SCVMC Nighttime Curriculum Fever Erin Augustine, MD Alan Schroeder, MD

SCVMC Nighttime CurriculumFever

Erin Augustine, MD

Alan Schroeder, MD

• Previously healthy 3 week infant presents with fever to 100.5˚F. Well-appearing and no source of infection on exam. Parents appropriate and able to follow up with pediatrician when recommended. Next step?

A) Reassurance, Close Follow-Up

B) Urine Culture; Close Follow-Up

C) Urine & Blood Culture; Close Follow-Up

D) Urine, Blood, & CSF Culture; Close Follow-Up

E) Urine, Blood, & CSF Culture; Ceftriaxone; Close Follow-Up

F) Urine, Blood, & CSF Culture; Admit; IV Antibiotics















Febrile Infants and Children

• Fever is Very Common Emergency Departments Outpatient Clinics

• Appropriate Management of Fever Has Changed Over Last Few Decades Is Debated Differs Among Physicians

Serious Bacterial Infections (SBI)

• Bacteremia• Meningitis• Urinary Tract Infection (UTI)• Bacterial Diarrhea• Pneumonia• Bone & Joint Infections

Prior to 1985

• Management of febrile infants <2-3 mo Hospitalization Sepsis Evaluation (Blood, Urine, CSF Cultures) IV Antibiotics

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Disadvantages to Hospitalization

• Nosocomial Infections• Adverse Effects of Antibiotics• Emergence of Resistant Bacteria• Stresses on Families• Cost

Rochester, Boston, & Philadelphia Criteria

Criteria established to predict infants <3 months at low risk for SBI.

A = RochesterB = BostonC = Philadelphia

Rochester Criteria

• Prospective study to determine if a set of criteria could accurately identify febrile infants <3 months at low risk of SBI.

• Low Risk Rochester Criteria Previously Healthy No Soft Tissue, Skeletal, or Ear Infection WBC 5,000-15,000 (Bands <1,500) UA WBC <10/hpf

Dagan R, et al. J Pediatr. 1985.

Boston Criteria

• Prospective consecutive cohort study to determine outcome of outpatient treatment of febrile infants 28-89 days with Ceftriaxone IM.

• Low Risk Boston Criteria Looks Well No Source of Infection WBC <20,000 Urine WBC <10/hpf or Leukocyte Esterase Negative CSF WBC <10 CXR Normal (If Obtained)

Baskin MN, et al. J Pediatr. 1992.

Philadelphia Criteria

• Randomized controlled study to evaluate efficacy of managing febrile infants 29-56 days without antibiotics or hospitalization.

• Low Risk Philadelphia Criteria Looks Well No Source of Infection WBC <15,000 Urine WBC <10/hpf CSF WBC <8 CXR Normal (If Obtained)

Baker MD, et al. New Engl J Med. 1993.

Baraff Practice Guidelines

• Infants < 28 Days

• Infants 28-90 DaysLow RiskHigh Risk

HospitalizeBlood, Urine, CSF Cultures

IV Antibiotics


IV Antibiotics

Option 1Blood, Urine, CSF Cultures

Ceftriaxone IMReturn 24 Hours

Option 2Urine & Blood Culture

Return 24 Hours Baraff. Ann Emerg Med. 2000.

Baraff Practice Guideline

• Infants 3-36 Months

Toxic Appearing

Non-Toxic Appearing

Temp <39 C

Temp >39 C


IV Antibiotics

No Diagnostic TestsReturn If Fever >48 Hours

Blood Culture if WBC >15,000 & No PCVUrine Culture if M <6 mo, Uncirc <12 mo, F <2 yr, UA Pos

Ceftriaxone if WBC >15,000 & No PCVReturn if Febrile >48 Hours

Baraff. Ann Emerg Med. 2000.

Management of febrile InfantsOffice Setting

• Prospective study of 3066 febrile infants ≤3 months seen by practitioners from the Pediatric Research in Office Setting (PROS) Network.

• Current guidelines followed in 42% • Only 2/63 with bacteremia or meningitis were not initially

treated with antibiotics. Both well after treatment.

