Junior Tutorial 1

8/17/2019 Junior Tutorial 1

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Fever without a Focus

“My child has a fever”


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History Taking


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How to take a good history

• Structured – have a backbone inmind

• Targeted – know what ddx you needto consider

• ractice makes !erfect"


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History Taking

• FeverLength #$onsecutive three days of

fever% vs#Tem!erature been down

for three days then kickedagain this morning%

Height &sually de'nes fever as ()*o$ core tem!erature

Pattern +o variation over the day

vs ,uotidian fever(Association)

-.ny chills or rigors/0


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History Taking

• 1ocalising sym!toms – &!!er res!iratory tract

– 1ower res!iratory tract

–

23 sym!toms – &rinary tract

– 4titis media

– $+S

– 5ones and 6oint


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History Taking•

1ocalising sym!toms – &!!er res!iratory tract7 cough8 9+8 sore throat8

hoarseness

– 1ower res!iratory tract7 sob8 cyanosis

–

23 sym!toms7 vomiting8 diarrhoea8 abdominal !ain – &rinary tract7 foul smelling: turbid urine:

haematuria in younger children; dysuria8 urgency8fre,uency8 and haematuria in older children

– 4titis media7 ear !ulling or tugging in younger

children; ear !ain in older children

– $+S7 altered consciousness8 irritability8 focalsei


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History Taking

• Localising symptoms??? – $onvulsion

– +oisy breathing

–

>omiting – 3rritability


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History Taking

• 4ther associated sym!toms – 9ash

Timing of onset

in relation tofever

?Very Sick Person Must Take no Exercise

?9oseola infantum

Characteristic Macular8 !a!ular8 macuol!a!ular8 vesicular8morbilliform8 scarlatiniform8 !olymor!hic

Distribution

andprogression

htt!7::learn@!ediatrics@ubc@ca:body=systems:general=!ediatrics:a!!roach=to=a=the=child=with=a=fever=and=rash:+57 sei


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History Taking

• $om!lications – oor feeding dehydration

– Side eAects of medication


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History Taking

• T4$$ history

• ast medical history

•

5irth history• 3mmunisation history

• Bevelo!ment

•

Family and social history


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$ase Biscussion

• . four=month=old boy !resented withfever for C day@


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Fever without locali


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Fever of &nknown 4rigin

• Fever (CECF -)*@)$0 of at least *daysG duration8 in whom no diagnosisis a!!arent after initial out!atient or

hos!ital evaluation that includes acareful history and !hysicalexamination and initial laboratory

assessment


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&rinary Tract 3nfection


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Biagnostic .!!roach

• The diagnosis of &T3 should beconsidered in any child aged youngerthan years with documented fever

-()*o$0 but no identi'able focus ofinfection@


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3nvestigations

• 3f !atient is se!tic looking8 collect catheterizedurine (CS) and send for 9:M8 $:ST; thencommence antibiotics without delay

– Su!ra!ubic as!iration -S.0 rarely !erformed inreality8 although being the #gold standard% of urinesam!le collection

• 3f !atient does not re,uire immediate antibioticthera!y8 urine can be collected by a non!

in"asi"e method -e@g@ bag urine0 and send for9:M; !roceed with a !ro!er urine sam!le for$:ST -!referably S. or $S&8 though !ro!erclean void urine is also acce!table0@


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&rinalysis -9:M0

#outine Microscop$

1eukocyte esterase Ihite cell count

nitrite 9ed cell count

blood 5acteria !resent -or not0

!H8 s!eci'c gravity8 glucose8!rotein8 ketones8 bilirubin


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$ulture and Sensitivity-$:ST0

• Be'nitive treatment guide• Any positive growth of uro!athogens from culture of

su!ra!ubic as!irated urine con'rms &T3@

• For culture of catheter urine8 a colony count of >10^4CFU/ml of a single uro!athogen indicates de'nite &T3@1ower counts of (CEJ) $F&:ml or growth of (Curo!athogens indicates !robable &T3@

• For culture of clean void urine8 a colony count of >10^5CFU/ml of a single uro!athogen indicates de'nite &T3@

