1. Febrile Child Dr. Steven Blyth Dr. David Johnson

2. Overview Introduction Occult bacteremia Antibiotic prevention of SBI Febrile seizure Fever and petechiae Fever in children with underlying illness Rare syndromes

3. Introduction Historical perspective Toxic looking child Fever, menigeal signs, lethargic, limb, mottled Admit, septic work-up, parental antibiotics Focal bacterial infection Any child with focal bacterial infection (excluding SBI) such as OM, pharyngitis, sinusitis, etc. Oral antibiotics, outpatient care Well looking child Risk for occult bacteremia and serious bacterial infection Previous decision analysis: pre-H. flu immunization Current decision analysis

4. Occult Bacteremia Incidence of occult bacteremia 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 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%

5. Occult Bacteremia Degree of temperature elevation 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 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

6. Occult Bacteremia WBC 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.

7. Occult Bacteremia Blood cultures 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 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)

8. Occult Bacteremia Assessment of observational scores: Bonadio Pediatric Clinics of NA 1998 Infants younger than 8 weeks Retrospective studies Prospective studies Infants and children older than 8 weeks Prospective studies

9. Occult Bacteremia Guidelines for managing OB Guidelines for febrile infants 0-3 months Baker et al NEJM 1993: Philadelphia protocol Infants under 3 months Philadelphia protocol: low risk vs high risk 100% sensitive; 100% negative predictive value Baker et al Pediatrics 1999: validation Validation of Philadelphia protocol Infants 29-60 days old; low risk vs high risk for SBI 100% sensitivity; 100% negative predictive value

10. Occult Bacteremia Guidelines for managing OB 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

11. Occult Bacteremia Guidelines for managing OB Guidelines for febrile infants 0-3 months Baraff et al Ann Emerg Med 1993 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

12. Occult Bacteremia Guidelines for managing OB 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

13. 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

14. Febrile seizure Synopsis of the American Academy of Pediatric practices parameters on the evaluation and treatment of children with febrile seizures (Peditrics 1999) 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

15. 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

16. Fever and petechiae Baker et al Pediatrics Dec 1989 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

17. Fever Fever in children with underlying illness 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

18. Fever in children with underlying illness Acquired Immunodeficiency Syndrome 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

19. Fever in child with underlying illness Sickle cell anemia Repeated splenic infarction leads to functional asplenia susceptible to overwhelming infection esp. encapsulated organisms such as pneumococci and H. flu Sickle cell patients with fever should have CBC and retic count infection esp Parovirus can cause aplastic crisis Osteomyelitis should be suspected in fever and bone pain CBC, blood culture, stool culture, and urine culture recommended At risk for Salmonella bacteremia; antibiotic choice should include third gen ceph; hospitalization recommended

20. Fever in child with underlying illness Congenital heart disease 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

21. 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

22. Febrile child Other conditions to consider in febrile child Collagen vascular disease Malignancy Drug-induced fever Toxic ingestion Heat exhaustion and heatstroke Kawasaki syndrome Thyrotoxicosis