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PEDS FEVER > Academic day > Flashcards

Academic day Flashcards

1
Q

Define Fever

A

> Elevation of core body temp > 38 degrees rectally

(Rosens and Uptodate definition)

** Temperatures greater then 38 cannot be attributed to bundling

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2
Q

Define hyperthermia

A

> Elevation in the body’s temperature set point (i.e heat stroke, ASA tox, hypothalamic damage)

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3
Q

Describe the age groups used in the approach to the febrile child

A

1) 0-28 days
2) 1-3 months
3) 3-36 months
4) 3yrs-adulthood

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4
Q

What is the most reliable method of temperature measurement, and when should you not use this method?

A

> Most reliable method= rectal thermometer

> Preferred method of measurement in high-risk groups (0 to 3 months old)

> Rectal route should not be used in patients who are potentially immunocompromised (eg, children with fever who are receiving cytotoxic chemotherapy) because of the risk of mucosal damage leading to bacteremia

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5
Q

What is a serious bacterial illness?

A

> Presence of pathogenic bacteria in a previously sterile site (UTI, bacteremia, meningitis, OM, pneumonia)

> When referring to meningitis and bacteremia, uptodate calls these etiologies “invasive bacterial infection” (IBI)

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6
Q

What is OCCULT bacteremia?

A

> Presence of pathogenic bacteria in the bloodstream in a WELL appearing child and in the absence of a focus of infection.

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7
Q

What are the most common bacterial and viral causes of fever in children < 28 days old?

A

Bacterial

  • GBS (GP cocci)
  • Listeria (GP bacilli)
  • Ecoli (GN bacilli)
  • Chlamydia (intracellular GN)
  • Gonorrhea (GN diplococcus)

Viral

  • HSV
  • Varicella
  • Enterovirus
  • RSV
  • Influenza (Rosens)
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8
Q

What are the most common bacterial and viral causes of fever in children 28 days- 3 months old?

A

Bacterial

  • Neisseria meningitidis (GN diplococcus)
  • Ecoli (GN bacilli)
  • Haemophilus (GN coccobacilli)
  • Strep pneumo (GP diplococci)

Viral

  • Varicella
  • Enterovirus
  • RSV
  • Influenza (Rosens)
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9
Q

What is the most common bacterial and viral causes of fever in children 3-36 months old?

A

Bacterial

  • Strep pneumo (GP diplococci)
  • Neisseria meningitidis (GN diplococcus)
  • Ecoli (GN bacilli)

Viral

  • Varicella
  • Enterovirus
  • RSV - Influenza
  • EBV
  • Roseola
  • Adenovirus
  • Norwalk
  • Coxsackievirus (Rosens)
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10
Q

What is early onset sepsis? and what are some risk factors?

A

> Early-onset neonatal bacterial sepsis (EOS) is sepsis occurring within the first seven days of life.

> Risk factors include GBS colonization, GBS bacteruria, previous infant with invasive GBS disease, prolonged rupture of membranes (≥18 h), maternal fever (temperature ≥38)

(CPS)

**These risk factors are essentially the same for IBI and SBI according to uptodate and also include:

  • Abx therapy in the last 7 days
  • Technology dependent
  • Chromosomal or congenital defect
  • Prematurity
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11
Q

What is the risk of SBI in children <3 months with fever?

A

> The risk of SBI in febrile infants < 3 months old with a temperature 38.0° C or greater is between 6% and 10% (Rosens)

>Children younger than 28 days old have the highest incidence (as high as 12%) (Rosens)

> Acording to Uptodate based upon observational studies performed since the introduction of conjugate vaccines, the estimated risk for bacterial infection in neonates 28 days of age and younger is as follows:

●Meningitis 0.3 to 3 percent

●Bacteremia or sepsis 1 to 5 percent

●UTI 16 to 28 percent

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12
Q

What are the rates of early onset GBS sepsis with no intrapartum antibiotic prophylaxis (IAP)?

A

> 1-2% (CPS)

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13
Q

Does the level of temperature elevation help predict if a child is at higher risk for bacterial infection vs viral?

A

> No aspect of the clinical presentation reliably distinguishes between bacterial and viral illness, including temperature (AAP)

** Although uptodate does use temperature as part of their criteria for working up 29-60 day old child with fever

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14
Q

How does circumcision affect rates of UTI in males?

A

> Circumcised males are at risk <6 months

> Uncircumcised are at risk until 1 year old

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15
Q

Approximately what was incidence of occult bacteremia in children 3-36 months before the introduction of conjugate vaccines?

A

> Before the adoption of the conjugate vaccines against Haemophilus influenzae type b and S. pneumoniae, the incidence of bacteremia in this population was approximately 5% (Rosens)

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16
Q

What is a conjugate vaccine?

