1. Fever in infants without source
Dr. tariq al thobiti

2. The Febrile Infant - Who Has SBI?

3. Background
Fever is the most common presenting chief complaint in pediatric patients presenting to the emergency department (ED).
Accounting for up to 20% of ED visits.
Most cases of fever are viral in origin, benign in course, and resolve spontaneously.
Because of the young infants and specially neonates bacterial infection can be missed easily.
Before the era of vaccination

4. Definition Bacterial gastroenteritis, Bacterial pneumonia, Cellulitis
Fever
Acute fever is fever for <7 days.
The febrile young infant is defined as an infant < 90 days of age with a rectal temperature ≥ 38.0°C.
In infants and children 3 to 36 months old, the threshold is 39°C (102.2°F).
Serious bacterial illness (SBI) is typically defined as the presence of pathogenic bacteria in a previously sterile site and include:
Urinary tract infection (UTI),
Bacteremia,
Meningitis,
Osteomyelitis,
Bacterial gastroenteritis,
Bacterial pneumonia,
Cellulitis
Septic arthritis

5. Incidence/Prevalence:
The incidence of serious bacterial infection (SBI) in febrile young infants (< 90 days of age) is 8% to 12.5%
Huppler AR, Eickhoff JC, Wald ER. Pediatrics. 2010;125(2): (Systematic review)
Higher in neonates (0 through 28 days of age), in whom the SBI rate is nearly 20%.
Schwartz S, Raveh D, Toker O, et al. Arch Dis Child. 2009;94(4): (Retrospective; 449 patients)
Bacterial meningitis is the most common missed diagnosis in pediatric medical malpractice claims.

6. Etiology And Pathophysiology

7. The febrile young infant is susceptible to both perinatally acquired and community-acquired infections including group B streptococcus (GBS), Escherichia coli and other gram-negative infections, Streptococcus pneumoniae, and Staphylococcus aureus
The cause of fever varies depending on the age of the child
The vast majority of pediatric fever is due to infections
the vast majority of infections are attributable to a viral source
Bacterial disease is also an important cause of fever in children
In all children less than 3 months of age, the urinary tract is the most common site of infection, followed by bacteremia and meningitis.

8. Why Fever tends to be of a higher clinical importance in younger children?
Infants <3 months of age, and especially neonates, are relatively immu­ nosuppressed
Incompletely vaccinated.
Lack of effective communication, neonates and young infants may demonstrate few, if any, clinical clues to an underlying illness.
Fever may be the only presenting symptom
ED management varies dramatically depending on the age due to unique spectrum of age specific pathogens.
Neonates and young infants demonstrate decreased macrophage and neutrophil function, and bone marrow exhaustion.
Infants and children demonstrate a poor immu­noglobulin G antibody response to encapsulated bacteria until 24 months of age.
Therefore, the age of the patient and the virulence of the bacteria are considerations for the evaluation of fever in children and the identification of SBI.
Management of children presenting to the ED varies dramatically depending on the age of the child with the following common, albeit arbitrary, divisions (0–28 days, 1–2 months, 2–3 months, 3–6 months, 6–36 months, 3 years to adulthood).
These divisions reflect differing immunologic and vaccination milestones as well as the spectrum of age specific pathogens.

10. Differential Diagnosis
Infectious causes:
Infection is most common cause of fever without source in infants
Noninfectious causes
Noninfectious causes less common in fever without source in infants and young children
Recent immunizations
Malignancy
Medications associated with fever
Immunological
Kawasaki disease
Immunodeficiency

11. Protocols & Guidelines

12. Do we really need them?
Studies have been conducted in an effort to identify patients who are low risk for bacterial infections and can be managed safely as outpatients with or without empiric antibiotic treatment.
These studies established that certain infants can be managed safely as outpatients and can avoid unnecessary hospitalization.
Huppier AR, Eickhoff JC, Wald ER, Pediatrics 2010;125:228.
The incidence of SBI among infants categorized as low-risk after appropriate evaluation ranged from 0.5%-1.1% in studies that utilized or excluded the lumbar puncture as part of the initial evaluation, respectively.
Baraff L, Ann Emerg Med 2000;36:
The Boston, Rochester, and Philadelphia criteria were established from some of the largest and most applicable studies.
Criteria have been developed to identify febrile young infants at low risk for SBI, and these criteria are utilized to avoid hospitalization in certain low-risk patients

