occult bacteremia - define: - epidemiology - labs

define: "occult bacteremia" = only a little fussy + bacteremia ==> low risk of SBI " septic" = appears ill, toxic + bacteremia ==> high risk of SBI; medical emergency epidemiology of occult bacteremia - use of vaccines = decreased risk of Strep pneumo, H inflluenza - other causes of occult bacteremia = Neisseria meningitidis, Salmonella enteritidis LABS - if immunized --> less likely true high WBC - if other RFs for SBI --> supported by high WBC, left-shift (bands)

Case 10: infant- Fever Flashcards by Marijana Waite

diffdx fever in an infant

vaccinations (w/in 24-48h) = esp. live vaccines; MMR/varicella = 7-10d fever post-vaccine

viral syndrome

URI
meningitis
acute gastroenteritis
HSV gingivostomatitis
roseola
fifth disease

SBI

UTI
meningitis
sepsis
pneumonia
bacterial gastroenteritis
osteomyelitis
septic arthritis
soft tissue infection

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signs of meningitis in infants (<12mo)

fever
hypothermia
bulging fontanelles
lethargy
irritability
restlessness
paroxysmal crying (crying when picked up)
poor feeding
vomiting and/or diarrhea
nuchal rigidity
opisthotonos = icreased extensor tone of neck and spine –> hyperextension of entire spine

+/- Kernig / brudzinski’s sign (usually >12mo)

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occult bacteremia

define:
epidemiology
labs

define:
“occult bacteremia” = only a little fussy + bacteremia ==> low risk of SBI
“ septic” = appears ill, toxic + bacteremia ==> high risk of SBI; medical emergency

epidemiology of occult bacteremia

use of vaccines = decreased risk of Strep pneumo, H inflluenza
other causes of occult bacteremia = Neisseria meningitidis, Salmonella enteritidis

LABS

if immunized –> less likely true high WBC
if other RFs for SBI –> supported by high WBC, left-shift (bands)

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when to use antibiotics and what kind, if you are worried that this kid has a serious bacterial illness (SBI) from a UTI

1) prophylactic antibiotics ==> can reduce UTI recurrence (esp. in kids with veisucoureteral reflux), but does NOT prevent renal scarring

2) ORAL > IV antibiotics
- in most cases

3) IV > oral
- if pts are toxic
- if unable to retain oral meds
- if concerned about compliance with oral meds

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define: Kernig’s sign

resistance to extension of the knee. (d/t to pain)

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define: Brudzinski’s sign

flexion of the hip and knee in response to flexion of the neck by the examiner

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diffdx of infant with a fever

sxs:
signs:
RFs:

0) VACCINE RXN = within 1-2d after

1) UTI
- sxs: fever; fussiness, lack of appetite; no focal signs
- signs: temp >39, >/= 24h without a source
- RFs: uncircumscribed male <6mo; female < 24mo

2) PNEUMONIA
- sxs: cough, tachypnea, fever, rales, low SaO2
- RFs: non-immunized

3) SEPSIS / BACTEREMIA =systemic response to infectious agent –> inflammation throughout body –> vasodilation, leukocyte accumulation, increased capillary permeability
- sxs: hypo/hyperthermia; “toxic;”
- signs:
1) early = tachycardia
2) late = end-organ hypoperfusion; delayed capillary refill; low BP, AMS, organ failure

4) OCCULT BACTEREMIA
- sxs: positive blood culture in a well-appearing child
- low risk of serious bacterial illness

5) BACTERIAL MENINGITIS (sxs of bacterial&raquo_space; viral) ==> S. pneumoniae; N. meningitidis
- signs: bulging fontanelle, nuchal rigidity / other signs of meningismus

6) VIRAL MENINGITIS ==>enterovirus
- sxs: less severe v. bacterial; fever; loose stools, rashes, URI

7) ROSEOLA = viral illness (HHV-6)
- sxs: (1) high fever for 3-5d; (2) rash for 1-4d
- RFs: kids <2y

8) PRIMARY HSV GINGIVOSTOMATITIS
- sxs: (1) fever, irritability, (2) oral lesions = vesicles –> ulcerations
- RFs: kids 10mo-3yo

9) OTITIS MEDIA
- sxs: poor mobility, mild bulging of tympanic membrane (+/- red TM)

