Infectious Disease Book

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Fever Without Focus Labs

Aka: Fever Without Focus Labs
  1. See Also
    1. Fever Without Focus
    2. Toxic Findings Suggestive of Occult Bacteremia
    3. Fever Without Focus Labs
    4. Fever Without Focus Management Birth to 3 Months
    5. Fever Without Focus Management 3 to 36 months
    6. Pediatric Sepsis
    7. Neonatal Sepsis
    8. Rochester Criteria for Febrile Infant 0 to 60 days
    9. Philadelphia Criteria for Febrile Infant 29-60 days
    10. Boston Criteria for Febrile Infant 28-89 days
    11. Yale Scale for Febrile Child 3 to 36 months
  2. Precautions
    1. Labs do not triage initial management of infants under 1 month or ill appearing children under 36 months
      1. All labs are performed in Fever Without Focus if under 1 month or ill appearing and under 36 months
      2. All infants with these risks are admitted and started on empiric antibiotics
    2. Urinalysis and Urine Culture
      1. Perform in all Fever Without Focus children under age 24 months
        1. Urinary Tract Infection is among the top two causes of serious Bacterial Infection under 36 months
          1. Rudinsky (2009) Acad Emerg Med 16(7): 585-90 [PubMed]
        2. Serious Urinary Tract Infections (Pyelonephritis, urosepsis) are increasing in Incidence
          1. Copp (2011) J Urol 186(3): 1028-34 [PubMed]
      2. Clean catch, catheterized urine or suprapubic aspirate for all samples
        1. Bag urine has 85% False Positive Rate
        2. Fineell (2011) Pediatrics 128(3):e749-70 [PubMed]
      3. Urine Culture all samples
        1. Urine dipstick False Negative Rate: 12%
        2. Gorelick (1999) Pediatrics 104(5): e54 [PubMed]
  3. Labs: Age under 29 days
    1. Complete Blood Count (CBC) with differential
    2. Blood Culture (1 set)
    3. Urinalysis and Urine Culture
    4. Lumbar Puncture for CSF Studies and CSF Culture
    5. Chest XRay
    6. Stool Culture and Fecal Leukocytes
      1. Diarrheal illness
  4. Labs: Age 1 to 36 months AND signs of serious illness
    1. Complete Blood Count (CBC) with differential
    2. Blood Culture
    3. Urinalysis and Urine Culture
      1. Age less than 24 months: Obtain both Urinalysis and Urine Culture
      2. Age 24 to 36 months: Consider Urinalysis and Urine Culture if urinary tract source is suspected
    4. Lumbar Puncture for CSF Studies and culture
      1. Age 1 to 3 months: All ill appearing infants
      2. Age 3-36 months: Neurologic or meningeal signs present
    5. Chest XRay Indications
      1. Respiratory symptoms
      2. Rectal Temperature > 102º F
      3. WBC >20,000
    6. Stool Culture and Fecal Leukocytes Indications
      1. Diarrheal illness
  5. Labs: Age 1 to 36 months without signs of serious illness
    1. Consider Influenza test during Influenza season in ages 3 to 36 months
      1. Positive Influenza test often obviates need for further Fever Without Focus evaluation
    2. Complete Blood Count (CBC) with differential
    3. Blood Culture (draw and hold) when other labs obtained
    4. Urinalysis and Urine Culture
      1. Age less than 24 months: Obtain both Urinalysis and Urine Culture
      2. Age 24 to 36 months: Consider Urinalysis and Urine Culture if urinary tract source is suspected
    5. Lumbar Puncture for CSF Studies and culture
      1. Age 1 to 3 months: All ill appearing infants
      2. Age 3-36 months: Neurologic or meningeal signs present
      3. Precaution
        1. Younger infants are less likely to demonstrate meningeal signs (Exercise caution)
        2. Normal WBC Count (between 5000 to 15000) does not rule-out Meningitis
          1. Bonsu (2003) Ann Emerg Med 41:206-14 [PubMed]
    6. Chest XRay Indications
      1. Respiratory symptoms (respiratory distress, Tachypnea, pulmonary rales)
      2. Rectal Temperature > 102.2º F
      3. White Blood Cell Count >20,000
      4. Oxygen Saturation <95%
    7. Stool Culture and Fecal Leukocytes Indications
      1. Diarrheal illness
  6. Labs: Experimental markers (age under 3 months)
    1. Inflammatory markers with greater Positive Predictive Value of serious infection than White Blood Cell Count
      1. C-Reactive Protein (CRP)
        1. CRP <10 mg/L has a Negative Predictive Value for Sepsis of 99%
        2. CRP >40 mg/L is more suggestive of serious Bacterial illness (but not sensitive or specific)
        3. Single CRP is inadequate for reassurance (repeat in 24 hours)
        4. Bilavsky (2009) Acta Paediatr 98(11): 1776-80 +PMID:19664100 [PubMed]
        5. McWilliam (2010) Arch Dis Child Educ Pract Ed 95(2): 55-8 +PMID:20351152 [PubMed]
      2. Procalcitonin (PCT)
        1. PCT <0.5 ng/ml has a Negative Predictive Value for serious Bacterial Infection of 90%
        2. PCT >0.6 (and WBC >19k, blasts >1.8k, Neutrophils >13k) suggests serious Bacterial Infection
        3. Olaciregui (2009) Arch Dis Child 94(7): 501-5 +PMID:19158133 [PubMed]
        4. Mahajan (2014) Acad Emerg Med 21(2): 171-9 +PMID:24673673 [PubMed]
      3. References
        1. Freyne (2013) Clin Pediatr 52(6): 503-6 +PMID:23613177 [PubMed]
        2. Stein (2015) Clin Pediatr 54(5): 439-44 +PMID:25294884 [PubMed]
    2. Rapid urine pneumococcal antigen assay
      1. Currently being researched for clinical application
      2. Test Sensitivity in pneumococcal bacteremia: 96%
      3. High False Positive Rate
      4. Neuman (2003) Pediatrics 112:1279-82 [PubMed]
  7. References
    1. Herman (2015) Crit Dec Emerg Med 29(12):14-19
    2. (1993) Ann Emerg Med 22(3):628-37 [PubMed]
    3. Baraff (2000) Ann Emerg Med 36:602-14 [PubMed]
    4. Baraff (1993) Pediatrics 92(1): 1-12 [PubMed]
    5. Daaleman (1996) Am Fam Physician 54(8):2503 [PubMed]
    6. Hamilton (2013) Am Fam Physician 87(4): 254-60 [PubMed]
    7. Kimmel (1996) Fam Pract Recert 18(7):69-85 [PubMed]
    8. Luszczak (2001) Am Fam Physician 64(7):1219-26 [PubMed]
    9. Lopez (1997) Postgrad Med 101(2):241-52 [PubMed]
    10. Sur (2007) Am Fam Physician 75:1805-11 [PubMed]

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