Clinicians use individualized judgment in treating febrile infants. Using clinical guidelines would not have improved care, but

would have resulted in more hospitalizations and labs.

Pantell RH, et al. (PROS Study). JAMA. 2004.

Special Patient Populations

• Neonates• Transplant recipients

– Bone marrow– Solid organ

• Oncology patients– Undergoing therapy, mucositis, central line– Most chemotherapy: nadir ~ 10 days after rx

• Asplenic patients, including sickle cell

Treatment for neonates ≤ 2 months

• If < 28 days old– Ampicillin AND cefotaxime OR – Ampicillin AND gentamicin

• Consider acyclovir

• If 29-60 days old– Ceftriaxone ± Ampicillin OR Vancomycin

– Until CSF results are known (cell count, protein, glucose), initiate therapy with meningitic dosing regimen

Urinary Tract Infection

• The prevalence of urinary tract infections in febrile children ≤24 months is closest to

A) 2-4%

B) 6-8%

C) 10-12%

D) 14-16%

E) 18-20%

• The prevalence of urinary tract infections in febrile uncircumcised males <3 months is closest to

A) 2-4%

B) 6-8%

C) 10-12%

D) 14-16%

E) 18-20%

UTI Prevalence• Meta-Analysis (18 Articles; 22,919 Children)• UTI Prevalence in Febrile Children ≤24 Months

Shaikh N, et al. Pediatr Infect Dis J. 2008.

7%

UTI Prevalence• UTI Prevalence in Male Infants <3 months


20%

2.4%

UTI Prevalence

• Prevalence By Age (%)

• Prevalence Highlights Decreases with Age Highest in Females < 1 Year Highest in Uncircumcised Males < 3 Months


Age Overall Females Males Circumcised Uncircumcised

< 3 mo 7.2 7.5 8.7 2.4 20.1

3-6 mo 6.6 5.7 3.3

6-12 mo 5.4 8.3 1.7

12-24 mo 4.5 2.1 0.3 7.3

• Previously healthy 3 month female presents with fever to 101.7˚F. Well-appearing on exam. Urinalysis positive. Parents appropriate and able to follow up with pediatrician when recommended. Next step?

A) Urine Culture; Close Follow-Up

B) Urine Culture; Oral Antibiotics; Close Follow-Up

C) Urine & Blood Culture; Oral Antibiotics; Close Follow-Up

D) Urine, Blood, & CSF Culture; Oral Antibiotics; Close Follow-Up

E) Urine, Blood, & CSF Culture; IM Ceftriaxone; Close Follow-Up


• Retrospective study of 354 children <2 years discharged with diagnosis of UTI to characterize patients with bactermia or meningitis.

• Bacteremia in 9% (33/354) Limited to age <6 months Inversely related to age

0-1 Month = 21% 1-2 Months = 13% 2-3 Months = 4%

• Meningitis in 1% (4/354) Limited to age <1 month

Bachur R, et al. Pediatr Emerg Care. 1995.

Bronchiolitis

• Previously healthy 5 week infant presents with fever, congestion, and cough. Exam consistent with bronchiolitis. Parents appropriate and able to follow up with pediatrician when recommended. Next step?







Bronchiolitis & Serious Bacterial Infection (SBI)Emergency Departments

• Multicenter prospective study of 1248 febrile infants ≤ 60 days to evaluate frequency of SBI in infants with and without RSV infection.

Levine DA, et al. Pediatrics. 2004.

Total Infants (n=1248)SBI in 11.4%

RSV Pos (n=269) RSV Neg (n=979)

SBI in 7%UTI in 5.4%

Bacteremia in 1.1%Bacterial Meningitis in 0%

SBI in 12.5%UTI in 10.1%

Bacteremia in 2.3%Bacterial Meningitis in 0.9%

• Prospective cohort study of 3066 febrile infants <3 months to evaluate frequency of SBI in infants with and without clinically diagnosed bronchiolitis.

• Infants with bronchiolitis, SBI in 0%.• Infants without bronchiolitis, SBI in 8%.

In office setting, SBI is uncommon in febrile infants <3 months with clinically diagnosed bronchiolitis.

Luginbuhl LM, et al. Pediatrics. 2008.