10) VIRAL URI
- congestion, cough, rhinorrhea, coryza

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w/up for fever without a source

UA, urine culture (catheterized or suprapubic catheterization)
CBC with differential
blood culture = for child that is ill-appearing, pale, inconsolable
lumbar puncture = for child that is ill-appearing, pale, inconsolable

IF NEEDED:

(diarrhea) stool guaiac, fecal leukocytes –> stool cultures
(lower respiratory tract disease, WBC > 20K) = CXR
rapid test for viral respiraotry pathogens
inflammatory markers = CRP, procalcitonin, IL-6

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in an immunized child with no respiratory findings and looking well, is a WBC necessary to r/out a pneumonia?

NO. because not likely to be a pneumonia in the first place

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in an immunized child with no respiratory findings and looking well, is a CBC/WBC necessary to r/out a pneumonia?

NO. because not likely to be a pneumonia in the first place

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in a fully immunized child (3-36mo) who appears well, normal fontanelle, no nuchal rigidity / other signs of meningismus, is a LP necessary to r/out a meningitis?

but you do need in <3mo –> b/c young infants CAN lack these signs and still be septic.

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in a fully immunized child (3-36mo) who appears well, normal fontanelle, no nuchal rigidity / other signs of meningismus, is a LP necessary to r/out a meningitis?

but you do need in <3mo –> b/c young infants CAN lack these signs and still be septic.

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most likely cause of serious bacterial illness

UTI

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18mo kid comes in only with a sore throat. do you perform a throat culture / rapid strep test?

strep pharygitis is unusual in young children
acute rheumatic fever rarely occurs in children <3yo

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describe how to interpret a UA for UTI

positive UA = positive nitrite, positive leukocyte esterase

positive pyuria (WBCs in urine): >5 WBCs per HPF
positive nitrite (reduced urinary nitrate into nitrite) ==> presence of bacteria in urine
positive leukocyte esterase test (presence of WBC releasing esterases released from broken-down leukocytes)

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you think a kid 2yo has a UTI, but the UA is negative for nitrites. how do you interpret this?

negative nitrite has poor sensitivity (lots of false negatives)

b/c young infants have little control over urination; it takes ~4h for bacteria in urine to reduce nitrite.

so can have UTI, but not detect nitrite

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what are the follow-up studies for an episode of pyelonephritis

1) US of kidneys and bladder == renal structure, dilatations in collecting systems
==> for first febrile UTI, @ completion of Abx course (or earlier if needed)

2) Renal technetium scan == evidence of pyelonephritis
==> for those not responding well to treatment

3) Voiding cystourethrogram (VCUG) == presence of vesicoureteral reflux (VUR)
==> esp. for US findings of high-grade VUR (== hydronephrosis)
==> after 2nd febrile UTI

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common cause of UTI in young infants

high-grade VUR (== hydronephrosis)

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Management of a young, febrile child

NOT empiric treatment with prophylactic Abx==> b/c most who are immunized will not develop bacteremia

w/up for source of infection

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Management of pyelonephritis

most common cause of pyelo = E. coli; Klebsiella, Proteus, enterococcus

PARENTERAL ABX

1) Ampicillin/gentamicin ==> E. coli, enterococci
2) Ceftriaxone ==> GNR
* * do NOT give at same time as Ca-containing meds –> Ca precipitates in lungs, kidneys
3) Piperacillin/tazobactam ==> GNR, Pseudomonas
4) Ciprofloxacin ==> complicated UTI with resistant organisms; children > 1yo

ORAL ABX

1) Cephalexin = best
2) Ciprofloxacin (same concentration in IV v. oral) - concerns about s/e profile (articular cartilage)
3) Amoxicillin/clavulanate n- concerns about s/e profile (skin, GI)

for UTI/cystitis, not pyelo
1) Nitrofurantoin = therapeutic level only in urine, NOT in blood

which do NOT use d/t resistance
- Sulfisoxazole

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what antibiotic can you not give with Ca-containing medications

Ceftriaxone

Ceftriaxone + Ca-containing meds –> Ca precipitates in lungs, kidneys

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define: fever without source

v. fever of unknown origin

fever without source = complete hx has been obtained and detailed physical exam performed, with no identified source for fever (usually viral)

fever of unknown origin = temperature greater than 38.3 C (101 F) for at least two weeks’ duration with failure to reach a diagnosis after one week of evaluation

management guidelines for fever without a source

in a fully immunized child (esp. PCV7), decreased likelihood of bacteremia (esp if WBC < 15,000) –>so no need to treat prophylactically
- almost all children now with elevated WBC represent false positives for bacteremia

