Pediatric fever of uncertain source: Difference between revisions
ClaireLewis (talk | contribs) No edit summary |
|||
(46 intermediate revisions by 9 users not shown) | |||
Line 2: | Line 2: | ||
*Medicine is an art as well as science, practice clinical judgment when using guidelines | *Medicine is an art as well as science, practice clinical judgment when using guidelines | ||
*Preemies: Count age by estimated postconception date (not by actual delivery date) for 1st-90d | *Preemies: Count age by estimated postconception date (not by actual delivery date) for 1st-90d | ||
*Fever accounts for 30% of pediatric visits | |||
*Children <3 mo are immunocompromised- poor opsonization, poor IgG response to encapsulated bacteria, macrophage and neutrophil dysfunction, bone marrow insufficiency | |||
*Serious bacterial illness (SBI) includes UTI, meningitis, pneumonia, bacteremia | |||
{| class="wikitable" | {| class="wikitable" | ||
Line 15: | Line 18: | ||
|} | |} | ||
===Facts and Figures | ===Facts and Figures=== | ||
*7% of patients < 2 years old with fever have | ''From ACEP's Clinical Policy on Pediatric Fevers<ref>Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545</ref> | ||
*7% of patients < 2 years old with fever have pneumonia, however the etiology (viral/bacterial) or even the presence of pneumonia has low inter-observer reliability even among pediatric radiologists | |||
*4% Prevalence of UTI with common other sources of fever (OM, viral URI, et cetera) | *4% Prevalence of UTI with common other sources of fever (OM, viral URI, et cetera) | ||
*1.5-2% background prevalence of asymptomatic bacteruria in healthy afebrile controls | *1.5-2% background prevalence of asymptomatic bacteruria in healthy afebrile controls | ||
Line 22: | Line 26: | ||
*0.3% of previously well children aged 3-36 months who have a fever without a source will develop significant sequelae, 0.03% will develop sepsis or meningitis | *0.3% of previously well children aged 3-36 months who have a fever without a source will develop significant sequelae, 0.03% will develop sepsis or meningitis | ||
=== Concomitant RSV or | ===Concomitant [[RSV]] or [[Influenza]] Infection=== | ||
*In RSV+ (by PCR) neonates aged 0-28 days, 6.1% had UTIs and 3.7% were bactremic; there was no difference in rates of SBI between RSV+ and RSV- neonates in a large prospective multicenter study entailing 1,248 children | *Relatively high coincidence of bronchiolitis w/ UTI, and of enterovirus and paraflu w/ UTI and bacteremia | ||
*In RSV+ (by PCR) neonates aged 0-28 days, 6.1% had UTIs and 3.7% were bactremic; there was no difference in rates of SBI between RSV+ and RSV- neonates in a large prospective multicenter study entailing 1,248 children<ref>Greenes, D.S.M., & Harper, M. B.M. (1999). Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatric Infectious Disease Journal, 18(3), 258-261.</ref> | |||
*RSV+ infants aged 29-60 days, the SBI rate was 5.5%, all of which were UTIs | *RSV+ infants aged 29-60 days, the SBI rate was 5.5%, all of which were UTIs | ||
*Influenza+, low risk of bacterial illness | *Influenza+, low risk of bacterial illness | ||
==Diagnosis & Management== | ===Evolving Practices for Febrile Infants 0-60 days (2019 JAMA Peds)<ref>Kuppermann N, Dayan PS, Levine DA, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatrics. 2019;173(4):342-351. doi:10.1001/jamapediatrics.2018.5501</ref>=== | ||
=== 0-28dy | *Prospective multicenter observational study with 1821 patients split into derivation and validation groups. | ||
*Inclusion fever >38C in ED or in past 24 hours measured. | |||
