Exam 1 - Fever without focus Flashcards
What is considered a fever without focus/source?
Acute fever or unknown etiology after thorough evaluation of a child less than 24 months
Which age group is at high risk for a serious bacterial infection and require a full work up?
Young infants (under 90 days of age); even in presence of a source
Differential diagnoses for fever without focus: bacterial infections
- Bacteremia
- Bacterial meningitis
- Bacterial PNA
- Skin and soft tissue infection
- Osteomyelitis
- Bacterial gastroenteritis
- Septic arthritis
- UTI
Differential diagnoses for fever without focus: viral infections
- Enterovirus
- Influenza
- RSV
- Rotavirus
- Adenovirus
- Herpes virus-6
- Parechovirus
Differential diagnoses for fever without focus: non-infectious
- Kawasaki disease
- Autoimmune or inflammatory disease
- Reaction to immunization
Red flags
- Ill or toxic appearing (even if no fever is present)
- Skin color ashen blue, mottled, pale
- Lethargic, weak, high pitched cry, poor feeding, decreased response
- Tachypnea or tachycardia
- Cap refill >3 seconds
- Decreased urine output
- Bulging fontanel
- Non-blanching skin rash
- Underlying health problem (including prematurity)
- Unreliable caretakers
True/false: Infants and children who are ill or toxic appearing, regardless of age or presence of fever, require a sepsis work up
True
Labs and diagnostics required for evaluation of pediatric fever
- For patients who are ill or toxic appearing
- CBC w/ diff
- Serum glucose (compare with CSF glucose)
- CSF testing
- Inflammatory markers (CRP and PCT)
- UA and urine culture
- Blood cultures
- Chest x-ray (if respiratory symptoms present)
- Stool culture (if diarrhea/blood in stool)
What findings on a CBC w/ diff would cause the provider to consider bacterial infection as the cause of fever?
High leukocytes, neutrophils, band/immature WBCs
True/false: infants who are less than 28 days of age do not require a full workup
False - patients who are less than 28 days of age require a full workup
Who are considered low risk infants in terms of fever/sepsis?
Not premature, no chronic health conditions
Labs and diagnostics for fever that should be ordered for infants ages 29-60 days
- CBC w/ diff
- Blood culture
- UA and urine culture
- PCT, CRP (if available within 60 minutes)
- Chest x-ray (if signs of respiratory symptoms
- LP
What conditions must be met for LPs to be indicated when evaluating infants ages 29-60 days?
- WBC count <5,000 micro/L or >15,000 micro/L
- Absolute band count >1,500 micro/L
- PCT >0.5 ng/mL
- CRP >20 mg/L
- PNA on chest x-ray
When evaluating an infant ages 61-90 days, who is well appearing, and has no focal infection or viral infection (e.g. flu or RSV), what labs should the provider order?
- UA and culture via catheter
- Maybe CBC w/ diff, blood culture, and PCT depending on UA and culture results
If an infant ages 61-90 days recently received immunizations within the past 24 hours with a temperature of 38.6 C/101.5 F, what should the provider due? What should the provider do if the fever persists?
Monitored with close follow up
- If fever persists for >48 hours, further work up warranted
When evaluating an infant ages 61-90 days who is RSV (+), what should the provider do?
No further work up warranted
When evaluating an infant ages 61-90 days who is influenza (+), what should the provider do?
Order UA and urine culture
What is the primary goal of testing when evaluating infants/children >3 months?
Rule out serious bacterial infection
When evaluating an infant/child who is >3 months, what one lab test is recommended?
Urine testing to rule out UTI
When evaluating an infant/child who is >3 months of age for fever, when are other tests (e.g. blood tests, chest x-ray, etc.) indicated?
Other testing can be ordered baased on clinical presenatation and risk for serious infection
- Start with urine testing
What one lab test is required for all infants <90 days who present with fever?
UA and urine culture
What other age group would UAs and urine cultures be indicated for?
Older infants and toddlers ages 3-24 months at risk
For older infants and toddlers ages 3-24 months who require a UA and urine culture, what risk factors put them at risk of fever?
- Temperature >102.2 F
- Females <12 months of age
- Uncircumcised males
- Duration of fever >24-48 hours
- Absence of another infection
What is UTIcalc?
Tool used to reduce the need for urine sampling and lower rates of missed UTIs
- Determines probability of UTI based on clinical presentation
Management of fever w/o source 29-90 days: what deems a patient to be low risk?
- Full term infant (>37 weeks)
- Normal UA, WBC, PCT
- < 1,500 bands
- Previously healthy, appears well
- No focal bacterial infection
- Normal chest x-ray
If a 29-90 day old infant is low risk and has reliable caregivers, what would management of their fever be?
Discharge home with close follow up in 12-24 hours
If low risk criteria is not met in an infant ages 29-90 days, what would management be?
- Child should be admitted
- CSF studies ordered
- IV antibiotics
- Can’t give antibiotics until LP obtained to avoid masking or undertreating undiagnosed meningitis
If low risk criteria is met for infants ages 29-90 days, but has unreliable caregivers, what would management be?
Admitted for observation