1) discuss concerns with parents
2) close & careful follow up
3) document findings

ONLY TREAT PROPHYLATICALLY with ABx if
- develop more serious sxs

Holly is a previously well 6-month-old girl with a 2-day history of high fever, fussiness, and poor appetite. On exam she is tachycardic, pale, and inconsolable but without apparent source for her fever.

Of the following, which do you think are the more likely causes of Holly’s illness?

 Multiple Choice Answer:
A		Bacterial meningitis	
B		Herpes simplex virus gingivostomatitis	
C		Occult bacteremia	
D		Otitis media	
E		Pneumonia	
F		Roseola (Exanthem subitum)	
G		Sepsis/bacteremia	
H		Urinary tract infection	
I		Vaccine reaction	
J		Viral meningitis	
K		Viral upper respiratory tract infection

bacterial meningitis
roseola
sepsis/bacteremia
UTI
viral meningitis

physical exam rules out otitis media, HSV gingivostomatitis
too ill to have occult bacteremia
fully immunized without respiratory sxs = less likely pneumonia, viral URI
too far out to be from vaccines (only MMR, given >6mo would lead to rsn this late)

indications to do a lumbar puncture

1) high pre-test probability of meningitis ==> febrile, ill-appearing infant (esp. <3mo) 2) where the treatment can be dangerous (e.g. IV abx that can cross BBB) ==> esp at the high doses needed to treat bacterial meningitis 3) fever in infant <1mo (regardless of sxs) otherwise, would be reasonable to: 1) give an antipyretic and wait 1 hour ==> she may be alert, interactive, more comfortable

common causes of meningitis in kids

E. coli ==> the same bugs that come from UTIs

concerns about ciprofloxacin in children

s/e of damage to articular cartilage (knee) --> arthropathy with cartilage erosions INDICATED USE (children >1yo) - cystic fibrosis for pseudomonas infections - complicated UTI - pyelonephritis - postexposure treatment for inhalation anthrax

kiddo has had a few UTIs. should you give them prophylactic abx, and what are you hoping to do with it?

prophylactic antibiotics ==> can reduce UTI recurrence (esp. in kids with veisucoureteral reflux) but does NOT prevent renal scarring

A 6-month-old infant arrives in the ED with a 12-hour history of poor feeding, emesis, and irritability. On exam, she is ill-appearing with T 39.2 C, P 160 bpm, R 40 bpm, BP 80/50 mmHg. CBC shows WBC 11.2, Hgb 13.5, Plt 250. Urinalysis shows > 100 WBC per hpf, positive leukocyte esterase, and positive nitrites. She has no history of prior urinary tract infection. Chest x-ray is negative. Urine and blood cultures are pending. After bringing her fever down, she was still uninterested in drinking, but her exam improved, and you were confident she did not have meningitis, so an LP was not performed. Which of the following is the best next step in management? ``` A Oral ampicillin B Oral ampicillin + gentamicin C Intravenous ciprofloxacin D Intravenous ceftriaxone E Intravenous piperacillin + tazobactam ```

D she looks ill UTI --> likely pyelo b/c systemic probs E. coli = want to cover GNR Given the ill appearance, vital signs, and white count, Upper tract disease (pyelonephritis) should be strongly considered. A parenteral (IV/IM) third-generation cephalosporin is the best choice of those listed for pyelonephritis, given its excellent gram negative coverage (except for Pseudomonas). this kiddo has no RF for pseudomonas (no cystic fibrosis)

A 3-month-old male presents to the ED with a fever that started the previous day. Mother reports that he was fussy and had decreased oral intake. He had had five fewer diaper changes than usual. He had no vomiting, diarrhea, or respiratory difficulty. On physical exam his temperature is 101.6 F, pulse 110 bpm, RR 24 bpm, and BP 95/67 mmHg. The baby seems irritable and is not consolable by the parent. HEENT exam was significant for dry mucous membranes. Other than his irritability, the rest of the physical exam was unremarkable. CBC showed WBC 3.5, but was otherwise normal. BMP was within normal limits. Urinalysis showed positive leukocyte esterase, positive nitrite, and WBCs > 10/hpf. An LP was performed, and urine and CSF culture results are pending. The patient is placed on IV fluids and is started on cefotaxime. What is the next best step in evaluation? ``` A Renal bladder ultrasound B Kidney-ureter-bladder (KUB) x-ray C Intravenous pyelogram D VCUG E Oral ampicillin ```

