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PEDS FEVER > Chapter 167 > Flashcards

Chapter 167 Flashcards

Peds Fever

1
Q

Define Fever

A

> Elevation of core body temp > 38 degrees rectally

(Rosens and Uptodate definition)

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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

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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4
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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5
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. The term typically refers to children 3 to 36 months old who are highly febrile (>102.2°F [39.0°C]).

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6
Q

What is 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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7
Q

What is 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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8
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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9
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 iand also include: - Abx therapy in the last 7 days - Technology dependent - chromosomal or congenital defect - prematurity

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10
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%; >

>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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11
Q

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

A

> 1-2% (CPS)

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12
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)

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13
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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14
Q

List six causes of petechiae in a febrile child

A

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

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15
Q

List IV meds for MRSA

A
  1. vanco
  2. linezolid
  3. dapto
  4. oritavancin
  5. dalfopristin
  6. tigecycline
  7. ceftaroline
  8. dalbavancin
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16
Q

List Abx effective against enterococcos

A
  1. amox
  2. nitrofurantoin
  3. fosfomycin
  4. ampicillin
  5. pen G
  6. vanco
  7. dapto
  8. linezolid
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17
Q

What is considered a positive urine?

A

> 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

18
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)

19
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

20
Q

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

A

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

21
Q

When are children typically immunized against pneumococcus? HIB?

A

> Pneumococcus= 2, 4 and 12 months

> HIB= 2, 4 and 6 months

22
Q

What are the most common sites for SBI?

A
  1. UTI
  2. Bacteremia
  3. Meningitis
23
Q

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

A

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

24
Q

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

A

False

25
Q

What is a febrile seizure?

A

> 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)

26
Q

What is the risk of epilepsy following a febrile seizure?

A

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)

27
Q

Define simple and complex febrile seizure

A

> 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

28
Q

What does sensitivity mean?

A

> 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

29
Q

What does PPV mean?

A

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

30
Q

What does specificity mean?

A

> 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

31
Q

What does NPV mean?

A

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

32
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

33
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%

34
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

35
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

36
Q

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

A

> 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

37
Q

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

A

> 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

38
Q

What is your workup and possible treatment for a 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: 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

39
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%.

40
Q

What is your workup and treatment for a a 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.

41
Q

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

A

> No

> Overall chidren with + viral studies do have less inicidence of SBI however not low enough to not continue to work the child up

PEDS FEVER (4 decks)

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