1. Fever: Nuts and Bolts Nightfloat Curriculum 2010-2011 Lucile Packard Children’s Hospital Residency Program

2. Teaching Goals Assess patient with fever Initiate laboratory evaluation and empiric therapy Determine which patients are at high risk of developing sepsis

3. Definition of fever 38.0 –Neonates (birth-2 months) –BMT patients –Oncology patients (sustained ≥38 x 1 hour) 38.5 –Oncology patients (≥38.5 once) 39.0 –Previously healthy children, nontoxic appearing These are general guidelines, individual patients/services may have different parameters

4. Assessment Vital signs Repeat physical exam –Overall appearance (sick, toxic) –Central/peripheral lines –Incisions/wounds –VP shunt/tracheostomy/gastrostomy tube –Oral mucosa/perineal area for neutropenic patients –Perfusion Call for help if concerning vital signs/exam –Hospitalist –Rapid response team (RRT)/PICU

5. Laboratory evaluation CBC with differential Blood culture Urinalysis and urine culture for at-risk patients –Circumcised males < 6 months –Uncircumcised males < 1 year –Females < 2 years –Oncology/BMT patients –History of UTI/pyelonephritis –Catheterized (except oncology/BMT) or clean-catch

6. Laboratory evaluation (2) Lumbar puncture –Neonates ≤ 2 months –Ill-appearing –Altered mental status –Studies: Gram stain and culture Cell count and differential Protein and glucose Extra tube for additional studies (enteroviral PCR, HSV PCR, CA encephalitis project)

7. Laboratory evaluation (3) Consider CRP, ESR Consider chest x-ray Consider nasopharyngeal DFA For immunosuppressed patients consider: –CMV PCR –EBV PCR –Additional imaging (CT scan)

8. Management Neonates ≤ 2 months –If < 28 days old Ampicillin: meningitis 100 mg/kg/dose q6 hrs non-meningitis 50 mg/kg/dose q6 hrs AND Cefotaxime: meningitis 75 mg/kg/dose q6 hrs non-meningitis 50 mg/kg/dose q6 hrs OR Gentamicin: 2.5 mg/kg/dose q8 hrs Acyclovir: 20 mg/kg/dose q8 hrs –If 29-60 days old Ceftriaxone: meningitis 50 mg/kg/dose q12 hrs non-meningitis 50 mg/kg/dose q24 hrs AND Ampicillin (see above) OR Vancomycin 15 mg/kg/dose

9. Management (2) Oncology patients: febrile neutropenia –Ceftazidime: GNR (including Pseudomonas) –Meropenem: GNR (including Pseudomonas), anaerobes (ill/septic patients) –Amikacin: double-coverage for GNR resistant to gentamicin or tobramycin (ill/septic patients) –Vancomycin: skin, central line, esp AML, relapsed leukemia (Staph/Strep viridans) –Flagyl/clindamycin: mucositis, typhlitis (anaerobes) BMT patients –Ceftazidime –Vancomycin These are general guidelines, individual patients/services may have different regimens

10. High-risk patients 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

11. Case # 1 4-month-old well-appearing girl admitted for croup and respiratory distress. Develops fever to 39.1.

12. Case # 2 12-year old boy with AML, in induction, admitted for febrile neutropenia. Currently on ceftazidime and vancomycin. Develops another fever to 38.5, chills, and new dizziness shortly after receiving antibiotics.