Chapter 167

Question 1

Define Fever

Answer 1

> Elevation of core body temp > 38 degrees rectally

(Rosens and Uptodate definition)

Question 2

Define hyperthermia

Answer 2

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

Question 3

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

Answer 3

> 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

Question 4

What is a serious bacterial illness?

Answer 4

> 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)

Question 5

What is OCCULT bacteremia?

Answer 5

> Presence of pathogenic bacteria in the bloodstream in a WELL appearing child and in the absence of a focus of infection. The term typically refers to children 3 to 36 months old who are highly febrile (>102.2°F [39.0°C]).

Question 6

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

Answer 6

Bacterial

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

Viral

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

Question 7

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

Answer 7

Bacterial

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

Viral

• Varicella
• Enterovirus
• RSV
• Influenza (Rosens)

Question 8

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

Answer 8

Bacterial

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

Viral

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

Question 9

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

Answer 9

> 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 iand also include: - Abx therapy in the last 7 days - Technology dependent - chromosomal or congenital defect - prematurity

Question 10

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

Answer 10

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

>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

Question 11

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

Answer 11

> 1-2% (CPS)

Question 12

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

Answer 12

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

Question 13

How does circumcision affect rates of UTI in males?

Answer 13

> Circumcised males are at risk <6 months

> Uncircumcised are at risk until 1 year old

Question 14

List six causes of petechiae in a febrile child

Answer 14

Meningococcemia, DIC, HSP, leukemia, HUS,TTP, ITP, rocky mountain spotted fever

Question 15

List IV meds for MRSA

Answer 15

1. vanco
2. linezolid
3. dapto
4. oritavancin
5. dalfopristin
6. tigecycline
7. ceftaroline
8. dalbavancin

Question 16

List Abx effective against enterococcos

Answer 16

1. amox
2. nitrofurantoin
3. fosfomycin
4. ampicillin
5. pen G
6. vanco
7. dapto
8. linezolid

Question 17

What is considered a positive urine?

Answer 17

> Greater then 10 to the 5 colony-forming units/ml ([CFUs]/mL) for clean catch

> Mix of two or more organisms

> IDSA: abnormal urinalysis and a colony count of >50000 CFU/mL of a single organism obtained by either a suprapubic aspirate or catheterization is considered diagnostic

> IDSA: More recent evidence would suggest that ≥10 to the 4 CFU/mL and a reliable detection of pyuria would pick up an additional significant proportion of children with true UTI

Question 18

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

Answer 18

> 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)

Question 19

What is a conjugate vaccine?

Answer 19

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

Question 20

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

Answer 20

> Less then 1% ** they still have significant risk for UTI (Rosens and Uptodate )

Question 21

When are children typically immunized against pneumococcus? HIB?

Answer 21

> Pneumococcus= 2, 4 and 12 months

> HIB= 2, 4 and 6 months

Question 22

What are the most common sites for SBI?

Answer 22

1. UTI
2. Bacteremia
3. Meningitis

Question 23

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

Answer 23

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

Question 24

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

Answer 24

False

Question 25

What is a febrile seizure?

Answer 25

\> Seizure with fever with no evidence of alternate cause (eg. CNS infection) in children younger then 5 years old **(Rosens)** \> 6 months- 5 years **(Uptodate)**

Question 26

What is the risk of epilepsy following a febrile seizure?

Answer 26

The risk of epilepsy in the general population is thought to be 0.5% to 1%, whereas the risk in a patient who has had a febrile seizure is 1% to 2%. **(Rosens)**

Question 27

Define simple and complex febrile seizure

Answer 27

\> **Simple:** \< 15min, only 1 in 24hrs, non-focal or generalized tonic clonic \> **Complex:** \> 15min, \> 1 in 24hrs, typically focal, prolonged, or occur outside the typical age range

Question 28

What does sensitivity mean?

Answer 28

\> Measures the proportion of actual positives that are correctly identified as such (e.g., the percentage of sick people who are correctly identified as having the condition). \> "the probababilty of detection" \* a highly sensitive test will lead to some false positive s

Question 29

What does PPV mean?

Answer 29

\> Probability that subjects with a positive screening test truly have the disease

Question 30

What does specificity mean?

Answer 30

\> Measures the proportion of actual negatives that are correctly identified as such (e.g., the percentage of healthy people who are correctly identified as not having the condition) \> "relates to the test's ability to correctly reject healthy patients without a condition" \* highly specific test will have some false negatives

Question 31

What does NPV mean?

Answer 31

\> Probability that subjects with a negative screening test truly don't have the disease

Question 32

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

Answer 32

\> 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

Question 33

Describe the Rochester criteria

Answer 33

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%

Question 34

Describe the Philadelphia criteria

Answer 34

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

Question 35

Describe the Boston criteria

Answer 35

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

Question 36

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

Answer 36

\> Requirement for LP in some \> What if only one of the elements is positive? Is treatment overkill? \> 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

Question 37

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

Answer 37

\> 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 +/- Vanco \*\* remember cant use CTX in children less then 30 days

Question 38

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

Answer 38

\> 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: Use the Rochester, Phildelphia, Boston Criteria \> UPTODATE: Divides it into 29-60 days. 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: * WBC ≤5000 or ≥15,000 * Absolute band count \>1500 * PCT \>0.3 ng/mL * CRP \>20 mg/L (2 mg/dL) * If pneumonia on chest radiograph \> UPTODATE: 60-90 days look for a recognizable viral infection TREATMENT if high risk according to traditional criteria: \*Remeber these are well appearing children you are not actually giving full treatment, unless you discover a focus in the CSF, urine of CSF \> give empiric Abx CTX 50 mg/kg and admit or bring back in 24 hours \*\*Remember however do not give empiric Abx and discharge if you have not done a full septic workup (i.e LP) TREATMENT (uptodate) if positive criteria and no focus on urine, CXR or CSF \> give empiric Abx CTX 50 mg/kg and admit or bring back in 24 hours

Question 39

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

Answer 39

\> 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%.

Question 40

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

Answer 40

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

Question 41

In children less then 60 days old does a positive viral study rule out cocomitant SBI?

Answer 41

\> No \> Overall chidren with + viral studies do have less inicidence of SBI however not low enough to not continue to work the child up