A. irritable - ill dehydrated wouldn't do any of those other tests until abx are done or are shown not to be working (usually) This infant has a fever without other respiratory symptoms. Meningitis and UTI must be considered in patients with fever. The only way to rule out meningitis is by lumbar puncture. This patient has a low WBC, suspicious for sepsis, and a UA that is highly suggestive of UTI. Empiric therapy should be started to cover common organisms including E.coli, P. mirabilis, and Klebsiella. Cefotaxime is reasonable empiric therapy. Renal ultrasound is recommended for all infants with pyelonephritis to assess for renal structural abnormalities or signs of obstructive uropathy (hydronephrosis). no oral abx for pyelo inpatient

A 10-day-old boy is brought to the ED by his mother because of “fever.” Mom describes that the baby has been “sleepy” and feeding less vigorously than in the previous two days. She believes his urine output has also decreased. His birth history is notable for prolonged membrane rupture (about 32 hours), and maternal fever at the time of delivery. Prenatal and neonatal ultrasound revealed bilateral hydronephrosis. On exam, the infant is sleepy with a temperature of 38.5 C. A blood sample is sent for CBC, BMP, and culture. Attempts are made to obtain CSF and urine for analysis and culture, but only very small volumes of these fluids are obtained. Volume resuscitation is begun. Chest x-ray is performed with indeterminate results. What is the most appropriate next step? A Send samples for gram stains and begin parenteral empiric antibiotic treatment B Send the urine for urinalysis and the CSF for cell count, glucose and protein and begin parenteral antibiotic therapy C Admit for observation and continue supportive care D Send samples for culture and begin parenteral antiobiotic treatment E Attempt to obtain larger samples. Antibiotics should not be started until all needed results are pending.

D ill dehydrated hydronephrosis get all the tests. young baby could have sepsis culture better v. lab tests to find specific organism Given the presentation of fever in a neonate who presents with sleepiness and poor feeding, samples should be sent for culture and the baby started on empiric antimicrobial therapy. This infant is likely to have a urinary tract infection, and urosepsis is certainly a possibility, especially given his known urinary tract anoamlies. We have no way of ruling out meningitis from this presentation, so antibiotics should be initiated at meningitic dosing. In an infant younger than one month, fever with any suspicion of sepsis, whatever the source, requires immediate evaluation and initiation of antibiotic treatment. Because infants at this age have immature immune systems, they do not localize infections as well as older children. An infection of the urinary tract may lead to bacteremia, which in turn may lead to CNS infection. Only cultures will give us the information required to determine the appropriate type length of antimicrobial therapy.

A 6-month-old female is brought into the pediatrician’s office for three days of high fever, fussiness, and decreased appetite. The patient has not had any upper respiratory tract symptoms, vomiting, diarrhea, or rash. On physical exam the patient is fussy, has a RR of 28 bpm and a pulse of 160 bpm. She is febrile to 102.8 F (rectal). The patient is alert and fully moving all extremities. Apart from her vital signs, no other significant exam findings are noted. A CBC demonstrates leukocytosis of 17.0 cells x 103 / µL with elevated bands. What diagnosis is most likely? ``` A Measles B Bacterial meningitis C Acute otitis media D Urinary tract infection E Roseola ```

D fussy, sick but not toxic UTI, the most common bacterial illness in a female infant, is consistent with her high fever, fussiness, and decreased appetite. Her CBC suggests that she has a bacterial infection (leukocytosis and elevated bands). A sample of her urine should be obtained by catheterization and sent for urinalysis and culture.

