Pediatric fever of uncertain source: Difference between revisions

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*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"  
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===Facts and Figures===
===Facts and Figures===
*Take parental report of confirmed fever at home seriously in the 0-28 day range, even if never febrile in ED, as this population has been shown to have rates of serious bacterial infection (SBI) as high as 4.7% and invasive bacterial infection (IBI) as high as 1.8%<ref>Serious bacterial infections in neonates presenting afebrile with history of fever Ramgopal S, Walker LW, Tavarez MM, et al. Pediatrics. 2019;144(2):e20183964.</ref>
''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>
''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
*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
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*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 Infulenza Infection===
===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<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>
*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
===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>===
*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==
==Differential Diagnosis==
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==Evaluation & Management==
==Evaluation & Management==
[[File:Pediatric Fever2.png|thumb|Algorithm for the evaluation of pediatric fever]]
[[File:Pediatric Fever2.png|thumb|Algorithm for the evaluation of pediatric fever]]
===0-28dy ===
===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"
|-
|-
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| '''Comments'''
| '''Comments'''
|-
|-
| '''Temp ≥38°'''  
| '''Temperature ≥38°'''  
'''Toxic or Well'''
'''Toxic or Well'''
|  
|  
*CBC  
*CBC  
*Blood cultures  
*Blood cultures  
*UA, Urine culture  
*[[Urinalysis]], Urine culture  
*LP-CSF  
*[[LP]]-CSF  
*CXR
*[[CXR]]
*+/- Stool studies (if diarrhea)
*+/- Stool studies (if diarrhea)
|  
|  
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{{Pediatric fever acyclovir indications}}
{{Pediatric fever acyclovir indications}}
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>===
===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>===
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*CBC  
*CBC  
*Blood cultures
*Blood cultures
*UA, Urine culture  
*[[Urinalysis]], Urine culture  
*[[LP]]-CSF  
*[[LP]]-CSF  
*+/- CXR
*+/- CXR
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*CBC  
*CBC  
*Blood cultures  
*Blood cultures  
*UA, UCx
*[[Urinalysis]], urine culture
*+/- [[LP]]-CSF (must do before giving antibiotics)  
*+/- [[LP]]-CSF (must do before giving antibiotics)  
*+/- CXR
*+/- CXR
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{{Pediatric fever acyclovir indications}}
{{Pediatric fever acyclovir indications}}


===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> ===
===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"
|-
|-
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*CBC  
*CBC  
*Blood cultures  
*Blood cultures  
*UA, UCx
*[[Urinalysis]], urine culture
*[[LP]]-CSF  
*[[LP]]-CSF  
*CXR^
*[[CXR]]^
|  
|  
{{Pediatric fever antibiotics 90dy-36mo}}
{{Pediatric fever antibiotics 90dy-36mo}}
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|-
|-
| '''T≥39°C + Well + Non-complete [[Prevnar]]'''
| '''T≥39°C + Well + Non-complete [[Prevnar]]'''
(No [[Prevnar]] or <4 wks post 1st [[Prevnar]] dose)
(No [[Prevnar]] or <4 weeks post 1st [[Prevnar]] dose)
|  
|  
*UA, Urine culture
*[[Urinalysis]], Urine culture
*CBC  
*CBC  
*+/- CXR
*+/- CXR
| If WBC(+):
| If WBC(+):
*[[Ceftriaxone]] 50mg-100mg/kg (also then consider [[blood culture]] and [[LP]], esp in <6mo old)
*[[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 wks post 1st [[Prevnar]] dose)
(2 [[Prevnar]] or ≥4 weeks post 1st [[Prevnar]] dose)
|  
|  
*Urine workup (UA, UCx) for:
*Urine workup (UA, urine culture) for:
**Circumcised males <6 months
**Circumcised males <6 months
**Uncircumcised males <12 months
**Uncircumcised males <12 months
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|}
|}
{{Pediatric fever CXR indications}}
{{Pediatric fever CXR indications}}
*Non-UTI SBI incidence of <.4% in children >6 mo


