Febrile Child Flashcards
Fever in children <2mo
100.4 F (38 C)
Fever in children >2mo-<3yo
102.2 (39)
Why is there an increased risk for SBI in children <60d
- Immune system immaturity
- Age specific pathogens
Most important component of PE in febrile child
General “look” of pt.
Examples of SBI
- Meningitis
- Bacteremia/sepsis
- UTI/pyelo
- Pneumonia
- Cellulitis
- Abscess
- Septic arthritis
- Osteomyelitis
- Bacterial enteritis
Ddx in well-appearing febrile child
- UTI
- Bacteremia
- Meningitis
- Pnuemonia
- SSTI
- Bacterial enteritis
- Bone & joint infections (osteo, septic arthritis)
- Enterovirus
- URTI
- Bronchiolitis
- Viral GE
- Neonatal HSV
Ddx in ill-appearing febrile child
- SBI
- Neonatal HSV
- Enterovirus
- RSV
- Ductal dependent R an L sided obstructive lesions
- Inborn erros of metabolism
- Congenital adrenal hyperplasia
- Malrotation w/ volvulus
Most common microbial etiology of septic arthritis
S. aureus
ABX used to treat osteomyelitis and septic arthritis (neonates, older children, adolescents)
Neonates: oxacillin + gentamicin
Older children: oxacillin + clindamycin
Adolescents: ceftriaxone
What patient population (age, sx) gets automatic admission and what type of treatment or w/u do they receive?
- Neonates <4wks w/ fever (treat w/ IV ABX and full sepsis w/u)
- ALL ill-appearing children <3yo w/ fever (full sepsis w/u)
M/C SBI
UTI
M/C microbial etiology of SBI
E. coli
Rates of bacteremia & meningitis are highest in what age group
0-4wks (neonates)
Physical exam is unreliable in what age group(s)
<2 mo
Sepsis RF in neonates
- Premature
- Ill-appearing
- Comorbidity
- Fever >40C
- Maternal infection (fever, prolonged ROM, GBS (+), genital HSV)
- Unimmunized
- Social factors limiting f/u
Common bacterial etiologies in neonates (0-4wks)
- E. coli
- GBS
Common viral etiologies in neonates (0-4wks)
- HSV
- VZV
- Enterovirus
- Influenza
- Adenovirus
- RSV
W/u in febrile neonates
- CBC w/ diff
- CMP
- Blcx
- UA
- Urine cx
- LP
- HSV RF assessment
- Viral testing ONLY if respiratory sx
What ABX do we use to treat non-focal, non-ill-appearing neonates w/o CSF infection?
Gentamicin + ampicillin
What ABX do we use to treat ill-appearing neonates w/ CSF infection/pleocytosis?
Ceftazidime + ampicillin
Common bacterial etiologies in infants (4-8wks)
- S. pneumo
- E. coli
- N. meningitidis
- HIB (rare d/t vaccine)
What is the purpose of the Rochester & Philadelphia criteria?
Determine low risk of SBI in infants 4-8wks
Rochester criteria (4-8wk infants)
- Well-appearing
- Full term infant
- NO prior h/o illness, ABX, hyperbilirubinemia, hospitalization
- No skeletal, soft tissue, skin, or ear infections
- CBC normal
- Other: fecal leukocytes <5 WBC if diarrhea, urine WBC <10
Philadelphia criteria (4-8wk infants)
- Well-appearing
- Reassuring exam
- WBC <15,000
- Band to neutrophils <0.2 ratio
- UA <10 WBC
- (-) urine GS
- CSF <8 WBC
- (-) CSF GS
- (-) CXR (no infiltrate) - if obtained
- Stool (-) blood and few to no leukocytes on smear - if obtained
What is the clinical prediction rule used to identify febrile infants <60d at low risk for SBI?
PECARN rule
PECARN rule used these 3 variables to predict risk
- Normal UA
- ANC <4,090
- Serum procalcitonin <1.71
W/u in febrile infants (4-8wks)
- CBC w/ diff
- Blcx
- UA
- Urine cx
- Procalcitonin
- Viral testing ONLY if respiratory sx
What ABX do we use to treat non-ill-appearing infants w/o CSF infection?
Ceftriaxone
What ABX do we use to treat ill-appearing infants w/ CSF infection?
Ceftriaxone + vanco
Under what circumstance do we add LP to the w/u of an infant?
If the infant is admitted (bc focal infection or high risk) and are not meeting low risk criteria w/ intervention
If an infection source is not found in a febrile child 2mo-3yo, what diagnostic test is considered?
Cath UA/cx in….
- Females <12mo
- Uncircumsized males
- Fever >24 hours or fever >39C
What commonly happens with the UA of a febrile child <12mo w/ a UTI?
The UA is (-) -> get a cx
CBC is NOT recommended in pt. of what age group?
2mo-2yo
Consider obtaining a CXR in pt. 2mo-2yr if well-appearing, immunocompetent and no obvious source of infection IF……(B recommendation)
- Cough
- Hypoxia
- Rales
- High fever (>39)
- Fever >48 hrs
- Tachycardia & tachypnea out of proportion to fever
Do NOT order a CXR in pt. 2mo-2yr if well-appearing, immunocompetent and no obvious source of infection IF……(C recommendation)
- Fever 100.4 (38)
- Wheezing
- High likelihood of brochiolitis
Signs of sepsis - compensated shock
- Resting tachycardia
- Widened PP
- Warm distal extremities
- Brisk cap refill
Signs of sepsis - decompensated shock
- Weak distal pulses
- Delayed cap refill
- Cool extremities
- Decrease sensorium
- Hypotension
What is more important than w/u in ED mgmt of sepsis?
Stabilization
What does stabilization of sepsis in the ED consist of?
- O2 (FM or HFNC)
- Close monitoring
- IVF (20 mg/kg bolus)
- Pan-cx, CXR, CBC, CMP
- Empiric ABX (immediately in unstable pt., get blcx & CSF cx first if stable)
What ABX do we give empirically to septic children in the ED?
Ceftriaxone + vancomycin
Common infectious etiology of meningitis in neonates
- E. coli
- GBS
Common infectious etiology of meningitis in infants/children
- N. meningitidis
- IF UNVACCINATED: S. pneumo, HIB
How do infants w/ meningitis present?
- Decrease responsiveness to stimuli
- Hypotonia
- Bulging fontanelle
- Poor feeding
- Vomiting
- Paradoxical irritability
- Lethargy
How do older children w/ meningitis present?
LIKE ADULTS
- HA
- Photophobia
- N/V
- Nuchal rigidity
- +/- Kernig’s/Brudzinski
- Seizures
What does the LP reveal in a pt. (+) for meningitis?
- CSF pleocytosis
- HIGH protein
- LOW glucose
What ABX do we give neonates w/ meningitis?
Ceftazidime + ampicillin
What ABX do we give children w/ meningitis?
Ceftriaxone + vanco
Do NOT delay ABX therapy in pt. w/ meningitis if…..
- Difficulty obtaining LP
- Difficulty obtaining head CT
- Unstable pt.
What is given to pt. w. meningitis on a case by case basis?
Dexamethasone