14. Diagnostic Performance for Identifying Serious Bacterial Infection in Validation Studies:

15. Boston criteria not validated and in study most commonly cited for its derivation authors concluded "Clinical screening criteria did not enable discrimination between infants with and those without serious bacterial infections" and all febrile infants were empirically treated with ceftriaxone intramuscularly (J Pediatr 1992 Jan;120(1):22)

16. Which one to choose?

17. Limitations
These studies varied in their patient population, inclusion/exclusion criteria, and uniformity in workup and management.
This had led to a lack of consensus and debate concerning the best approach to care for the febrile infant.
Despite the established guidelines, variability in application exists among many practitioners.
Goldman RD, Scolnik D, Chauvin-Kimoff L. Pediatrics 2009;124:
Bergman DA. Pediatrics 2006;117:
Pantell RH.. JAMA 2004;291:

18. Limitations
Infants <28 days have found an increased number of missed SBI in this age group and higher prevalence of SBI when compared to their older counterparts.
The patient population in the Boston and Philadelphia studies excluded infants under 1 month of age.
A retrospective study that applied these low-risk criteria to febrile infants 1-18 days of age revealed a negative predictive value of 97% for both protocols.
The Philadelphia and Rochester protocols also were reevaluated a prospective study that enrolled infants 56 days or younger. The authors here found the negative predictive value for the Philadelphia and Rochester criteria to be 97.1% and 97.3%, respectively, compared to the original report of 99.7% and 98.9%, respectively.
Garra G, Cunningham SJ, Crain EF. Acad Emerg Med 2005;12:
Studies that have evaluated the applicability of the various screening strategies to infants younger than 28 days have found an increased number of missed SBI in this age group and higher prevalence of SBI when compared to their older counter-parts ,33,34 The patient popula-tion in the Boston and Philadelphia studies excluded infants under 1 month of age. A retrospective study that applied these low-risk criteria to febrile infants 1-18 days of age revealed a negative predictive value of 97% for both protocols. 37 The authors concluded that these proto-cols, when applied to infants 28 days or younger, will miss 3% of febrile infants with SBI. The Philadelphia and Rochester protocols also were re-evaluated recently in a prospective study that enrolled infants 56 days or younger. The authors here found the negative predictive value for the Philadelphia and Rochester criteria to be 97.1% and 97.3%, respectively, compared to the original report of 99.7% and 98.9%, respectively. 38 Adequate compensation for this small percentage of missed SBI is addressed through the admission of all infants less than 1 month of age and the establishment of timely follow-up.
The recognition of occult SBI in well-appearing neonates and infants <3 months of age is difficult.
No single clinical variable or diagnostic test can correctly, or reliably, identify SBI in this age group.

20. National Institute for Health and Clinical Excellence (NICE) guidelines on clinical assessment of feverish illness in children < 5 years old
high risk for serious illness associated with
pale/mottled/blue/ashen color, nonblanching rash
no response to social cues, does not wake, or if roused, does not stay awake
weak, high-pitched, or continuous cry
grunting, tachypnea, moderate or severe chest indrawing
reduced skin turgor
temperature ≥ 39 degrees C (102.2 degrees F) in infants aged 3-6 months
bulging fontanelle, neck stiffness, status epilepticus, focal neurologic signs or focal seizures
bile-stained vomiting
appearing ill to pediatrician
NICE 2007 May:CG47, summary can be found in BMJ 2007 Jun 2;334(7604):116

