febrile child ping-wei chen pgy-1 emergency medicine dr. lorraine mabon
TRANSCRIPT
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Febrile Child
Ping-Wei ChenPGY-1 Emergency Medicine
Dr. Lorraine Mabon
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Objectives
• Definition of Fever• Measuring Fever• Approach to Managing Febrile Patient– <30 days old– 1-3 months old– >3 months old
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What is a fever?
• Pathophysiology– Increased hypothalamic set point
• Pyrogens– Exogenous (eg: Gram Neg. LPS)– Endogenous (eg: IL-1, IL-6, TNF)
• Prostaglandin E-2– Central effects– Peripheral effects
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No, seriously, what is a fever?
• Various definitions – Wunderlich 1868 Das Verhalten der Eigenwdrlne
in Krankheilen• 25,000 patients: several million measurements• Axillary measurements• Fever >38C
• Landmark Studies– Fever ≥ 38.0C
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Temperature Measurement
• Variations in temperature – diurnal, age, gender, prandial state
• Axillary < Oral < Rectal
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Here at Home
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• 275 subjects– 5 temperature measurements• 4 temple (nurse x 2, parent x 2), 1 rectal
• Results• good correlation (r=0.68)• “fair” agreement; 95% CI difference: -1.0C to +1.5C
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Case 1
• 25 day old female– Mother thought “baby feels warm”, measured
rectal temp: 38.3C• Otherwise, no concerns.
What else do you want to know on history?
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History
• Length/Duration of Illness• Antipyretic use• Birth History (maternal fever, GBS, PROM, STIs)• Medical History (immunocompetency)• Immunization status• Sick contacts • Behaviour/Localizing symptoms – eg: HNT, Resp, GI, GU
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Case 1
• On Exam– 38.4C, 132bpm, RR26, 100% Room Air– Otherwise examines well. • No focus of infection identified.
What do you want to do with this patient?
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<30 days old
• Rate of serious bacterial illness– Approximately 9% to 12%
• Immature Immune systems-decreased opsonin activity-impaired neutrophil chemotaxis-decreased macrophage function
• Unimmunized Status• Limited sick behaviours
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Infants between 1 and 28 days old with a fever should be presumed to have a serious bacterial infection. (Level A Recommendation)
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<30 days old
• Admit• Full Septic Workup– CBC with differential– Blood Culture– Urine dip, R+M– Urine Culture– LP
• IV Antibiotics – Ampicillin/Cefotaxime– ?Acyclovir
• Chest Xray– Only if 1 of: RR>50,
Coryza, Cough, Nasal flaring,Grunting, Stridor, Rales, Rhonchi, Wheezing, ?WBC>20
• Stool Culture– If diarrhea or
>5WBC/Hpf
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Bugs
• Commonly:– Group B Streptococcus– Listeria Monocytogenes– E. Coli– Enterococcus
• Less Commonly:– S. pneumoniae, H. influenzae, N. meningitidis
• Rarely: – S. aureus, Salmonella
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Case 2
• 62 day old male– Mother concerned about possible increased
lethargy for 1 day– Rectal temperature 38.6C– Review of systems otherwise negative– Healthy, Immunizations UTD, normal pregnancy
• P/E: -Vitals: 38.7C, 133bpm, RR24, 100% Room Air -otherwise examines well (no focus of infection)
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Management Strategies
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Rochester Criteria• Management
– Option 1:• Admission• Observation • No Abx
– Option 2:• Full Septic Workup• Single Dose IM Ceftriaxone• F/U 24 hours
– Only if reliable parents!
• 233 infants • Low Risk Criteria
-appear well-previously healthy-WBC 5.0-15.0 -Bands <1.5-Urine <10 WBC/Hpf-Stool <5 WBC/Hpf (if
diarrhea)-NOTE: No LP criteria!
• NPV = 98.9%
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Philadelphia Criteria
• 747 patients• Low Risk Criteria
– WBC <15– Urine WBC <10/Hpf– Benign urine on R+M– CSF WBC <8/mm3– CSF Negative Gram Stain– Negative CXRay
• NPV = 98%
• Management– Full septic workup– Outpatient– No antibiotics
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Philadelphia Results
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Boston Criteria
• 503 patients• Low Risk Criteria– Not ill appearing– No ear, soft tissue, joint,
bone infection identified– WBC <20– CSF WBC <10 – Urine neg. leukocytes
• NPV = 95%
• Management– Full septic workup– Outpatient therapy– IM ceftriaxone
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Pittsburgh Criteria• 404 patients• Low Risk Criteria
– Well appearance– Not premature, No Abx, Not
ill– WBC >5 and <15– Bands <1500/mm3– CSF WBC <5– Urine WBC <9/mm3– Urine negative Gram stain– Stool WBC <5 (if done)– Negative CXRay (if done)
• NPV = 100%
• Management– Full septic workup– Admission – Observation – No Abx
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1-3 month old
• High Risk Management– Full Septic Workup– Admission– Empiric Antibiotics
• Cefotaxime• Ceftriaxone
• “Low Risk” Management– Guided by your study of
choice
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Case 3
• 2 year old male– 2 days of increased lethargy, decreased appetite– Rectal temperature 38.7C
• P/E: Vitals 38.7C, 125bpm, RR24, 99% Room Air -examines and appears well (no focus of infection)
- Healthy- Immunizations UTD- Review of Systems negative
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Alberta’s Routine Immunization Schedule
Two months • DTaP-IPV-Hib1• Pneumococcal conjugate• Meningococcal conjugateFour months • DTaP-IPV-Hib• Pneumococcal conjugate• Meningococcal conjugateSix months • DTaP-IPV-Hib• Pneumococcal conjugate• Meningococcal conjugate
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Prevnar Vaccine (PCV7)
• Covers Serotypes 4,6B,9V,14,18C,19F,23F• Polysaccharide conjugated to protein• Introduced in Calgary July 2002
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>3 months old
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Urine Studies
• Clinical decision rule to identify febrile young girls at risk of urinary tract infection
Gorelick MH et al. Arch Pediatr Adoles Med 2000;154(4):386-390
• 1469 females <2 year of age with UTI2 of 5: -Less than 12 months old-White race-Temperature of 39.0°C or higher-Fever for 2 days or more-Absence of another source of fever on examination
Sensitivity: 95% Specificity: 31%
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What about boys?
• No Clinical Decision Rule• Urine Cultures– All boys <6 months– Uncircumcised boys <12 months
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Chest Radiography
Level B Recommendation: A chest radiograph should be obtained in febrile children aged younger than 3 months with evidence of acute respiratory illness.
Level C Recommendation:Consider a chest radiograph in children older than 3 months with a temperature >39.0C and a WBC count greater than 20.
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Questions?
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Summary
• Sick? – Full Septic Workup/Admission/Empiric Abx
• <30 days old– Full Septic Workup/Admission/Empiric Abx
• 1 to 3 months old– Let the landmark studies guide you
• >3 months– Let the immunization status guide you