August 9, 2010

Morning Report

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.

Definition of Fever

Rectal temperatures are standard for detection of fever in <3mo Rectal temp > 100.4 F is considered a fever

If the caregiver reports a measured temp of 100.4 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.

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

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 5.4-13.1% of febrile infants.

Evaluation

Evaluation (<28 days)

CBC c differentialCMPUrinalysis and urine cultureBlood cultureCSF

Gram stain and culture Protein and glucose Cell count and differential **HSV PCR**

Consider CXR, viral panel, stool studies if indicated

Treatment

Neonates Organisms

GBS, E. coli Listeria, Strep pneumo, Staph aureus, Enterococcus

Antibiotic selection Ampicillin & (gentamicin OR cefotaxime) Acyclovir**, Vancomycin**

Infants 29-90 days Organisms

Strep pneumo, H. influenza, N. meningiditis Antibiotic selection

Ceftriaxone or cefotaxime Vancomycin or ampicillin*

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 0.25-0.32/1000 live births

Early onset vs. late onset

Clinical Features

Neurologic findings 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

Organisms

< 7 days 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

CSF Analysis

Cell count WBC > 20-30 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*

Treatment

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

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.

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

Complications

Cerebral edemaHydrocephalusHemorrhageVentriculitisAbscess formationCerebral infarction

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.

Questions??