Infectious Disease Book

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Fever Without Focus Management 3 to 36 months

Aka: Fever Without Focus Management 3 to 36 months
  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. Pediatric Sepsis
    6. Neonatal Sepsis
    7. Rochester Criteria for Febrile Infant 0 to 60 days
    8. Philadelphia Criteria for Febrile Infant 29-60 days
    9. Milwaukee Criteria for Febrile Infant 28-56 days
    10. Boston Criteria for Febrile Infant 28-89 days
    11. Yale Scale for Febrile Child 3 to 36 months
  2. Indications
    1. Previously well child
    2. Febrile child 3 to 36 months without obvious source
  3. History: Immunization Effects on Occult BacteremiaIncidence
    1. HaemophilusInfluenzae Type B Vaccine (Hib Vaccine) introduced in U.S. 1985
      1. Occult BacteremiaIncidence with high fever dropped from 3-9% to 2-3%
      2. Primary cause of Occult Bacteremia changed to Streptococcus Pneumoniae
    2. Pneumococcal Conjugate Vaccine (Prenar 7) introduced in U.S. 2000
      1. Occult BacteremiaIncidence with high fever dropped from 2-3% to <0.5%
    3. Pneumococcal Conjugate Vaccine (Prenar 13) introduced in U.S. 2010
      1. Invasive pneumococcal disease dropped more than 50% (21.9 to 9.3 per 100,000)
  4. Approach: Triage
    1. Toxic appearing febrile child
      1. See Yale Observation Scale
      2. See Toxic Findings Suggestive of Occult Bacteremia
      3. Admit to hospital
      4. Full rule-out Sepsis workup
        1. See Fever Without Focus Labs
      5. Parenteral antibiotics
        1. See antibiotic selection in Step 5 below
    2. Non-toxic child with fever <39.0 C (<102.2 F)
      1. Avoid further diagnostic tests or antibiotics unless otherwise indicated
      2. Fever Symptomatic Treatment
      3. Careful examination to rule out serious infection
        1. Urinary Tract Infection
        2. Pneumonia
        3. Abscess
        4. Cellulitis or Impetigo
        5. Acute Sinusitis
        6. Otitis Media
        7. Osteomyelitis
        8. Lymphadenitis
        9. Streptococcal Pharyngitis or Scarlet Fever
      4. Re-evaluation criteria
        1. Fever persists longer than 48 hours
        2. Condition deteriorates
      5. Consider Urinalysis
        1. Girls age <12 months
        2. Boys age <6 months (or <12 months if uncircumcised)
    3. Non-toxic child with fever >38.9 C (>102.1 F)
      1. See protocol below
  5. Diagnosis: Predictors of Occult Bacteremia for ages 3-36 months
    1. Toxic Findings Suggestive of Occult Bacteremia
    2. Pre-Hib Era: Fever in non-toxic child ages 3-36 months
      1. Temperature <39.5 C (103.1 F): 1.6% Positive Blood Culture
      2. Temperature <34.0 C (93.2 F): 2.1% Positive Blood Culture
      3. Temperature <41.0 C (105.8 F): 3.5% Positive Blood Culture
      4. Temperature >41.0 C (105.8 F): 9.3% Positive Blood Culture
    3. Post-Hib Era: Fever in non-toxic child ages 3-36 months
      1. Temperature <39.5 C (103.1 F): 0.9% Positive Blood Culture
      2. Temperature <34.0 C (93.2 F): 1.1% Positive Blood Culture
      3. Temperature <40.5 C (104.9 F): 1.7% Positive Blood Culture
      4. Temperature <41.0 C (105.8 F): 2.4% Positive Blood Culture
      5. Temperature >41.0 C (105.8 F): 2.8% Positive Blood Culture
    4. Post-Hib Era: WBC in non-toxic child ages 3-36 months
      1. WBC <5k C: 0.0% Positive Blood Culture
      2. WBC <10k C: 0.1% Positive Blood Culture
      3. WBC <15k C: 0.5% Positive Blood Culture
      4. WBC <20k C: 3.5% Positive Blood Culture
      5. WBC <25k C: 6.8% Positive Blood Culture
      6. WBC <30k C: 7.2% Positive Blood Culture
      7. WBC >30k C: 18.3% Positive Blood Culture
  6. Evaluation: Step 1 - Evaluate Fever by Rectal Temperature
    1. Fever with Rectal Temperature <102.2 F (39 C)
      1. Observe without testing (or consider Urinalysis)
      2. Follow-up if worsening or >48 hours of fever
    2. Fever with Rectal Temperature >102.2 F (39 C)
      1. Go to Step 2 unless criteria below met
      2. Consider Urinalysis (esp fever>2 days without source)
        1. Girls age <12 months
        2. Boys age <6 months (or <12 months if uncircumcised)