21. National Institute for Health and Clinical Excellence (NICE) guidelines on clinical assessment of feverish illness in children < 5 years old
at least intermediate risk for serious illness associated with
pallor reported by caregiver
not responding normally to social cues/no smile, wakes only with prolonged stimulation, decreased activity, poor feeding
nasal flaring, tachypnea, crackles, oxygen saturation ≤ 95% on room air
dry mucous membranes, reduced urine output
capillary refill time ≥ 3 seconds
fever duration ≥ 5 days
limb or joint swelling, decreased use of an extremity, new lump > 2 cm
NICE 2007 May:CG47, summary can be found in BMJ 2007 Jun 2;334(7604):116

22. National Institute for Health and Clinical Excellence (NICE) guidelines on clinical assessment of feverish illness in children < 5 years old
low risk for serious illness associated with absence of high or intermediate risk factors and all of
normal skin, lip, and tongue color
normal response to social cues, content/smiles, stays awake or awakens quickly, strong cry or not crying
normal skin and eyes, moist mucous membranes
NICE 2007 May:CG47, summary can be found in BMJ 2007 Jun 2;334(7604):116

23. ACEP guidelines for children < 3 years old presenting to ED with fever
Infants aged 1-28 days with fever should be presumed to have serious bacterial infection (SBI) (A recommendation)
Response to antipyretic medication does not change likelihood of SBI and should not be used for clinical decision-making (A recommendation)
Role of blood tests (including cultures) not described in ACEP guidelines
Regarding urinary tract infection (UTI)
children < 1 year old with fever without source should be considered at risk for UTI (A recommendation)
urethral catheterization or suprapubic aspiration are best methods for diagnosing UTI (B recommendation)
obtain urine culture in conjunction with other urine studies when UTI suspected in child < 2 years old because negative urine dipstick or urinalysis may not exclude UTI (B recommendation)
Obtain chest radiograph in febrile children < 3 months old with evidence of acute respiratory illness (B recommendation)
Ann Emerg Med 2003 Oct;42(4):530

24. Conlcusion
Due to increased risk of SBI in young infants specially neonates <28days
Protocols & guidelines established a systematic approach for young infants:
<28 days
1-3 months
3-36 months

25. History and Physical for young infants <90 days

26. History & Physical
Used to identify possible causes and assess risk for serious illness
If the physical examination does not identify a source of infection causing fever, decision making is based first upon age and then by height of fever.
There are no abso­lute rules in the evaluation and management of fever

27. History
Ask how temperature was taken (accuracy of temperature reading depends on measurement method)
Bundling may increase skin but not rectal temperature.

28. Medication history
Ask about recent or regular medication use or possible accidental ingestion, including
antipyretics
acetaminophen
ibuprofen
aspirin
antibiotics which may
affect evaluation by partially treating infection or confounding culture results
be associated with fever due to drug hypersensitivity
If infant is breastfeeding, ask about mother's medications
may partially treat infection
may confound cultures
may be associated with fever or drug reactions

29. Past medical history (PMH):
ask about prior febrile illnesses
immunization status
as potential cause of fever
to determine susceptibility to pathogens
chronic illness
seizures
prematurity
presence of indwelling medical devices
periodic fever syndromes and autoinflammatory syndromes associated with recurrent fevers in children

30. Social history (SH): ask about
exposure to illness in family members, caretakers, friends, or others
daycare
travel history, including
list of exposures and risk factors
information about pre-travel immunizations or chemoprophylaxis during travel
description of accommodations
Reference - Am Fam Physician 2003 Oct 1;68(7):1343

31. Review of systems (ROS): to identify possible etiology for fever consider asking about
lethargy
irritability
apnea
shaking
sweating
decreased appetite or feeding difficulties
congestion
cough
eye redness or discharge
batting at ear
trouble swallowing
tachypnea
dyspnea
wheezing
vomiting
diarrhea
rash
cyanosis
jaundice
seizures
joint swelling

32. Physical

33. General appearance Pediatric Assessment Triangle
The pediatric assessment triangle (PAT) offers a sensible, orderly approach that can be used to assess children of all ages, identify abnormal cardiopulmonary physiology, and define the urgency and need for lifesaving interventions. Before touching the patient, one should observe the child from a distance for visual and auditory clues.

