1. SCVMC Nighttime Curriculum Fever Erin Augustine, MD Alan Schroeder, MD

2. 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

3. 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

4. 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

5. Febrile Infants and Children Fever is Very Common  Emergency Departments  Outpatient Clinics Appropriate Management of Fever  Has Changed Over Last Few Decades  Is Debated  Differs Among Physicians

6. Serious Bacterial Infections (SBI) Bacteremia Meningitis Urinary Tract Infection (UTI) Bacterial Diarrhea Pneumonia Bone & Joint Infections

7. Prior to 1985 Management of febrile infants <2-3 mo  Hospitalization  Sepsis Evaluation (Blood, Urine, CSF Cultures)  IV Antibiotics

8. Disadvantages to Hospitalization Nosocomial Infections Adverse Effects of Antibiotics Emergence of Resistant Bacteria Stresses on Families Cost

9. Rochester, Boston, & Philadelphia Criteria Criteria established to predict infants <3 months at low risk for SBI. A = Rochester B = Boston C = Philadelphia

10. 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.

11. Boston Criteria Prospective consecutive cohort study to determine outcome of outpatient treatment of febrile infants 28- 89 days with Ceftriaxone IM. Low Risk Boston Criteria  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.

12. Philadelphia Criteria Randomized controlled study to evaluate efficacy of managing febrile infants 29-56 days without antibiotics or hospitalization. Low Risk Philadelphia Criteria  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.

14. Baraff Practice Guidelines Infants < 28 Days Infants 28-90 Days Low RiskHigh Risk Hospitalize Blood, Urine, CSF Cultures IV Antibiotics Hospitalize Blood, Urine, CSF Cultures IV Antibiotics Option 1 Blood, Urine, CSF Cultures Ceftriaxone IM Return 24 Hours Option 2 Urine & Blood Culture Return 24 Hours Baraff. Ann Emerg Med. 2000.

15. Baraff Practice Guideline Infants 3-36 Months Toxic Appearing Non-Toxic Appearing Temp <39 C Temp >39 C Hospitalize Blood, Urine, CSF Cultures IV Antibiotics 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.

16. 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.

17. 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

18. 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

19. Urinary Tract Infection

20. 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%

21. 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%

22. UTI Prevalence Meta-Analysis (18 Articles; 22,919 Children) UTI Prevalence in Febrile Children ≤24 Months Shaikh N, et al. Pediatr Infect Dis J. 2008. 7%

23. UTI Prevalence UTI Prevalence in Male Infants <3 months Shaikh N, et al. Pediatr Infect Dis J. 2008. 20% 2.4%

24. UTI Prevalence Prevalence By Age (%) Prevalence Highlights  Decreases with Age  Highest in Females < 1 Year  Highest in Uncircumcised Males < 3 Months Shaikh N, et al. Pediatr Infect Dis J. 2008. AgeOverallFemalesMalesCircumcisedUncircumcised < 3 mo7.27.58.72.420.1 3-6 mo6.65.73.3 6-12 mo5.48.31.7 12-24 mo4.52.10.37.3

25. 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

26. Retrospective study of 354 children <2 years discharged with diagnosis of UTI to characterize patients with bactermia or meningitis. Bacteremia in 9% (33/354)  Limited to age <6 months  Inversely related to age  0-1 Month = 21% 1-2 Months = 13% 2-3 Months = 4% Meningitis in 1% (4/354)  Limited to age <1 month Bachur R, et al. Pediatr Emerg Care. 1995.

27. Bronchiolitis

28. 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

29. 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. Levine DA, et al. Pediatrics. 2004. 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%

30. 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. Bronchiolitis & Serious Bacterial Infection (SBI) Primary Care Offices

31. Conclusion To identify febrile infants and children at risk of serious bacterial infections, clinicians should use a combination of  Clinical Judgement  Published Guidelines  Clinical and Laboratory Indices  Immunization status

32. References 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.

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