Evaluation of the Febrile Infant

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The Febrile InfantSteven Lanski, MD FAAP Emory University School of Medicine Children’s Healthcare of Atlanta @ Egleston

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ObjectivesReview the management options available when evaluating a febrile infant Review pertinent literature Management options Special cases

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What Would You Do?Well appearing 3 week infant fever 38 at home afebrile during evaluation 2) Well appearing 7 month circumcised male with diarrhea for 5 days and fever 3 days, temp 39.1 in office 3) Tired appearing 4 y.o. female, temp 40.5, no source

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EvaluationHistory Timeline and degree Associated symptoms Past medical conditions Decreased defense Hardware Physical Appearance Other source Skin involvement

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GuidelinesExpert consensus Based on available evidence Regional variation Account for changing patterns and advances Limit unnecessary evaluations Invasive procedures False positives Maximize available resources

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Management Based on Age Neonates 28-90 days 3 – 6 months 6 – 24 months >24 months

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Published Practice Guidelines Baraff et al. Annuals Emerg Med and Pediatrics 1993 Expert consensus based on literature Fever > 38 (0-3 months) and > 39 (3-36 months) Infants at greatest risk during 0-3 months Rochester criteria selected as screening criteria

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Rochester CriteriaDagan R, et al. Journal of Pediatrics 1985. Well appearing term infants Follow-up assured Temp > 38 WBC 5-15,000/mm3 Band count < 1500 /mm3 Urinalysis with < 10 WBC/hpf No evidence of ear, soft tissue or bone infection Modified (1988) if diarrhea present <5 WBC / hpf

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Management < 28 daysNeonates frequently do not show early signs of serious bacterial infections (SBI) Rates of serious bacterial infection in febrile infants < 2 months is 8-14% Poor immunity Maternal pathogens (GBBS, E. coli) and Listeria Infants less than 28 days of age should have full evaluation and hospitalization with IV antibiotics Ampicillin and Cefotaxime or Gentamicin

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Management 29-60 Days Work–up CBC/D, BCX, UA/UCX (consider CRP and LP) Stool and CXR based on history / exam Antibiotics and admission for patients with abnormal labs Positive UA, WBC >15,000, Band >1500 LP if not already done Ceftriaxone or Cefotaxime

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Management 60-90 DaysAt risk for occult bacteremia Pneumococcus and HIB Exam may still be unreliable Beginning to develop immunity Limited investigations (blood and urine) Abnormal – management as previously described Low risk – follow-up within 24 hours with or without antibiotics Strongly consider LP if giving antibiotics

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Management 3-6 monthsOccult Bacteremia remains a concern Exam more reliable in identifying children at risk particularly those with meningitis Pneumococcal vaccine begins to have protective effect to what extent ? Fever cut-off raises to >39

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Management 3-6 month cont…In patients without well defined source ASOM, Bronchiolitis, Stomatitis, Croup, AGE… Screen blood and urine WBC >15,000 (send cultures) consider antibiotics (consensus recommendations) WBC >20,000 or ANC > 10,000 give antibiotics Follow-up within 24 hours

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Invasive Pneumococcal Disease CDC: Active Bacterial Core Surveillance, eight states, 1998-2005 CDC: Active Bacterial Core Surveillance, eight states, 1998-2005

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Management 6-24 monthsIn a fully immunized infant with fever > 39 Urine based on age and sex Circumcised males >6 months unnecessary unless clinical condition dictates Uncircumcised males until 1 year of age Females until 2 years Consensus recommends blood <36 months Prior to pneumococcal vaccine

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Bronchiolitis and SBIKuppermann N. Arch Ped Adol Med 1997 Compared rates of bacteremia and UTIs in febrile children w/o bronchiolitis 432 children aged 0-24 months Children with bronchiolitis had fewer positive cultures Blood 0% vs 2.7% Urine 1.9% vs 13.6% (Titus and Wright – Peds 2004) No child < 2 months positive for bronchiolitis had a positive culture

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UTI - Clinical Decision RuleGorelick M. Arch Ped Adol Med 2000 Risk factors T > 39 Fever > 2 days White race < 12 months Absence of another source All + UTI had at least 1 risk factor Using 2 risk factors as the screening requirement 0.8% probability of UTI in those screening negative 6.4% probability of a UTI in those screening positive

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Special CasesPrematurity Immunocompromised Patients with hardware

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Best Course of Action?Regional epidemiology Regional practice patterns Consensus guidelines Personal risk tolerance Risk minimizer vs Test minimizer

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Children’s Healthcare of Atlanta Guidelines < 29 days

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CHOA Guidelines 29 – 60 days

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CHOA Guidelines 2-6 months

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CHOA Guidelines >6-24 months

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Questions

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Last Updated: 8th March 2018

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