34. Temperature measurement
accuracy of temperature reading depends on type of thermometer and measurement site
National Institute for Health and Clinical Excellence (NICE) recommendations on feverish illness in children < 5 years old suggest
not using oral or rectal routes to measure temperature
in infants < 4 weeks old use electronic thermometer in axilla
in children aged 4 weeks to 5 years, use electronic thermometer or chemical dot thermometer in axilla or infrared tympanic thermometer
American College of Emergency Physicians (ACEP) clinical policy for children < 3 years old presenting to emergency department with fever considers rectal temperature > 38 degrees C (100.4 degrees F) the reference standard for defining fever

35. Temperature measurement
infrared ear thermometer
infrared ear thermometer does not appear to accurately predict rectal temperature
tympanic thermometer appears to have low sensitivity for fever (rectally defined) in infants and preschool children
tympanic temperature reported to accurately reflect pulmonary artery temperature so may be more accurate than rectal temperature
home-use tympanic thermometers may be less accurate than clinical-use tympanic thermometers
axillary temperatures may not accurately reflect rectal temperatures in children
temporal artery thermometer appears more sensitive than tympanic thermometer but sensitivity for detecting rectally defined fever varies widely across 3 studies
infrared skin thermometer applied to central forehead appears to agree with rectal thermometer readings in newborn infants
pacifier thermometer may suggest fever in infants < 3 months old if high temperature but poor sensitivity limits utility

36. Temperature measurement Conclusion
GO for Rectal

37. Skin look for evaluate skin turgor (hydration status) specific rash
blistering or ulcerating lesions
petechiae
cyanosis or pallor
capillary refill time ≥ 3 seconds
evaluate skin turgor (hydration status)

38. HEENT look forbulging or sunken fontanelle red tympanic membrane
nasal flaring
nasal discharge
red throat or gums
ulcerations
dry mucous membranes

39. Neck:
evaluate for nuchal rigidity
Cardiac:
listen for cardiac murmur
Lungs:
evaluate inspiration and expiration
listen for wheezing, rales
Abdomen:
evaluate for tenderness, distention, mass

40. Height of fever.. Response to antipyretic..
fever > 40 degrees C (104 degrees F) may be associated with increased risk of serious bacterial infection in infants < 3 months old.
Pediatr Emerg Care 2005 May;21(5):291
response to antipyretic medication is not prognostic
response to antipyretic medication does not change likelihood of child having serious bacterial infection and should not be used for clinical decision-making (A recommendation) ACEP guidelines
decrease or lack of decrease in temperature 1-2 hours after antipyretic administration should not be used to differentiate between serious and nonserious illness. NICE guidelines

41. Workup For Alternative Sources Of Infection
Controversy exists as to the extent of testing that should be performed in febrile young infants with alternative sources of fever, such as viruses.
does the febrile infant aged < 90 days with bronchiolitis require the full sepsis workup, or can the fever be attributed to a viral source?
concomitant bacterial and viral infections can occur, but viral infection may suggest lower risk of bacterial infection in febrile infants

42. documented viral infection associated with lower risk of SBI in high-risk febrile infants ≤ 90 days old
based on prospective cohort study
1,385 infants ≤ 90 days old with temperature ≥ 38 degrees C (100.4 degrees F) had viral testing, bacterial cultures, and risk assessment by Rochester criteria
456 infants (33%) classified as low-risk, 922 (67%) classified as high-risk
comparing infants with vs. without viral infection
SBI in 4.2% vs. 12.3% (p = )
bacteremia in 1% vs. 2.7% (p = 0.038)
in high-risk infants SBI in 5.5% vs. 16.7% (p < )
no significant differences in SBI occurrence in low-risk infants
Pediatrics 2004 Jun;113(6):1662