==Low Risk Lab Criteria==
==Low Risk Lab Criteria==
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*Neg Nitrate and Leukocyte esterase
*Neg Nitrate and Leukocyte esterase
*WBC <10/high powered field
*WBC <10/high powered field
===CSF===
===CSF===
====0-28 days====
====0-28 days====
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*Protein: 15-25mg/dL
*Protein: 15-25mg/dL


==Symptomatic Managment==
==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% and 92.0% & 99.3% sensitivity'''''
 
'''Patients must have all of the following to be low risk: '''
*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 within a week
 
==Symptomatic Management==
{{Acetaminophen pediatric dosing chart}}
{{Acetaminophen pediatric dosing chart}}


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[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:ID]]

Revision as of 19:28, 20 February 2020

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

  • Take parental report of confirmed fever at home seriously in the 0-28 day range, even if never febrile in ED, as this population has been shown to have rates of serious bacterial infection (SBI) as high as 4.7% and invasive bacterial infection (IBI) as high as 1.8%[1]

From ACEP's Clinical Policy on Pediatric Fevers[2]

  • 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[3]
  • 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)[4]

  • 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

Evaluation & Management

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%
Child Appearance Work Up Treatment Disposition & Follow-up Comments
Temperature ≥38°

Toxic or Well

  • CBC
  • Blood cultures
  • Urinalysis, Urine culture
  • LP-CSF
  • CXR
  • +/- Stool studies (if diarrhea)
 Admit SBI incidence
  • Ill appearing: 13%–21%
  • Not ill appearing: <5%

^Acyclovir if:

  • HSV infection in baby or mother
  • CSF pleocytoisis
  • Concerning skin lesions
  • Seizures
  • Abnormal LFTs

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[5]

Appearance Work Up Treatment Disposition & Follow-Up
Temp≥38° + Toxic
  • CBC
  • Blood cultures
  • Urinalysis, Urine culture
  • LP-CSF
  • +/- CXR
  • +/- Stool studies (if diarrhea)
 Admit

Temp≥°38 + Well

  • CBC
  • Blood cultures
  • Urinalysis, urine culture
  • +/- LP-CSF (must do before giving antibiotics)
  • +/- CXR
 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:

  • HSV infection in baby or mother
  • CSF pleocytoisis
  • Concerning skin lesions
  • Seizures
  • Abnormal LFTs

90dy-36mo[6]

Appearance Work Up Treatment Disposition & Follow-Up
T≥38° + Toxic Admit
T≥39°C + Well + Non-complete Prevnar

(No Prevnar or <4 weeks post 1st Prevnar dose)

If WBC(+): Outpatient (24 hour follow-up)
T≥39°C + Well + Prevnar

(2 Prevnar or ≥4 weeks post 1st Prevnar dose)

  • Urine workup (UA, urine culture) for:
    • Circumcised males <6 months
    • Uncircumcised males <12 months
    • All females
  • +/- CXR
 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)[7]
  • 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[8][9]

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[10]

Study validated against Rocheter criteria and Lab-score for identifying low risk for invasive bacterial infections (IBI), with NPV ~98% and 92.0% & 99.3% sensitivity

Patients must have all of the following to be low risk:

  • Well appearing
  • Age > 21 days
  • No leukocyturia
  • Procalcitonin < 0.5 ng/mL
  • ANC < 10,000/mm3
  • CRP < 20 mg/L

Low Risk Management[11]

  • Offer no LP, no antibiotics, 24 hrs observation
  • Plan for prompt follow-up within a week

Symptomatic Management

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

External Links

References

  1. ↑ Serious bacterial infections in neonates presenting afebrile with history of fever Ramgopal S, Walker LW, Tavarez MM, et al. Pediatrics. 2019;144(2):e20183964.
  2. ↑ Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545
  3. ↑ 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.
  4. ↑ 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
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ 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
  11. ↑ 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.
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