A 6-month-old female with normal birth and developmental history presents with fever for the past two days, fussiness, and decreased appetite. ROS is negative. No abnormalities are noted on the physical examination. A urinalysis from a bag specimen is positive for leukocytes and nitrite, which suggests the presence of a UTI; a culture from this sample is pending. The patient is ill-appearing, dehydrated, and unable to retain oral intake. She is hospitalized, receives a 20 cc/kg NS bolus and is placed on maintenance IV fluids with clinical improvement. What is the best next step for management of this patient? A Urinary catheterization B Renal bladder ultrasound C Begin parenteral antimicrobials D Midstream clean catch urine collection E Increase intravenous fluid administration rate to flush the kidneys

A. Urinary catheterization is correct . It is the best method for obtaining a specimen for culture that has not been contaminated by perineal bacteria (as it would be if from a bag), and for this ill child, you must determine the cause of the fever with accuracy. sick baby dehydrated can't take oral

which of the following is a true statement re body temp a. the first phase of a febrile response often is assoc with feeling cold b. normal body temp is usually highest on waking in the AM c. parental reporting of tactile fever is an accurate measure of the presnce of true fever d. the control of body temp is primary regulated by the thalamus e. measuring the temperature of the tympanic membrane has been proven to be the most accurate method of determining body temperature

which of the following is NOT a known complication of fever associated associated with infection? a. tachycardia b. increased catabolism c. seizure d. cerebral damage e. tachupnea

you are evaluating a 10mo girl who has had a temp to 102.0F (38.9C) for 2d. her parents deny other sxs except a slight increase in fussiness. her immunization are up to date. findings on physical examination are normal and she appears well. which of teh following tests i most helpful in estabolishing a dx in this child? a. blood culture b. cbc c. urine culture d. crp e. chest radiography

you are taking call one night when a worried mother phones you b/c her 2yo son has a temp of 103F (39.5C) 1h ago that has not resolved with a dose of acetaminophen. she reports taht he is eating well and still playful and she denies other sxs. of the followting which is the most appropriate advice? a. she should give another dose of acetaminophen immediately b. she should encourage fluids and monitor for thedevelopment of other sxs c. she should place the boy in a cool bath untl his temp is normal d. the child needs immediate attention b/c the last of response to antipyretics indicates a serious bacterial infection e. the height of the fever indicates a bacterial infection so antibiotics should be given

the parents of a 4yo infant are concerned that he is irritable and feels warm. they should measure temp: a. with infrared TM thermometry b. with temporal artery themometry c. in the axilla d. rectally e. using a pacifier thermometer for an oral temperature

the rate of occult bacteremia in a fully immunized well appearing 18mo child is a. 0.1% b. 0.2% c. 0.7% d. 1.5% e. 3%

a parents call the office to say their 4yo has daily fever to 39 for 8d without other sxs. managementof fever of unknown origin (FUO) in this child can begin with a. phone advice to visit the office if there are sxs other than fever b. a hx and PE in the office c. a hx and PE + CBC, blood Cx, UCx, stool Cx, and CXR d. the choices in C + CRP, ESR, serum chemistries, ANA and rheumatoid factor e. admission to the hospital + consultations from peds ID, heme/onc and rheumatology

a good option for treatment of fver is a. acetaminophen, 10mg/kg, q6-8h b. acetaminophen, 20mg/kg, q4-6h c. alternating acetaminophen, 15mg/kg,and ibuprofen 10mg/kg q4h d. ibuprofen 5mg/kg q4h 3. ibuprofen 10mg/kg q6h

a good way to combat "fever phobia" is to a. not disucss fever at health maintenance visits b. give specific instructions about treating a temp > 38.5C wiht antipyretics c. talk about "fever therapy"instead of "fever control" d. instruct parents on how to measure temp most accurately e. explain that fever is more predictive of bacterial infections

a UTI is suspected as the cuase of fever in a 3mo, uncircumcised boy who has had a tmep of 39C. in order to properly diagnose and treat UTi in this age group , the work up shouldbe a. a bag urine specimen sent for UA, microscopy and culture b. a suprapubic bladder aspirate sent for UA, microscopy and culture c. a bag urine specimen set for UA, microscopy and culture, only if multiple attempts to collect the urine via catheterization have failed D. UA and microscopy viabag specimen, followed by culture of a catheterized spcimen if there are abnormalities in the uA and microscopy e. if catheterization has failed, just treat for a presumptive UTi

