The febrile child and sepsis

Question 1

Sites to measure temperature, which is lower

Answer 1

1. Axillary->lower 2. Rectal 3. Tympanic 4. Skin

Question 2

History in fever (4 key)

Answer 2

1. Localising symptoms 2. Travel 3. Sick contacts 4. Immunisations

Question 3

Examination in fever

Answer 3

1. General 2. Colour 3. Activity 4. Respiratory 5. Hydration 6. Prolonged fever 7. Swelling of limb/joint, not weight bearing, new lump 8. Non-blanching rash, bulging fontanelles, neck stiff 9. Status epilepticus, focal neurology, focal seizures 10. Bile stained vomiting 11. Consider well or unwell 12. Localising signs: ENT, neck, WOB, abdominal, skin rash, joint swelling

Question 4

Investigations in fever: <1 month, 1-3 months

Answer 4

1. 38 rectal Discuss with senior Full sepsis w/u= FBE/film, BC, urine culture (SPA), LP +/- CXR Admit for empirical antibiotics 2. 1-3 months corrected, >38 Discuss with senior Full sepsis w/u (CXR only if resp) +/- LP D/c with r/v in 12 hours if: previously healthy, looks well, WCC 5-15000, urine microS clear, CXR clear, CSF clear if done If unwell/above not met->admit to hospital for obs +/- empirical antibiotics

Question 5

Investigations in fever: >3 months w/ and w/o clear focus

Answer 5

1. >38 + clear focus a. Looks well Treat as clinically indicated b. Looks unwell Discuss with senior Investigate depending on focus Admit for treatment 2. >38 w/o clear focus a. Looks well urine (SPA up to 12mo) >12 mo->Urine MCS consider DC with symptomatic Arrange RV in 24 hours, or sooner if deteriorates b. Looks miserable, still interactive urine (SPA up to 12mo) >12 mo->Urine MCS consider Discuss with senior prior to investigations c. Unwell Full septic w/u: FBE, BC, urine culture +/- CXR, LP Admit for observations +/- IV antibiotics

Question 6

LP contraindications

Answer 6

1. Impaired conscious state 2. Focal neurological signs 3. Hemodynamically unstable 4. Coagulopathy 5. Severe cardiorespiratory compromise

Question 7

Should bag urine specimens be sent for culture

Answer 7

1. No 2. If positive on reagent strip do SPA or catheter urine, send sample for culture.

Question 8

High risk children

Answer 8

1. Immunosuppressed 2. Chronic lung disease 3. Congenital heart disease

Question 9

Discharging child with fever

Answer 9

1. Infants less than 1 month of age with fever should be admitted. 2. Infants 1 to 3 months of age: The child is well All investigations are normal The child has been reviewed by a senior registrar/consultant Follow up in 12 hours has been arranged 3. Children older than 3 months: The child is well Follow up has been arranged 4. Give parent information sheet

Question 10

If positive blood culture

Answer 10

Contact the family immediately and arrange clinical review: a. Strep pneumoniae - Child well and afebrile: If the child is on antibiotic therapy, a 7 day course of antibiotics should be completed. If the child has not received antibiotics, they do not need to be investigated or treated as they have cleared the infection themselves. Review if clinical deterioration occurs. - Child unwell or febrile: Sepsis workup and admission for i.v. antibiotics b. Any other organism (regardless of clinical condition) Discuss with ED Consultant (or General Paediatric Consultant on call if patient is admitted) if isolate is thought to be a contaminant. Sepsis workup and admission for i.v. antibiotics.

Question 11

When should parents see the doctor with child + fever

Answer 11

1. Complaining of stiff neck, sore eyes 2. Vomiting and refusing to drink much 3. Rash 4. Sleepy more than usual 5. Problems with breathing 6. Pain

Question 12

At home care for parents with febrile child

Answer 12

1. Dress enough so not shivering 2. Tepid sponging and fanning not recommended 3. >38.5 and miserable/other symptoms may give paracetamol. If child fever + well, no need to treat. 4. May not make fever go away, aims to make child feel better. Give fluids 5. Paracetamol in other medicine, make sure if giving that other medications containing haven’t been given 6. Every four hours as on the bottle. No more than 4 in 24 hours. Do not give for more than 2 days without seeing doctor 7. Come back if more sick or not improved at 48 hours.

Question 13

Early onset sepsis, causative agents, risks

Answer 13

1. w/i 48 hours of life 2. Pneumonia, meningitis, sepsis 3. GBS, gram -ve, Listeria 4. Risks PPROM Fetal distress Maternal fever/infection Surgical sutures Previous GBS on culture Preterm

Question 14

Late onset sepsis, cause, risks

Answer 14

1. Acquired out os hospital 2. Coag negative staph, GBS, gram -ve 3. Risks +time in hospital Cross contamination Cannula/catheter Anatomic anomaly->bladder, pelvis, NTD

Question 15

Management of sepsis

Answer 15

Involves