*Exclusion premature < 36 weeks, previously known diagnosis/illness, or severe illness. | |||
*Incidence of SBI in cohort 9.3% (8.3% UTI) | |||
*Following elements had 97.7% sensitivity and 60% specificity for SBI | |||
**'''ANC of 4090 or less''' | |||
**'''Procalcitonin 1.71 or less''' | |||
**'''Negative urinalysis''' | |||
*No cases of bacterial meningitis missed. 3 missed SBI, all of which were > 28 days. | |||
*May lead to decreased unnecessary LPs, will have variable adoption pending further validated studies/applications. | |||
==Differential Diagnosis== | |||
{{Pediatric fever DDX}} | |||
==Evaluation & Management== | |||
[[File:Pediatric Fever2.png|thumb|Algorithm for the evaluation of pediatric fever]] | |||
===0-28dy=== | |||
*SBI in ill-appearing febrile neonate as high as 20% | |||
*SBI in well-appearing febrile neonate as high as 5% | |||
{| class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
Line 37: | Line 61: | ||
| '''Comments''' | | '''Comments''' | ||
|- | |- | ||
| ''' | | '''Temperature ≥38°''' | ||
'''Toxic or Well''' | '''Toxic or Well''' | ||
| | | | ||
*CBC | *CBC | ||
*Blood | *Blood cultures | ||
* | *[[Urinalysis]], Urine culture | ||
*LP-CSF | *LP-CSF | ||
*CXR | *[[CXR]] | ||
*+/- Stool studies (if diarrhea) | *+/- Stool studies (if diarrhea) | ||
| | | | ||
Line 56: | Line 80: | ||
{{Pediatric fever acyclovir indications}} | {{Pediatric fever acyclovir indications}} | ||
=== 28dy-90dy | Note: | ||
*CXR is optional if no resp sx and another source identified | |||
*LP is necessary even if another source identified due to immature blood-brain barrier | |||
*Do not give ceftriaxone to children <28d as may cause hyperbilirubinemia | |||
===28dy-90dy<ref> Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Powell, K. R., et al. (1994). Febrile infants at low risk for serious bacterial infection-an appraisal of the Rochester criteria and implications for management. Pediatrics 94(3), 390-396.</ref>=== | |||
{| class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
Line 67: | Line 96: | ||
| | | | ||
*CBC | *CBC | ||
*Blood | *Blood cultures | ||
* | *[[Urinalysis]], Urine culture | ||
*[[LP]]-CSF | *[[LP]]-CSF | ||
*+/- CXR | *+/- CXR | ||
Line 81: | Line 110: | ||
| | | | ||
*CBC | *CBC | ||
*Blood | *Blood cultures | ||
* | *[[Urinalysis]], urine culture | ||
*+/- [[LP]]-CSF (must do before giving antibiotics) | *+/- [[LP]]-CSF (must do before giving antibiotics) | ||
*+/- CXR | *+/- CXR | ||
| | | | ||
*+/-[[Ceftriaxone]] (50- | *+/-[[Ceftriaxone]] (50-100mg/kg IM/IV) | ||
| Workup(+): Antibiotics and admit | | Workup(+): Antibiotics and admit | ||
Workup(-): ?antibiotics; home with 24 follow-up | Workup(-): ?antibiotics; home with 24 follow-up | ||
|- | |- | ||
|} | |} | ||
^^Can use [[ceftriaxone]] 50- | ^^Can use [[ceftriaxone]] 50-100mg/kg, but concern for bilirubin displacement | ||
{{Pediatric fever CXR indications}} | {{Pediatric fever CXR indications}} | ||
Line 97: | Line 126: | ||
{{Pediatric fever acyclovir indications}} | {{Pediatric fever acyclovir indications}} | ||
=== 90dy-36mo | ===90dy-36mo<ref>Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Powell, K. R., et al. (1994). Febrile infants at low risk for serious bacterial infection-an appraisal of the Rochester criteria and implications for management. Pediatrics 94(3), 390-396.</ref>=== | ||
{| class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
Line 108: | Line 137: | ||
| | | | ||
*CBC | *CBC | ||
*Blood | *Blood cultures | ||
* | *[[Urinalysis]], urine culture | ||
*[[LP]]-CSF | *[[LP]]-CSF | ||
*CXR^ | *[[CXR]]^ | ||