in neonates (,29do) with fever of 38C or higher and no other findings on hx or PE, the initial work up includes a. a CBC, blood Cx, UA, urine Cx. CSF need only be collected if the infant does not have low risk lab results b. a CBC, blood Cx, UA, urine Cx, CXR, and stool Cx. CSF need only be collected if the infant does not have low risk lab results c. a CBC, blood Cx, UA, urine Cx. CSF for gram stain, culture, cell count, glucose and protein d. a CBC, blood Cx, UA, urine Cx. CSF for gram stain, culture, cell count, glucose and protein and HSV and/or other viral PCR studies

a 45do infant has a 1d hx of watery diarrhea. VS are temp 38.5C, HR 160, RR 50, BP 70/35, O2 sat 97% on RA. there are no other findings on hx or PE, the initial lab work up includes: a. a CBC, blood Cx, UA, urine Cx. b. a CBC, blood Cx, UA, urine Cx and CSF studies c. a CBC, blood Cx, UA, urine Cx and CSF studies, CXR and stool culture d. a CBC, blood Cx, UA, urine Cx., stool leukocytes e. a CBC, blood Cx, UA, urine Cx, CXR, stool culture

a14 do with a fever of 38.3C and no source on PE has hte following lab results CBC: WBC 17.6 , 2000 bands, Hb 13.6, plt 444 UA: 1.015, LE neg, nitrate neg, 0-5 RBC/wpf, 0-5 WBC/hpf CSF: no organisms, glucose 46, protein 117, 12 RBCs, 102 WBCs your choice for intiial antibiotic therapy is: a. ampicillin, ceftriaxone and acyclovir b. ampicillin, gentamicin and acyclovir c. ampicillin, gentamicin d. ampicillin, ceftriaxone e. ceftriaxone

which infant meets low-risk criteria, and can be discharged home with a f/up within 12-24h? presume infants all are well-appearing, previously healthy and haveno obvious source of infection and that the parents are reliable have telephone access and transportation a. 20d old with a temp of 38.1C, UA 5 WBC/hpf, negative urine gram stain, CBC with 7000, WBC 1000 band forms b. 40d old with a temp of 38.1C, UA 5 WBC/hpf, negative urine gram stain, CBC with 7000, WBC 1000 band forms c. 60d old with a temp of 38.1C, UA 15 WBC/hpf, negative urine gram stain, CBC with 7000, WBC 1000 band forms d. 40d old with a temp of 38.1C, UA 5 WBC/hpf, negative urine gram stain, CBC with 7000, WBC 2000 band forms e. 60d old with a temp of 38.1C, UA 15 WBC/hpf, negative urine gram stain, CBC with 7000, WBC 2000 band forms

a well appearing 45do infant with fever to 38.8 Cmeets all low-risk critera. an LP is not performed. the infant has reliable parents, and access to transportation and telephone. the parents wish to go home and see their pediatrician tomorrow. the pediatrician is willing to see them tomorrow. further management should be: a. family can be discharged home without antibiotics, with an appointment within the next 24h b. family can be discharged home after a dose of ceftriaxone, with an appointment within the next 24h c. infant should be admitted to the hospital for observation without Abx d. infant should be admitted to the hospital for observation for IV ceftriaxone e. infant should be admitted to the hospital for observation for IV ampicillin and ceftriaxone

You are on your second day of newborn nursery in Concord. The nurse taking care of the term newborn that you saw yesterday tells you that he has a rectal temperature of 38.8, a HR of 170 and a RR of 70. This infant is 72 hours post a c-section delivery for PROM. You were getting ready to do his discharge examination. A. Ask the nurse to un-bundle the baby—he’s probably just environmentally overheated—and do the discharge exam B. Disregard the temperature because it was taken with a temporal artery thermometer—do the discharge exam C. Examine your patient, watch and wait for a while Examine your patient, order D. a CBC, blood culture, UA, urine culture Examine your patient, order E. a CBC, blood culture, UA, urine culture, do a lumbar puncture

