Academic day Flashcards

Question

Describe the Boston criteria

Answer 1

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

Answer 2

\> 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

Answer 3

\> 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

Answer 4

**\> 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

Answer 5

\> 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.

Answer 6

\> 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

Answer 7

\> 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%.

Answer 8

\> 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

Answer 9

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)

Answer 10

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.

Answer 11

? 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

Answer 12

●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.