A

> Combine a weak antigen with a stronger antigen so that the immune system will have a stronger response to the weaker antigen

17
Q

What is the current overall rate of occult bacteremia in immunized children 3-36 months?

A

> Less then 1%

(Rosens and Uptodate )

18
Q

When are children typically immunized against pneumococcus? HIB?

A

> Pneumococcus= 2, 4 and 12 months

> HIB= 2, 4 and 6 months

19
Q

What are the most common sites for SBI?

A
  1. UTI
  2. Bacteremia
  3. Meningitis
20
Q

How much fever response can be attributed to the degree of tachycardia?

A

> Theoretically, approximately 10 beats/min for every 1 degree

(Rosens)

21
Q

True or False, we can use a bag specimen for urine samples

A

False

22
Q

What is the purpose of the Rochester, Boston and Philadelphia criteria

A

> Originally intended to safely and reliably identify infants (0-90 days) who are febrile and at a low risk of having a treatable, potentially serious or invasive bacterial infection

> The creators intentionally valued sensitivity over specificity, looking to minimize failure to detect the presence of treatable bacterial infections

> Each tool performs well in that regard

23
Q

Describe the Rochester criteria

A

Determines whether febrile infants are low risk for serious bacterial infection (term, no pernatal abx, no chronic illness, no hospitalization > 1 month after delivery, no recent hospitalization, no unexplained hyperbilirubinemia)

> Age <60 days

> Temp > 38

> Well appearing no focus

> WBC’s 5000-15000

> Absolute band count <1500

> UA < 10 WBC/hpf

> Stool <5 WBC/hpf (if obtanied)

High risk= admission + abx

Low risk= home, no abx

Sensitivity 92% (reasonable but may not pick up all the true positives)

Specificity 50%

PPV=12%

NPV= 98.9%

24
Q

Describe the Philadelphia criteria

A

Determines whether febrile infants are low risk for serious bacterial infection

> Age 29-60 days

> Temp > 38.2

> Well appearing no focus

> WBC > 15000

> Band neutrophil ratio <0.2

> UA < 10 WBC/hpf (negative gram stain)

> CSF <8 WBC’s/hpf (negative gram stain)

> Normal chest x ray if done

> Stool negative if done

High risk= Admission with abx

Low risk= Home no Abx

Sensitivity 98% (will pick up most of the true positives) Specificity 42%

PPV 14%

NPV 99.7

25
Q

Describe the Boston criteria

A

Determines whether febrile infants are low risk for serious bacterial infection

> Age 28-90 days

> Temp > 38

> Well no focus

> WBC’s < 20000

> UA < 10 WBC/hpf

> CSF <10 WBC’s/hpf

> Normal CXR if done

High Risk= admission and Abx

Low risk= home empirical abx

Sensitivity not available

Specificity not available

PPV not avaiable

NPV 94.6

26
Q

What are some drawbacks of the Rochester, Boston and Philadelphia criteria?

A

> Requirement for LP in some

> not all less then 90 days, some are 60 and younger

> What if only one of the elements is positive? Is treatment overkill?

> prevnar

> Specificity for identifying patients with SBI is poor. Therefore large numbers of infants are considered high risk, receive broad-spectrum antibiotics, and may be hospitalized

> Fail to adequately identify neonates (≤28 days) at low risk for SBI

27
Q

What is the step by step appraoch?

A

> Available on med calc

> Developed by a group of emergency physicians in Europe

> Validated- was better then Rochester in that study

> Lowest number of patients with SBI in patients who were determined to be low risk

> Uses 21 days- 4/7 of the missed patients were 22-28 days

> 5 specific steps- if yes to any step then they are high risk patient

> Unfortunately uses PCT- not univerally avaiable in a clinically relevant time frame

> But some people seem to modify it

> Low risk get f/u

> Intermediate gets further workup IV Abx and possible admssion

> High risk is admitted with IV abx

28
Q

What is your workup and possible treatment for a child < 28 days old who appears well but is presenting with fever?

A

> This is the easy group!! Do it all!

> Uptodate recommends a a full septic workup, admission and Abx

> Rosens recommends a a full septic workup, admission and abx

> TREATMENT

Ampicillin 50mg/kg q 6 hours to cover Listeria

Cefotaxime 50g /kg q 8 hours to cover GBS, Nisseria, Strep Pneumo, Ecoli

+/- Acyclovir 60mg/kg/day divided q8h

+/- Vanco 40-60mg/kg/day q 8h

** remember cant use CTX in children less then 30 days because of a theoretical risk of inducing acute bilirubin encephalopathy as ceftriaxone causes bilirubin to be displaced from its protein binding sites

** remember if you find a focus like a cellulitis a full septic workup is still recommended in this age group

29
Q

What is your workup and possible treatment for an immunized child 1-3 months old who appears well but is presenting with fever?