E baby < 1week old (DO THE FULL THING EVEN IF NO SXS) risk for serious bacterial infection obviously unimmunized

``` All the lab results, including the CSF were normal, and the baby was started on ampicillin and gentamicin. He has not had further fever, and his HR and RR have come down a bit. At 14 hours after laboratory samples were sent, the lab calls to say the blood is growing gram positive cocci in chains. The most likely pathogen is: A. Staphylococcus aureus B. Streptococcus agalactiae C. Streptococcus pneumoniae D. Enterococcus faecalis E. Listeria monocytogenes ```

B PROM and unsure GBS status GBS + Enterococcus = 85%

You are really enjoying your outpatient pediatric experience in Gorham. Dr. Beale is a great teacher. The last patient of the day is a 2 week old you saw in the hospital after delivery. The infant comes in for her two week check, and has a rectal temperature of 38.5 C. Her mother was GBS+ and incompletely treated. Everyone has a cold, and the baby’s PE is normal. Your initial work-up and management are: A. None. It’s difficult to get a full work-up in Gorham, and the baby likely has a cold. Have them come back tomorrow for a re-check. B. Obtain a CBC, blood culture, UA, urine culture; do the LP only if high risk criteria are met. Antibiotics only if abnormalities are found. C. Obtain a CBC, blood culture, UA, urine culture, LP. Antibiotics only if abnormalities are found. Obtain a CBC, blood culture, UA, urine culture, D. LP. Give first dose antibiotics and admit the patient to the hospital

D any neonate (<30d) with a fever should be full workup + empiric an`tibiotics

You are in Exeter having a busy day—everyone is behind by 2 patients when you see a 14 month old boy with 4 days of fever to 40.5 C. His father reports he is fussy when febrile, but gets better with antipyretics. He is fully immunized. In the office, his temperature is 39.1 C tympanic. He is interactive and plays with a toy, but does not want to get off his father’s lap. There are no findings on PE. When presenting to your preceptor, you recommend: A. No work-up, this is likely viral. Have them back in a day or 2 to see how he is doing B. Obtain a catheterized urine sample to look for UTI in this circumcised boy C. Obtain a CBC and BCx to screen for occult bacteremia D. Obtain a catheterized urine sample and a CBC and BCx E.Initiate a full work up for Kawasaki disease

A. 14 month old for UTI = would expect this to be the cause of fever due to if came back with rash all over his face and body == would expect roseola (+ high fever, bulging fontanelles)

You come into the ward at CPMC one morning, and are short on patients. The attending asks you to see a 21 day old admitted for fever of 39.2 C last evening. He has WBCs 7.9, 10% band forms, plts 334. UA was normal, CSF had 5,000 RBC, 400 WBCs, glucose 46, protein 102, no organisms on gram stain. Culture and viral studies are pending. He is being treated with ampicillin and gentamicin. On examination he is sleepy, and he has not eaten much overnight. You suggest: A. Continue the plan from overnight B. Start maintenance fluids and continue the current antibiotics C. Place a nasogastric tube to supplement nutrition and continue the current antibiotics D. Start maintenance fluids, continue the current antibiotics, add acyclovir E. Place a nasogastric tube to supplement nutrition, continue the current antibiotics, add acyclovir

D or E <29 day old == CSF pleocytosis (high WBC) --> add acyclovir 5000 RBCs could be traumatic tap or could be HSV

In August, you are at South Royalton and see a three year old with 12 hours of fever to 38.5, headache, photophobia, and neck stiffness. He is awake and alert, but in pain. He answers all questions in an age-appropriate manner. On PE, your only finding is neck stiffness. Laboratory work-up should include: A. None—this is likely viral meningitis due to enterovirus. The treatment is supportive care. B. Complete blood count, blood culture, Lyme serology. Lumbar puncture only needs to be done if the results are high-risk. C. Complete blood count, blood culture, Lyme serology, lumbar puncture. Empiric antibiotic treatment with ceftriaxone if there is CSF pleiocytosis with a negative gram stain. D. Complete blood count, blood culture, Lyme serology, lumbar puncture. Empiric antibiotic treatment with ceftriaxone and vancomycin if there is CSF pleiocytosis with a negative gram stain. E. Complete blood count, blood culture, Lyme serology, lumbar puncture. Empiric antibiotic treatment with ceftriaxone, vancomycin and acyclovir if there is CSF pleiocytosis with a negative gram stain.

D HSV expected in younger kid (but can't assess mental status). if HSV in older kid == would be HSV encephalitis ==> would be very sick If an older kid has good mental status, ``` ceftriaxone = strep pneumo vancomycin = beta-lactamase strep pneumo ``` NOT strep pneumo meningitis == because would likely be sicker --> likely enteroviral or CNS lyme disease ==> ceftriaxone