Bronchiolitis & Serious Bacterial Infection (SBI)Primary Care Offices

Conclusion

• To identify febrile infants and children at risk of serious bacterial infections, clinicians should use a combination of Clinical Judgement Published Guidelines Clinical and Laboratory Indices Immunization status

References• Baker MD, Bell L, Avner JR. Outpatient Management Without Antibiotics of Fever in

Selected Infants. New Engl J Med. 1993. 329(20): 1437-41.• Baraff LJ. Management of Fever Without Source in Infants and Children. Ann Emerg

Med. 2000. 36:602-14. • Baraff LJ, Bass JW, Fleisher GR, Klein JO, McCracken Jr GH, Powell KR, Schriger DL.

Practice Guideline for the Management of Infants and Children 0-36 Months of Age with Fever Without Source. Ann Emerg Med. 1993. 22:108-20.

• Baskin MN, O’Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28-89 days of age with intramuscular administration of ceftriaxone. J Pediatr. 1992. 120:22-7.

• Bachur R, Caputo GL. Bacteremia and meningitis among infants with urinary tract infections. Pediatr Emerg Care. 1995. 11:280-4.

• Carstairs KL, Tanen DA, Johnson AS, Kailes SB, Riffenburgh RH. Pneumococcal Bacteremia in Febrile Infants Presenting to the Emergency Department Before and After the Introduction of the Heptavalent Pneumococcal Vaccine. Ann Emerg Med. 2007. 49:772-7.

• CDC. www.cdc.gov. 2002 & 2008.• Dagan R, Powell KR, Hall CB, Menegus MA. Identification of infants unlikely to have

serious bacterial infection although hospitalized for suspected sepsis. J Pediatr. 1985. 107:855-60.

• Dagan R, Sofer S, Phillip M, Shachak E. Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections. J Pediatr. 1998. 112:355-60.

References• Garra G, Cunningham SJ, Crain EF. Reappraisal of Criteria Used to Predict Serious

Bacterial Illness in Febrile Infants Less than 8 Weeks of Age. Acad Emerg Med. 2005. 12:921-5.

• Herz AM, Greenhow TL, Alcantara J, Hansen J, Baxter RP, Black SB, Shinefield HR. Changing Epidemiology of Outpatient Bacteremia in 3- to 36-Month-Old Children After the Introduction of the Hepatavalent-Conjugated Pneumococcal Vaccine. Pediatr Infect Dis J. 2006. 25:293-300.

• Huppler AR, Eickhoff JC, Wald ER. Performance of Low-Risk Criteria in the Evaluation of Young Infants with Fever: Review of the Literature. Pediatrics. 2010. 125:228-33.

• Jaskiewicz JA, McCarthy CA, Richardson AC, White KC, Fisher DJ, Powell KR, Dagan R. Febrile Infants at Low Risk for Serious Bacterial Infections – An Appraisal of the Rochester Criteria and Implications for Management. Pediatrics. 1994. 94:390-6.

• Kadish HA, Loveridge B, Tobey J, Bolte RG, Corneli HM. Applying Outpatient Protocols in Febrile Infants 1-28 Days of Age: Can the Threshold Be Lowered? Clin Pediatr. 2000. 39:81-8.

• Levine DA, Platt SL, Dayan PS, Macias CG, Zorc JJ, Krief W, Schor J, Bank D, Fefferman N, Shaw KN, Kuppermann N. Risk of Serious Bacterial Infection in Young Febrile Infants With Respiratory Syncytial Virus Infections. Pediatrics. 2004. 113:1728-34.

• Luginbuhl LM, Newman TB, Pantell RH, Finch SA, Wasserman RC. Office-Based Treatment and Outcomes for Febrile Infants With Clinically Diagnosed Bronchiolitis. Pediatrics. 2008. 122:947-54.

• Pantell RH, Newman TB, Bernzweig J. Management and Outcomes of Care of Fever in Early Infancy. JAMA. 2004. 291:1203-12.

• Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of Urinary Tract Infection in Childhood. Pediatr Infect Dis J. 2008. 27:302-8.

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SCVMC Nighttime Curriculum Fever Erin Augustine, MD Alan Schroeder, MD