Fever without a source. Management of Febrile Infants (0 3 months) or Please, can t I just send them home? Saturday Night Fever
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1 Saturday Night Fever Management of Febrile Infants (0 3 months) or Please, can t I just send them home? K. Alexander, M.D. Section of Pediatric Infectious Diseases Fever without a source! Normal infants age 0 3 months! Fever! 38 C by a reliable source! No physical signs of infection 1
2 Well-appearing and febrile versus Sick A infant sick in the first week of life Where s the problem? EKG Hypoplastic left heart 2
3 Well-appearing febrile infant! A 23 day-old male infant brought to the ER by mother! Uncomplicated pregnancy/labor/ delivery! Felt warm earlier this evening.! T = 38.4 C at triage! Exam entirely normal except for fever Possible outcomes! Spontaneous resolution of fever. Child grows up to become an educated liberal-voting Hyde Park Democrat.! Child dies 36 hours later of overwhelming Group B Strep. sepsis The problem of the febrile infant! Most babies with fevers will be fine if left alone! A few babies with fevers have something really bad! Just by looking at them, we can t distinguish which babies will do well and which babies will get sicker 3
4 The cost of missing a serious infection is very high. Asymptomatic bacteremia! Common in infants!decreases in incidence as age increases! Common pediatric pathogens! Most often resolves spontaneously! May progress to complicated bacteremia!meningitis, UTIs, sepsis, bone infections, etc. Other problems with febrile infants!babies lack the ability to contain infections!local infections are often associated with bacteremia!local infections are often associated with other local infections 4
5 There is no test or combination of tests that is sensitive and specific for prediction of bacteremia or meningitis What makes young infants sick?! Infection!Bacteria!Group B Strep.!Pneumococcus!UTIs (E. coli)!meningococcus!staph. aureus (especially MRSA)!B. pertussis What makes young infants sick?! Infection!Viruses!HSV!Respiratory viruses!rsv, enteroviruses, influenzaviruses, parainfluenzaviruses, adenoviruses!vomiting and diarrhea viruses!rotaviruses, adenoviruses, noroviruses 5
6 What I want you to think about as you care for febrile young infants Darth lifting by neck Evaluation of febrile infants (T > 38 C) under age 3 months!a careful history!a good physical exam!a relationship with the parents Evaluation of febrile infants (T > 38 C) under age 3 months!cbc with differential!blood culture!urine analysis!urine culture!lumbar puncture 6
7 For culture: A bag urine isn t worth the piss that s in it. Axillary temperatures are not very useful. Make a virologic diagnosis!influenza!rsv!parainfluenza!adenovirus!rotavirus 7
8 Tests not worth doing routinely:!chest X-ray!Stool cultures!hsv serologies!nasal cultures!stool cultures Management of febrile young infants!admission!48 hours!empirical antibiotic therapy!age < 1 month: Amp/Gent*!Age 1-3 months: Ceftriaxone *Gentamicin levels will not likely be necessary When to suspect congenital HSV!Age 5 days 6 weeks!seizure(s)!mental status changes!characteristic skin lesions!elevated liver enzymes 8
9 If you suspect HSV, call for a Peds I.D. consult Marcus Welby and Jerry Lewis Why do we need to be more aggressive than real doctors?!your patients are:!often referred in for evaluation!sicker than average 9
10 Why do we need to be more aggressive than real doctors?!many of your patients are from high-risk populations!crowding!poverty!compliance!follow-up New doctor Evaluating febrile infants: A numbers game 10
11 In a private office: 3 babies/week join practice 5% run fevers in first month of life 5% are bacteremic 10% go on to have complications 3 x 52 x 0.05 x 0.05 x 0.1 = babies/year On average, one baby every 25 years At a tertiary medical center: 2 febrile babies come to ER per day 5% are bacteremic 10% go on to have complications 3 x 365 x 0.05 x 0.1 = 3.7 babies/year Happy Vodka 11
12 Car accident During sepsis evaluations!what are parents thinking?!what are we thinking? Worst reasons not to do an LP!The baby looked O.K.!The baby had an ear infection!the baby had a UTI!We got a blood culture 12
13 Worst reasons not to do an LP!The CBC/CRP/ESR/ procalcitonin were normal!the kid already had antibiotics!the baby didn t have a stiff neck If you think about doing an LP, do an LP. An ill-appearing patient likely has a significant diagnosis. Well-appearance does not exclude a significant diagnosis. 13
14 Don t let concerns about bacteremia and meningitis keep you from thinking about the more common diagnosis of UTI. For febrile young babies (age < 3 months): Just do it. Blood Culture Urine Culture LP Admission Antibiotics What else makes a young infant sick?!heart problems!left side obstructive lesions!respiratory problems 14
15 Good follow-up is everything. 15
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