| | | | ||
{{Pediatric fever antibiotics 90dy-36mo}} | {{Pediatric fever antibiotics 90dy-36mo}} | ||
Line 117: | Line 146: | ||
|- | |- | ||
| '''T≥39°C + Well + Non-complete [[Prevnar]]''' | | '''T≥39°C + Well + Non-complete [[Prevnar]]''' | ||
(No [[Prevnar]] or <4 | (No [[Prevnar]] or <4 weeks post 1st [[Prevnar]] dose) | ||
| | | | ||
* | *[[Urinalysis]], Urine culture | ||
*CBC | *CBC | ||
*+/- CXR | *+/- CXR | ||
| If WBC(+): | | If WBC(+): | ||
*[[Ceftriaxone]] 50mg- | *[[Ceftriaxone]] 50mg-100mg/kg (also then consider [[blood culture]] and [[LP]], especially in <6mo old) | ||
| Outpatient (24 hour follow-up) | | Outpatient (24 hour follow-up) | ||
|- | |- | ||
| '''T≥39°C + Well + [[Prevnar]]''' | | '''T≥39°C + Well + [[Prevnar]]''' | ||
(2 [[Prevnar]] or ≥4 | (2 [[Prevnar]] or ≥4 weeks post 1st [[Prevnar]] dose) | ||
| | | | ||
*Urine workup (UA, | *Urine workup (UA, urine culture) for: | ||
**Circumcised males <6 months | **Circumcised males <6 months | ||
**Uncircumcised males <12 months | **Uncircumcised males <12 months | ||
**All females | **All females | ||
*+/- CXR | *+/- CXR | ||
| Treat [[cystitis]] or [[ | | Treat [[cystitis]] or [[pneumonia]] if postitive | ||
| Outpatient (48hour | | Outpatient (48hour follow up) | ||
|- | |- | ||
| '''T≥38-38.9°C + Well''' | | '''T≥38-38.9°C + Well''' | ||
| Consider UA, CXR based on symptoms, etc | | Consider UA, CXR based on symptoms, etc | ||
| Treat [[cystitis]] or [[ | | Treat [[cystitis]] or [[pneumonia]] if positive | ||
| Outpatient (48-72 hour follow-up) | | Outpatient (48-72 hour follow-up)<ref>Baker, M.D., Bello, L.M., & Avner, J.R. (1993). Outpatient management without antibiotics of fever in selected infants. New England Jouranl of Medicine, 329(20), 1437-1441.</ref> | ||
|- | |- | ||
|} | |} | ||
{{Pediatric fever CXR indications}} | {{Pediatric fever CXR indications}} | ||
*Non-UTI SBI incidence of <.4% in children >6 mo | |||
* | |||
If low-risk criteria below not met, LP (if not done) and admit for | ==Low Risk Lab Criteria== | ||
''If low-risk criteria below not met, then perform the LP (if not done) and admit for inpatient antibiotics''<ref> Smitherman, H.F. & Macias, C.G. (2014). Evaluation and management of fever in the neonate and young infant (less than three months of age) [Electronic Version]. UpToDate,Teach, S.J., Kaplan, SL, Wiley, JF.</ref><ref>Dagan, R. Sofer, S., Phillip, M., & Shachak, E. (1988). Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serous bacterial infections. Journal of Pediatrics, 112(3), 355-360.</ref> | |||
===CBC=== | |||
*WBC 5-15 /mm<sup>3</sup> | |||
*Absolute Band count <1500 /mm<sup>3</sup> | |||
===Urinalysis=== | |||
*Clear | |||
*Neg Nitrate and Leukocyte esterase | |||
*WBC <10/high powered field | |||
===CSF=== | |||
====0-28 days==== | |||
*WBC: 0-22/mm<sup>3</sup> | |||
*Protein: <100mg/dL | |||
====>29 days==== | |||
*WBC 0-7/mm<sup>3</sup> | |||
*Protein: 15-25mg/dL | |||
===Low Risk by Step-By-Step Approach<ref>Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics. 2016;138(2):e20154381</ref>=== | |||
''Study validated against Rocheter criteria and Lab-score for identifying low risk for invasive bacterial infections (IBI), with '''''NPV ~98%''''' | |||
*Well appearing | |||
*Age > 21 days | |||
*No leukocyturia | |||
*Procalcitonin < 0.5 ng/mL | |||
*ANC < 10,000/mm3 | |||
*CRP < 20 mg/L | |||
====Low Risk Management<ref>Mintegi S, Gomez B, Martinez-Virumbrales L, et al. Outpatient management of selected young febrile infants without antibiotics. Arch Dis Child. 2016 Jul 28. pii: archdischild-2016-310600. doi: 10.1136/archdischild-2016-310600.</ref>==== | |||