      3. Criteria for observation without labs, antibiotics
        1. See Toxic Findings Suggestive of Occult Bacteremia
        2. Non-toxic appearance
        3. Immunizations up-to-date
        4. Follow-up within 24-48 hours
  7. Evaluation: Step 2 - Obtain Initial Labs
    1. Labs
      1. Complete Blood Count with differential
      2. Urinalysis with Urine Culture
        1. Indicated in under 24 months or findings suggestive of UTI in 24-36 month old children
        2. May defer in a well appearing infant over age 3 months
          1. Must have close follow-up within 2-3 days
          2. Child is likely to have localizing symptoms by 2-3 days
          3. Informed Consent with parents
            1. Risk of initially missed Pyelonephritis vs urine catheterization
          4. Sacchetti and Newman in Majoewsky (2013) EM:Rap 13(5): 4-5
    2. Protocol
      1. Go to step 3 unless criteria below are met
    3. Criteria for low-risk observation (24 hour follow-up)
      1. See Toxic Findings Suggestive of Occult Bacteremia
      2. White Blood Cell Count <15,000
      3. Absolute Neutrophil Count <10,000
      4. Urinalysis normal
  8. Evaluation: Step 3 - Obtain Cultures
    1. See Fever Without Focus Labs
    2. Urine Culture
      1. Obtain in all cases in which Urinalysis is ordered
      2. Urinalysis alone is insufficient
    3. Blood Culture
      1. All cases in which labs abnormal above
      2. Obtain if antibiotics are given
    4. Cerebrospinal fluid (CSF) by Lumbar Puncture
      1. Indicated if neurologic or meningeal signs present in ill appearing children
      2. Not required if no meningeal and neurologic signs
        1. Should be a non-toxic appearing child over age 3 months
        2. Should have a normal White Blood Cell Count
  9. Evaluation: Step 4 - Additional Studies
    1. Chest XRay Indications
      1. Oxygen Saturation (O2 Sat) <95%
      2. Respiratory distress or Tachypnea
      3. Rales on lung auscultation
      4. Fever over 39.0 to 39.5 C (102.2 to 103.1 F) or higher
      5. Asymptomatic with White Blood Cell Count >20,000
    2. Stool Culture Indications
      1. Diarrhea
      2. Findings on stool exam that increase likelihood of Bacterial Infection
        1. Stool blood or mucus present
        2. Fecal Leukocytes > 5 WBCs per high powered field
  10. Evaluation: Step 5 - Consider Antibiotics (fever >39 C)
    1. Decision to use antibiotics empirically
      1. Ill appearing young children with high fever should be treated and admitted
        1. See Toxic Findings Suggestive of Occult Bacteremia
        2. See approach to triage above
      2. Close interval follow-up without antibiotics is a reasonable approach
        1. Indicated in non-toxic appearing children
      3. Decision to start empiric antibiotics is one of clinical judgement
        1. Based on likelihood of serious underlying occult infection
    2. General empiric coverage
      1. Ceftriaxone (Rocephin) 50 mg/kg/day (max: 1 g)
    3. Suspected urinary tract source
      1. Cefotaxime (Claforan) 50 mg/kg IV every 8 hours or
      2. Cefixime (Suprax) 8 mg/kg twice daily for day one, then 8 mg/kg daily
    4. Suspected Pneumonia
      1. Amoxicillin 80 mg/kg/day divided every 8-12 hours or
      2. Azithromycin 10 mg/kg orally on day 1, then 5 mg/kg on days 2-5
        1. Alternative if Penicillin allergic
    5. If antibiotics are given, then:
      1. Obtain all cultures that are indicated in Step 3
      2. Re-evaluate within 24 hours
  11. Step 4: Disposition
    1. Admit patients with unreliable follow-up
    2. Follow-up
      1. Return within 24 hours if antibiotics started
      2. Return in 48 hours indication
        1. Fever persists
        2. Condition deteriorates
    3. Home management
      1. Observe for toxic appearance
      2. Fever Symptomatic Treatment
  12. Step 5: Blood Culture or Urine Culture positive
    1. Admit if child febrile or toxic appearance
    2. Outpatient antibiotics if afebrile and well-appearing
  13. 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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