43. bacterial infection found in 7% of febrile infants < 90 days old with enterovirus infection
based on prospective cohort study
1,061 infants aged 1-90 days with temperature ≥ 38 degrees C ( degrees F) had full sepsis evaluation and testing for enterovirus by polymerase chain reaction and/or viral culture
enterovirus infection found in 20%
among infants with enterovirus infection, 7% had concomitant SBI
urinary tract infection in 12 infants (5.6%)
bacteremia in 3 infants (1%), all in infants < 28 days old
no infants had bacterial meningitis
Reference - Pediatr Infect Dis J 2005 Jun;24(6):546

44. risk of SBI appears to be decreased in febrile infants ≤ 60 days old with influenza infection
based on cross-sectional study
844 infants ≤ 60 days old with fever in emergency department had rapid antigen testing of nasopharyngeal wash or aspirate for influenza were evaluated
positive influenza test in 123 infants (14%)
among 809 infants with determination of SBI status, SBI identified in 95 (11.7%)
comparing infants with positive vs. negative influenza test
SBI in 2.5% vs. 13.3% (p < 0.001)
urinary tract infection in 2.4% vs. 10.8% (p = 0.002)
no significant differences for bacteremia, meningitis, or enteritis
all SBIs in influenza-positive patients were urinary tract infections
Reference - Pediatrics 2009 Jul;124(1):30

45. bacteremia found in 1.1% febrile infants < 60 days old with RSV infection
based on prospective cohort study
none had bacterial meningitis
1,248 infants < 60 days old with fever ≥ 38 degrees C (100.4 degrees F) presented to 8 pediatric emergency departments during RSV season over 3 years
comparing infants with RSV infection vs. infants without RSV infection
serious bacterial infection (bacterial growth from any source) in 6.3% vs. 11.8% (based on entire cohort)
blood culture and cerebrospinal fluid analysis were done on all infants
urinary tract infection in 5.4% vs. 10.1% (p < 0.05) based on 1,227 infants tested
269 (22%) had RSV infections
1.1% had bacteremia - pathogens included Escherichia coli (8 cases), group B streptococci (7 cases), Klebsiella pneumoniae, Streptococcus pneumoniae, Salmonella, Enterobacter, Enterococcus, Staphylococcus aureus, and Bacteroides
bacteremia in 1.1% vs. 2.3% (not significant) based on 1,235 infants tested
bacterial meningitis in 0% vs. 0.9% (not significant) based on 1,189 infants tested
Reference - Pediatrics 2004 Jun;113(6):1728

46. serious bacterial infections may be rare in infants with clinical bronchiolitis
based on retrospective cohort study
329 febrile infants < 90 days old with clinical bronchiolitis and no other localizing findings
94% had blood cultures, 61% had cerebrospinal fluid cultures
no cases of bacteremia or meningitis were identified
Reference - Pediatr Infect Dis J 2003 Dec;22(12):1053

47. RSV+
Levine et al prospectively enrolled 1248 febrile infants aged ≤ 60 days
269 of whom were positive for RSV.
RSV-negative patients had an SBI rate of 12.5%
RSV-positive patients had an SBI rate of 7.0%.
This lower rate of SBI in febrile young infants with RSV was significant but still accounted for a substantial number of SBIs, especially UTI.
When stratified by age, neonates aged ≤ 28 days with RSV infection had a 10.1% rate of SBI, including 3 patients with bacteremia (though no meningitis), and the SBI rate was not significantly different from RSV-negative neonates.
In the 29- to 60-day age group, RSV-positive patients had a significantly lower rate of SBI than RSV-negative patients (5.5% vs 11.7%), and all infections were UTI

48. Acute otitis media - AOM
an increasing incidence in young children and earlier onset of acute otitis media (AOM).
One likely explanation is the high rate of daycare attendance
Baskin MN. Pediatr Ann 1993;22:462.
the presence of otitis does not correlate or increase the risk of an associated serious bacterial infection.
Nozicka CA, Hanly JG, Beste DJ, et al. Otitis media in infants aged 0-8 weeks. Pediatr Emerg Care 1999;15:
In the evaluation of 137 infants < 2 months of age with AOM, Turner et al reported no SBI in 37 children who were low risk outside of having AOM.
Turner D, Leibovitz E, Aran A, et al. Pediatr Infect Dis J 2002;21:

49. Workup For Alternative Sources Of Infection… Conclusion
Given the high incidence of SBI in patients aged ≤ 28 days, the full sepsis workup should be performed in neonates with bronchiolitis or viral upper respiratory infection
There is no standard of care in febrile infants aged 29 to 60 days with bronchiolitis. Given the high incidence of UTI, a urinalysis and urine culture should be performed, and strong consideration should be given to performance of a CBC and blood culture.
it may be reasonable to treat an infant > 1 month of age with AOM, who is otherwise low risk, the same as a low-risk child without AOM.

50. Birth-28 days old

51. History and physical are not reliable to rule-out serious bacterial infection (SBI)
12-28% of febrile neonates have SBI, and a high rate of missed SBIs exist.
(Ishimine, EM Clinics of N Amer, 2007)
SBI includes
UTIs (20%)
bacteremia (3%)
meningitis (1%)
Think about other causes for SBI’s
Pathogens: E. coli, GBS, HSV >> Listeria, Salmonella, Staph aureus

52. Management Investigation CBC with differential Blood cultures
Catheterized urinalysis and urine culture (or via suprapubic tap)
CSF studies (cell count, glucose, protein, gram stain, culture, extra tube to hold for potential other studies)
Consider: Stool culture (if diarrhea)
Consider: CXR and rapid viral testing (if respiratory sx or increased work of breathing, although viral testing should not change sepsis workup)

54. Young infants 1-3 months

55. SBI includes UTIs (up to 15%), bacteremia (1%), meningitis (0.2-0.4%)
History and physical are not reliable to rule-out serious bacterial infection (SBI)
SBI includes UTIs (up to 15%), bacteremia (1%), meningitis ( %)
Think about other causes for SBI’s
Pathogens: E. coli, GBS, S. pneumo >> N meningitides, H flu (type B), Staph aureus
Management
Criteria for low-risk for serious bacterial infection:
Boston, Philadelphia, and Rochester criteria are 3 commonly used approaches for identifying febrile infants < 3 months old at low-risk for serious bacterial infection.
NICE Guidelines
ACEP Guidelines

58. Empiric parenteral antibiotics (if indicated) may include regimens:
in neonates < 1 week old - cefotaxime 50 mg/kg ( mg/kg if suspected meningitis) IV every 12 hours plus ampicillin mg/kg IV every 8 hours
in neonates 1-4 weeks old - cefotaxime 50 mg/kg ( mg/kg if suspected meningitis) IV every 8 hours plus ampicillin mg/kg IV every 6 hours
in infants aged 1-3 months - ceftriaxone mg/kg IV once daily (some experts recommended adding ampicillin)
antibiotic selection may vary with suspected infection, early culture results, and local resistance patterns
oral antibiotics not recommended
consider acyclovir in neonates at risk for herpes simplex virus infection

59. Laboratory & Diagnostic Studies

60. Which one better? Can we really exclude SBI?
Blood culture
Complete blood count with differential (CBCD)
IT Ratio (immature-to-total neutrophil)
UA & Urine culture
LP – CSF analysis
CXR
Stool
CRP
ESR
Procalcitonin

61. Blood Culture
indicated for all infants ≤ 3 months old with fever ≥ 38 degrees C ( degrees F)
Ishimine P. Emerg Med Clin North Am Nov;25(4):

62. Complete blood count with differential (CBCD)
Recommended by National Institute for Clinical Health and Excellence (NICE) for all infants < 3 months old with fever
Alternative approach
measure in all infants < 2 months old with fever ≥ 38 degrees C (100.4 degrees F), but WBC not adequate to identify infants with vs. without serious bacterial infection
optional in low-risk infants aged 2-3 months with fever ≥ 38 degrees C ( degrees F)

63. WBC counts may NOT predict bacteremia in febrile infants < 90 days old
based on retrospective cohort study
3,810 infants < 90 days old with fever ≥ 38 degrees C (100.4 degrees F) seen in emergency department were assessed
bacteremia in 38 children (1%)
no significant differences in WBC counts in infants with vs. without bacteremia
Reference - Ann Emerg Med 2003 Aug;42(2):216

