1. Morning Report
August 9, 2010

2. 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

3. Definition of Fever
Rectal temperatures are standard for detection of fever in <3mo
Rectal temp > F is considered a fever
If the caregiver reports a measured temp of 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

4. 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

5. 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 % of febrile infants.
The patient already has a fixed obstruction. When the patient becomes agitated it causes a worsening dynamic obstruction.

6. Evaluation 6

7. 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

8. 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 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

9. 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 /1000 live births
Early onset vs. late onset

10. 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

11. 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

12. CSF Analysis Bacterial meningitis Cell count
WBC > 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

13. 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

14. 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

15. 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

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

17. 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

18. Questions??