1ower counts of (CEJK $F&:ml or growth of (Curo!athogens indicates !robable &T3@

* Probable UTI should be interpreted taking into account the clinical

picture and infammatory markers.* Culture o bag urine has high contamination rates and should not be

used or conrming UTI@


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Treatment

• For stable non=toxic !atients – Standard dose oral .ugmentin

– $overage7 common gram negative

uro!athogens8 including LS51=!roducingL@coli and enterococci

• For ill !atients or young infants –

3> antibiotics8 mero!enem if LS51=!roducing L@coli need to be covered

• .ntibiotics course should be =CK days


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Follow=u! 3maging Studies

NICE - 2007 AAP -2011

3maging

strategy after'rst &T3/

95&S for all childrenDNm 49 aty!ical orrecurrent &T3;>$&2 or BMS.

de!ending on C0 age8 0aty!ical &T38 )0 recurrent&T3>$&2 O:=BMS. ifabnormal 95&S

95&S for all childrenDy;

>$&2 if abnormal 95&S;if recurrent &T3

BMS./ 3ncluded in worku!+ot recommendedunless in research

ro!hylacticantibioticindications

For recurrent &T3 -with orwithout >&90

+ot addressed


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Hong %ong &uide'ine ! *+

3maging strategyafter 'rst &T3/

95&S for all young children8 aged to Kmonths

>$&2 after 'rst &T3/

C0 95&S shows dilated renal !elvis or other

'ndings indicating com!lex urologicalabnormalities; 0 9ecurrent febrile &T3)0 $an be considered when the 'rst febrile &T3was accom!anied by one or more of thefollowing risk factors7

resenting with severe se!sis or !roven

se!ticaemia al!able abdominal mass 3m!airment of baseline renal function History of abnormal urine stream &T3 due to non=L@coli organisms +o clinical res!onse to a!!ro!riate antibiotic

treatment within K* hours >&9 in 'rst degree relatives

BMS./

C0 2rade 333 or above >&9 detected on >$&2;0 9ecurrent febrile &T3

To be done at least K=N months from &T3 to

look for renal scar


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>esicoureteric 9ePux


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Hong %ong &uide'ine ! *+

3maging strategyafter 'rst &T3/

95&S for all young children8 aged to Kmonths

>$&2 after 'rst &T3/

C0 95&S shows dilated renal !elvis or other

'ndings indicating com!lex urologicalabnormalities; 0 9ecurrent febrile &T3)0 $an be considered when the 'rst febrile &T3was accom!anied by one or more of thefollowing risk factors7

resenting with severe se!sis or !roven

se!ticaemia al!able abdominal mass 3m!airment of baseline renal function History of abnormal urine stream &T3 due to non=L@coli organisms +o clinical res!onse to a!!ro!riate antibiotic

treatment within K* hours >&9 in 'rst degree relatives

BMS./

C0 2rade 333 or above >&9 detected on >$&2;0 9ecurrent febrile &T3

To be done at least K=N months from &T3 to

look for renal scar


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1ong Term Management

• ro!hylactic antibiotics

– Meta=analysis on six recent 9$Ts on!ro!hylactic antibiotics during year EEN=

ECE – +o signi'cant bene't with antibiotics

!ro!hylaxis for !reventing &T3 recurrence in!atients with >&9 grade 3 to 3>

–

2rade > >&9 was not tested in the meta=analysis; but it was 6udged to be rare -CQ0 inchildren with 'rst time &T38 and it wouldlikely be detected by 95&S abnormalities


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• ro!hylactic antibiotics

– The Swedish 9ePux Trial showed signi'cantreduction in &T3 recurrence and BMS.

deterioration in girls with 2rade 333=3> >&9 – 3n !ractice8 we would consider antibiotic

!ro!hylaxis in !atients with >&9 grade 333 orabove@ atients with recurrent &T3 but

without: with >&9 grade 33 or below can bediscussed for the bene't of antibiotic!ro!hylaxis@


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• Surgical $orrection – atients with grade 333 or above >&9 and

signi'cant renal scarring as shown by

BMS. can be oAered surgical referral – For !atients with grade 333 or above >&9

-with or without renal scarring08 if febrile&T3 recurs despite antibiotic prophylaxis-i@e@ third e!isode of febrile &T308 surgicalreferral is recommended


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9eferences

• +ational 3nstitute for $linical Lxcellence-EE0 &rinary tract infection in children

• $linical 2uideline on The Biagnosis and

3nitial Management of &rinary Tract3nfections in 3nfants and $hildren aged toK months8 aediatric &T3 2uidelineIorking 2rou!8 H.H48 LAective Bate7

C*:E:ECK• +elson Textbook of ediatrics

Documents

Junior Tutorial 1