A

> Although there is a relative consensus as to the evaluation and management of febrile infants younger than 28 days old, there is debate about the appropriate evaluation for the slightly older febrile infants

> ROSENS: Divides it into 29-90 days. Use the traditional criteria Rochester, Phildelphia, Boston Criteria

TREATMENT if no high risk features according to traditional criteria:

> d/c home and have followup in 24 hours

TREATMENT if high risk according to traditional criteria: then

> admit and Abx (CTX +/- vanc)

Another option is give empiric Abx CTX 100 mg/kg bring back in 24 hours if say they have only one of the features is abnormal (ie WBC of 16)

**Remember do not give empiric Abx and discharge if you have not done a full septic workup (i.e LP)

> UPTODATE: Divides it into 29-60 days and then 60-90. If no risk factors for IBI, no infectious focus, no immunization within the previous 48 hours then do CBC, PCT, CRP, CXR, Urine and blood culture THEN LP if any are postive

POSITIVE:

  • Temp >38.6
  • WBC ≤5000 or ≥15,000
  • Absolute band count >1500

•PCT >0.3 ng/mL

  • CRP >20 mg/L (2 mg/dL)
  • Immature to mature neutrophil (band to poly) ratio >0.2
  • If pneumonia on chest radiograph

TREATMENT if a positive criteria then do an LP

> If nothing postive then no ABx and follow up

> If a positive criteria give empiric Abx CTX 50 mg/kg and admit or bring back in 24 hours

> obviously if CXR or CSF is positive then treat accordingly

** When you bring a patient back after CTX over and over, you are waiting for the cultures to be resulted.

30
Q

What is your workup and treatment for an immunized child 3-36 months old who appears well but is presenting with fever?

A

> Typically, focal infections are apparent on the basis of history and physical examination findings, and diagnostic testing and treatment should be directed accordingly.

> The evaluationof highly febrile children 3 to 36 months old has evolved from one of universal screening for occult bacteremia to one where clinicalgestalt determines the need for blood work

31
Q

What is the risk of cocomitant bacteremia in children > 3 months of age and a recognizable viral syndrome?

A

> In over a study with over 1300 patients with temperature above 39.0°C, who had a recognizable viral syndrome, the risk of bacteremia was 0.2%.

32
Q

In children less then 60 days old does a positive viral study or obvious focus like a cellulitis or UTI, rule out cocomitant SBI?

A

> No

> Overall these chidren with + viral studies or objective foci do have less inicidence of SBI however not low enough to not continue to work the child up (ROSENS)

> The work up can be modified in older children but not in children less then 28 days (UPTODATE)

> Blood brain barrier is quite open in the very young and therefore bacteria from UTI can more easily cause menningitis so all these patients still need a urine

33
Q

List 10 non infectious casues of fever in children

A

Use the DIMES pneumonic

D- drugs

salicylates, iron, sympathomimetics, MH, NMS, serotonin syndrome, thyroid

M- metabolic

Metabolic, Leukemia, Lymphoma, Neuroblastoma, Wilms tumor, Juvenile RA, **kawasaki’s disease**, Vasculitides, hyperthyroidism

E- Enviornmental

S- Structural

Central stroke/brain tumour, CNS hemorrhages usually cause hyperpyrexia (>41.5 c)

34
Q

Lets review those approaches again

A
35
Q

What are the low risk criteria for meningitis?

A

Children who lack all of the following criteria have a low risk (0.1%) of bacterial meningitis:

–Positive CSF Gram’s stain

–CSF ANC of at least 1000 cells/mL

–CSF protein concentration of at least 80 mg/dL

–Peripheral blood ANC of at least 10,000 cells/mL

–History of seizure before or at the time of presentation.

36
Q

When should you perform a urinalysis and culture in a child less then 3 years old?

A

? Always (CPS)

Recent 2019 meta analysis by McDaniel CE, Ralston S, Lucas B, Schroeder AR:

When a positive UA result is added as a diagnostic criterion, the estimated prevalence of concomitant UTI is less than recommended testing thresholds for children with bronchiolitis >28 days old

37
Q

What are some inidications for CXR in the febrile child?

A

●Very high WBC (> 25,000)

●Hypoxemia

●Respiratory distress

●Tachypnea

●Focal lung findings on auscultation

●High fever > 39 C and an elevated ANC*

**Since the advent of universal vaccination, the number of occult pneumonias has declined (15% to 9%) but is not yet low enough to recommend not obtaining radiographs on highly febrile children with leukocytosis or elevated ANC and no other apparent source ofinfection.

PEDS FEVER (4 decks)

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