64. band count may not be helpful in differentiating bacterial vs
band count may not be helpful in differentiating bacterial vs. viral infections in febrile children
Based on subgroup analysis of prospective cohort study
100 children ≤ 2 years old who presented to pediatric emergency department with fever and diagnosed with laboratory-documented bacterial or respiratory viral infections were assessed
fever defined as temperature ≥ 38 degrees C (100.4 degrees F) in infants < 3 months old
comparing bacterial infection vs. viral infection
bacterial infection associated with higher mean
WBC count (p < 0.01)
absolute neutrophil count (p < 0.01)
age (p = 0.04)
temperature (p < 0.01)
no significant differences in mean
absolute band count
percentage band count
band/neutrophil ratio
Reference - Arch Pediatr Adolesc Med 1999 Mar;153(3):261 full-text

65. Inflammatory markers:
procalcitonin (PCT)
C-reactive protein (CRP)
ESR

67. Urine studies: urinalysis and urine culture
indicated for all febrile infants ≤ 3 months old
collect urine by catheterization or suprapubic aspiration to avoid specimen contamination
rapid urine testing may include dipstick, microscopy, or Gram stain

68. Chest x-ray: Indicated for fever associated with respiratory symptoms
Chest x-ray may show pneumonia in 26% of febrile children < 5 years old with white blood cell count (WBC) ≥ 20,000/mm3

69. Other models for assessing risk of SBI

70. Intermountain Clinical Programs
Moving Evidence into Practice
Reducing variation in compliance with evidence-based guidelines
Care Process Models (CPMs) are narrative documents that aim at representing state-of-the-art medical knowledge.  
Clinical Decision Support Tools can include all ways in which health care knowledge is represented in health information systems.

71. Advantages of computerized EB-CPM
Provide readily accessible references and allow access to knowledge in guidelines that have been selected for use in a specific clinical context
Often improve the clarity of a guideline
Can be tailored to a patient’s clinical state
Propose timely decision support that is specific for the patient

72. Key Quality Measures Included in the EB-CPM (The Intervention)
Six Sigma process
Core Laboratory Testing (CBC and UA)
Admit Patients High Risk for SBI
Viral Testing (EV and Respiratory Viruses)
Appropriate Antibiotics
Stop Antibiotics within 36 hours for Infants with Negative Bacterial Cultures
LOS 42 hours or less

73. EB-CPM
Included history and physical examination recommendation to obtain complete blood count and urinalysis for all infants, and assessment of risk for SBI.
Risk classification and care model appears to reduce antibiotic use and shorten length of stay without increasing risk of discharge with missed SBI
Pediatrics 2012 Jul;130(1):e16

81. Child 3-36 months

82. Fever that should prompt workup in this age group: T ≥39.0C / 102.2F
Fever in children 3 to 36 months of age is incredibly common and most cases represent self-limited viral illnesses.
Common viral causes of fever in this age group include:
viral upper respiratory infections, croup, bronchiolitis, stomatitis (typically caused by HSV or coxsackievirus), gastroenteritis, roseola, and Fifth’s disease (parvovirus B19 infection).
Common bacterial infections include:
Focal infections such as pyelonephritis, periorbital cellulitis, bacterial pharyngitis (group A Streptococcus), septic arthritis, retropharyngeal abscess, meningitis, as well as bacterial pneumonia.

83. Typically, these focal infections are apparent based on history and physical examination, and diagnostic testing and treatment should be directed accordingly.
The history in this age group should focus on the duration of illness, associated symptoms that may focus the evaluation, immunization history
classic meningeal signs such as nuchal rigidity are seen in less than 27% of infants (0–6 months) with bacterial meningitis.

84. Ishimine P. The Evolving Approach to the Young Child Who Has Fever and No Obvious Source. Emerg Med Clin N Am 25 (2007)

86. Thank You