*Offer no LP, no antibiotics, 24 hrs observation | |||
*Plan for prompt follow-up | |||
==Symptomatic Managment== | ==Symptomatic Managment== | ||
{{Acetaminophen pediatric dosing chart}} | {{Acetaminophen pediatric dosing chart}} | ||
== See Also | ==See Also== | ||
*[[ | *[[Acute fever]] | ||
*[[ | *[[Fever of unknown origin (peds)]] | ||
*[[ | *[[Urinary tract infection (peds)]] | ||
*[[Sepsis ( | *[[Sepsis (peds)]] | ||
*[[Meningitis ( | *[[Meningitis (peds)]] | ||
*[[Febrile | *[[Febrile seizure]] | ||
==External Links== | |||
*[http://www.pemed.org/blog/2011/10/9/fever-of-unknown-source-part-1.html PEM ED Algorithm for Pediatric Fever] | *[http://www.pemed.org/blog/2011/10/9/fever-of-unknown-source-part-1.html PEM ED Algorithm for Pediatric Fever] | ||
*[http://ddxof.com/pediatric-fever/ DDxOf: Pediatric Fever] | |||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Pediatrics]] | ||
[[Category:ID]] |
Revision as of 19:35, 6 October 2019
Background
- Medicine is an art as well as science, practice clinical judgment when using guidelines
- Preemies: Count age by estimated postconception date (not by actual delivery date) for 1st-90d
- Fever accounts for 30% of pediatric visits
- Children <3 mo are immunocompromised- poor opsonization, poor IgG response to encapsulated bacteria, macrophage and neutrophil dysfunction, bone marrow insufficiency
- Serious bacterial illness (SBI) includes UTI, meningitis, pneumonia, bacteremia
Age | 0-14 days | 14-28 days | 28-60 days (pre vaccine) | 28-60 days (post vaccine) | 60-90 days | > 90 days |
Meningitis/SBI Prevalence | 1/10 | 1/20 | 1/100 | 1/1000 | 1/1000-10,000 | > 1/10,000 |
Facts and Figures
From ACEP's Clinical Policy on Pediatric Fevers[1]
- 7% of patients < 2 years old with fever have pneumonia, however the etiology (viral/bacterial) or even the presence of pneumonia has low inter-observer reliability even among pediatric radiologists
- 4% Prevalence of UTI with common other sources of fever (OM, viral URI, et cetera)
- 1.5-2% background prevalence of asymptomatic bacteruria in healthy afebrile controls
- 0.3% Rate of occult bactremia with healthy, well-appearing child who has a fever 2-24 months
- 0.3% of previously well children aged 3-36 months who have a fever without a source will develop significant sequelae, 0.03% will develop sepsis or meningitis
Concomitant RSV or Influenza Infection
- Relatively high coincidence of bronchiolitis w/ UTI, and of enterovirus and paraflu w/ UTI and bacteremia
- In RSV+ (by PCR) neonates aged 0-28 days, 6.1% had UTIs and 3.7% were bactremic; there was no difference in rates of SBI between RSV+ and RSV- neonates in a large prospective multicenter study entailing 1,248 children[2]
- RSV+ infants aged 29-60 days, the SBI rate was 5.5%, all of which were UTIs
- Influenza+, low risk of bacterial illness
Evolving Practices for Febrile Infants 0-60 days (2019 JAMA Peds)[3]
- Prospective multicenter observational study with 1821 patients split into derivation and validation groups.
- Inclusion fever >38C in ED or in past 24 hours measured.
- Exclusion premature < 36 weeks, previously known diagnosis/illness, or severe illness.
- Incidence of SBI in cohort 9.3% (8.3% UTI)
- Following elements had 97.7% sensitivity and 60% specificity for SBI
- ANC of 4090 or less
- Procalcitonin 1.71 or less
- Negative urinalysis
- No cases of bacterial meningitis missed. 3 missed SBI, all of which were > 28 days.
- May lead to decreased unnecessary LPs, will have variable adoption pending further validated studies/applications.
