation 6

Evaluation (<28 days) CBC c differential CMP Urinalysis and urine culture Blood culture CSF Gram stain and culture Protein and glucose Cell count and differential **HSV PCR** Consider CXR, viral panel, stool studies if indicated The patient already has a fixed obstruction. When the patient becomes agitated it causes a worsening dynamic obstruction. 7

Treatment Infants 29-90 days Neonates Organisms Antibiotic selection GBS, E. coli Listeria, Strep pneumo, Staph aureus, Enterococcus Antibiotic selection Ampicillin & (gentamicin OR cefotaxime) Acyclovir**, Vancomycin** Infants 29-90 days Strep pneumo, H. influenza, N. meningiditis Ceftriaxone or cefotaxime Vancomycin or ampicillin* Nebulized data give mixed results Second dose not routinely done but reserved for persistent symptoms, and in progressive cases

Neonatal Meningitis Bacterial meningitis is more common in the 1st month of life than any other time. Mortality has decreased from 50% to 10% since 1970, but the morbidity remains unchanged. Incidence between 0.25-0.32/1000 live births Early onset vs. late onset

Clinical Features Other Neurologic findings Temperature instability Irritability (up to 60%) Lethargy Poor tone Tremors or twitching Seizures (more common with gram negative and HSV) **fontanelle and neck stiffness not reliable in neonates** Other Temperature instability Poor feeding and vomiting Respiratory distress Apnea Diarrhea

Organisms < 7 days > 7 days Suspect HSV… GBS E. coli and other enteric bacilli Listeria monocytogenes > 7 days Antimicrobial-resistant gram negative organisms must be considered in addition to the above pathogens. Suspect HSV… Vesicular rash Markedly elevated LFTs Neonatal seizures Uncommon 11

CSF Analysis Bacterial meningitis Cell count WBC > 20-30 is consistent with meningeal inflammation *Traumatic tap* Serum RBC:WBC to help predict expected CSF WBC -adjustment can result in significant loss of sensitivity with only marginal gain in specificity Bacterial meningitis Elevated protein (>100mg/dL) Decreased glucose ( <30mg/dL) Gram stain and culture results *the absence of organisms on gram stain does NOT exclude the diagnosis* Uncommon

Treatment Duration Antimicrobials Ampicillin and gentamicin/cefotaxime Vancomycin (if coag-negative staph suspected) Acyclovir* Duration Culture positive 14 days for uncomplicated GBS and other gram + 21 days for complicated GBS, E. coli, and other gram – Culture negative 48-72 hours of negative cultures if unproven meningitis 10 days for those with CSF pleocytosis and bacteremia Uncommon 13

Treatment Supportive care with CR monitoring, oxygen, and IVF should be initiated in the ICU setting. The administration of dexamethasone did NOT significantly affect mortality or neurologic outcome at 2 years of age. Adjunctive steroid therapy for treatment of neonatal meningitis is not currently recommended. Uncommon 14

Monitoring Repeat LP 24-48 hours after initiation of therapy Delayed sterilization is associated with increased risk of neurologic sequelae. The persistence of organisms may indicate inadequate therapy or may indicate the need for diagnositic neuroimaging… Obstuctive ventriculitis Multiple small vessel thrombi Uncommon 15

Complications Cerebral edema Hydrocephalus Hemorrhage Ventriculitis Abscess formation Cerebral infarction Uncommon 16

Prognosis Survivors are at a significant risk of moderate to severe disability (25-50%). Developmental delay. Referral to early intervention programs may be indicated. Hearing loss. BAER should be completed within 4-6 weeks of therapy completion. Learning and/or behavior problems. Decreased visual acuity. 5-20% have future epilepsy. Uncommon 17

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