Differential Diagnosis
Pediatric fever
- Upper respiratory infection (URI)
- UTI
- Sepsis
- Meningitis
- Febrile seizure
- Pneumonia
- Acute otitis media
- Whooping cough
- Unclear source
- Kawasaki disease
- Neonatal HSV
- Specific virus
Evaluation & Management
0-28dy
- SBI in ill-appearing febrile neonate as high as 20%
- SBI in well-appearing febrile neonate as high as 5%
Child Appearance | Work Up | Treatment | Disposition & Follow-up | Comments |
Temperature ≥38°
Toxic or Well |
|
|
Admit | SBI incidence
|
^Acyclovir if:
Note:
- CXR is optional if no resp sx and another source identified
- LP is necessary even if another source identified due to immature blood-brain barrier
- Do not give ceftriaxone to children <28d as may cause hyperbilirubinemia
28dy-90dy[4]
Appearance | Work Up | Treatment | Disposition & Follow-Up |
Temp≥38° + Toxic |
|
|
Admit |
Temp≥°38 + Well |
|
|
Workup(+): Antibiotics and admit
Workup(-): ?antibiotics; home with 24 follow-up |
^^Can use ceftriaxone 50-100mg/kg, but concern for bilirubin displacement
- Consider CXR for:
- Respiratory symptoms
- Fever >48 hrs
- Tachypnea
- Hypoxia
^Acyclovir if:
90dy-36mo[5]
Appearance | Work Up | Treatment | Disposition & Follow-Up |
T≥38° + Toxic |
|
|
Admit |
T≥39°C + Well + Non-complete Prevnar |
|
If WBC(+):
|
Outpatient (24 hour follow-up) |
T≥39°C + Well + Prevnar |
|
Treat cystitis or pneumonia if postitive | Outpatient (48hour follow up) |
T≥38-38.9°C + Well | Consider UA, CXR based on symptoms, etc | Treat cystitis or pneumonia if positive | Outpatient (48-72 hour follow-up)[6] |
- Consider CXR for:
- Respiratory symptoms
- Fever >48 hrs
- Tachypnea
- Hypoxia
- Non-UTI SBI incidence of <.4% in children >6 mo
Low Risk Lab Criteria
If low-risk criteria below not met, then perform the LP (if not done) and admit for inpatient antibiotics[7][8]
CBC
- WBC 5-15 /mm3
- Absolute Band count <1500 /mm3
Urinalysis
- Clear
- Neg Nitrate and Leukocyte esterase
- WBC <10/high powered field
CSF
0-28 days
- WBC: 0-22/mm3
- Protein: <100mg/dL
>29 days
- WBC 0-7/mm3
- Protein: 15-25mg/dL
Low Risk by Step-By-Step Approach[9]
Study validated against Rocheter criteria and Lab-score for identifying low risk for invasive bacterial infections (IBI), with NPV ~98%
- Well appearing
- Age > 21 days
- No leukocyturia
- Procalcitonin < 0.5 ng/mL
- ANC < 10,000/mm3
- CRP < 20 mg/L
Low Risk Management[10]
- Offer no LP, no antibiotics, 24 hrs observation
- Plan for prompt follow-up
Symptomatic Managment
Acetaminophen Pediatric Dosing Chart
Weight (kg) | Weight (lbs) | Age | Dosage (mg) |
3-4 | 6-11 | 0-3 mo | 40 |
5-7 | 12-17 | 4-11 mo | 80 |
8-10 | 18-23 | 1-2 y | 120 |
11-15 | 24-35 | 2-3 y | 160 |
16-21 | 36-47 | 4-5 y | 240 |
22-26 | 48-59 | 6-8 y | 320 |
27-32 | 60-71 | 9-10 y | 400 |
33-43 | 72-95 | 11 y | 480 |
- Dosage can be given q6 hours
See Also
- Acute fever
- Fever of unknown origin (peds)
- Urinary tract infection (peds)
- Sepsis (peds)
- Meningitis (peds)
- Febrile seizure
External Links
References
- ↑ Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545
- ↑ Greenes, D.S.M., & Harper, M. B.M. (1999). Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatric Infectious Disease Journal, 18(3), 258-261.
- ↑ Kuppermann N, Dayan PS, Levine DA, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatrics. 2019;173(4):342-351. doi:10.1001/jamapediatrics.2018.5501
- ↑ Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Powell, K. R., et al. (1994). Febrile infants at low risk for serious bacterial infection-an appraisal of the Rochester criteria and implications for management. Pediatrics 94(3), 390-396.
- ↑ Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Powell, K. R., et al. (1994). Febrile infants at low risk for serious bacterial infection-an appraisal of the Rochester criteria and implications for management. Pediatrics 94(3), 390-396.
- ↑ Baker, M.D., Bello, L.M., & Avner, J.R. (1993). Outpatient management without antibiotics of fever in selected infants. New England Jouranl of Medicine, 329(20), 1437-1441.
- ↑ Smitherman, H.F. & Macias, C.G. (2014). Evaluation and management of fever in the neonate and young infant (less than three months of age) [Electronic Version]. UpToDate,Teach, S.J., Kaplan, SL, Wiley, JF.
- ↑ Dagan, R. Sofer, S., Phillip, M., & Shachak, E. (1988). Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serous bacterial infections. Journal of Pediatrics, 112(3), 355-360.
- ↑ Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics. 2016;138(2):e20154381
- ↑ Mintegi S, Gomez B, Martinez-Virumbrales L, et al. Outpatient management of selected young febrile infants without antibiotics. Arch Dis Child. 2016 Jul 28. pii: archdischild-2016-310600. doi: 10.1136/archdischild-2016-310600.