Hot Hot Tot:! The Hot Tot. Fever in KIds <90 Days 5/26/10

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Eugene Bishop
6 years ago
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Medicine The Hot Tot 1 day of fever to 38.

1 Hot Hot Tot:! Fever in KIds <90 Days Judith Klein, MD FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Department of Emergency Medicine The Hot Tot 1 day of fever to Mild cough PE: T 38. 2, o/w WNL Do weeks matter?: 2 week old? 6 week old? 11 week old? 1

Goals A short history of the kiddie fever business Vaccinations Rapid viral testing

Some immutable facts Controversial topic Most infants with fever have viral infections

2 Goals A short history of the kiddie fever business Vaccinations Rapid viral testing Month-by-month approach to fevers in these little folks A few thoughts on management Some immutable facts Controversial topic Most infants with fever have viral infections Bacterial infections in young kids can have bad outcomes what about Vaccinations? Early 1990 s: H. influenzae type b (Hib) 2000: Pneumococcal-PCV : PCV-13 (serotype 19a) Impact on <90 day group: -Hib: Big -PCV-7: Not much (only 5-10% of positive Cx are pneumococcus) 2

Rapid Viral Testing Rapid testing available: -RSV -Influenza A/B -Parainfluenza Kids with viral

significant Test all admitted patients Some Fever ground rules Fever: >38.

Higher fevers, ill contacts, underlying medical conditions, prematurity count more Fever length (if <5

3 Rapid Viral Testing Rapid testing available: -RSV -Influenza A/B -Parainfluenza Kids with viral infections are less likely to have bacterial infections Impact on <90 day group: potentially significant Test all admitted patients Some Fever ground rules Fever: >38.0 rectal Fevers at home count! Higher fevers, ill contacts, underlying medical conditions, prematurity count more Fever length (if <5 days) & antipyretic response don t count Kids who look sick are sick! What does Sick Look Like? Difficult to arouse/lethargic Respiratory distress Pale or cyanotic/crt>2 sec Poor suck/tone Rash: petechiae, vesicles 3

gastroenteritis Osteomyelitis Fresh out of the Oven 2 week old term

5 Maternal GBS+ -->got ampicillin peripartum PE: T 37.

4 What is an SbI? Bacteremia Meningitis Pyelonephritis Pneumonia Bacterial gastroenteritis Osteomyelitis Fresh out of the Oven 2 week old term female 1 day fever to 38.5 Maternal GBS+ -->got ampicillin peripartum PE: T 37.9 o/w WNL What now? Neonatal (<30 days) Fever 12-28% will have SBI: lots of meningitis Bad bugs: GBS, E. coli, Enterococcus, Listeria Even viruses are bad (herpes) Can t tell which are sick 4

5 Approach to Neonates BCx, UA/UCx (cath or SPA only), CSF for all CXR (respiratory sx), stool studies (diarrhea) prn CXR indications: RR, hypoxia (<97%), G/F/R, abnormal lung exam Viral studies not helpful: RSV+ still have high rate of SBI A word on the LP... Position: consider upright No lidocaine in the kit??? Neonates are sensate..be kind: -EMLA or other topical analgesic -lidocaine -glucose water orally MANAGEMENT OF NEONATES ADMIT THEM ALL Increasing ampicillin resistance; vancomycin if sick or maternal ampicillin Give ampicillin/vancomycin and 3rd generation cephalosporin like cefotaxime or gentamicin. Add acyclovir if risks for HSV 5

.. 6 week old term male with 2 days T to 38.9 PE: T 39, RR 70, smiles, o/w WNL What next?

6 A word on Neonatal HSV May not have fever Usually < 2 weeks old Empiric acyclovir if risks: -primary maternal infxn -prolonged ROM -skin/eye/mouth lesions -seizure at presentation -CSF pleocytosis Now I can Smile... 6 week old term male with 2 days T to 38.9 PE: T 39, RR 70, smiles, o/w WNL What next? Do a few weeks make a Difference? <30 days old days old vegetable social smile Up to 6% of low risk kids have SBI Lab tests can better predict high risk 6

Approach to 30-60 day old Clinical exam helpful, but still misses SBI Rochester/Philadelphia criteria Full work-up: CBC/BCX, UA/ UCx, LP for all**;

Role of Viral Studies Levine 2002: SBI in <60d with and without RSV -SBI 12.

5% if flu + -Most SBI were UTI Large but underpowered to detect meningitis/bacteremia Be conservative with this age Management of 30-60 DAY old

7 Approach to day old Clinical exam helpful, but still misses SBI Rochester/Philadelphia criteria Full work-up: CBC/BCX, UA/ UCx, LP for all**; CXR and stool as indicated Social: reliable caretaker? transportation? willing parent? Role of Viral Studies Levine 2002: SBI in <60d with and without RSV -SBI 12.5 to 7% if RSV+ -Most SBI were UTI Krief 2009: SBI in <60d with and without influenza -SBI 13.3% to 2.5% if flu + -Most SBI were UTI Large but underpowered to detect meningitis/bacteremia Be conservative with this age Management of DAY old Admit if: -WBC<5K >15K, Band/Neut >0.2 -UA >5 wbc/hpf -CSF >8 wbc -Stool >5 wbc/hpf -CXR with infiltrate OR IF -High risk: preemie, long hospitalization, immunocompromised, on antibiotics, fever >5 days May discharge if lab tests/ XR normal and social situation adequate -Antibiotics? (ceftriaxone) Abx of choice: ceftriaxone 7

The ancient one 11 week old female NSVD 2 days of T 39. PCV-7 2 wks ago. PE: T 38.

PE for sick becoming more reliable Decreasing risk for meningitis and OB - <1 mo: 4.

7%/no meningitis* Some studies consider fever to be T>39 Predominant bugs: E.

Approach to 60-90 DAY old Full workup if toxic or high risk history OPTION #1: UA/UCx

8 The ancient one 11 week old female NSVD 2 days of T 39. PCV-7 2 wks ago. PE: T 38.9, smiling, o/w NL. What next? Do a few more weeks make even more of a difference? PE for sick becoming more reliable Decreasing risk for meningitis and OB - <1 mo: 4.1% -1-2 mos: 1.9% -2-3 mos: 0.7%/no meningitis* Some studies consider fever to be T>39 Predominant bugs: E. coli but increasing pneumococcus *Pantell, JAMA Approach to DAY old Full workup if toxic or high risk history OPTION #1: UA/UCx CBC/BCx Consider CSF CXR prn resp sx Stool WBC/Cx prn How to decide? RSV Influenza - + Low High OPTION #2 UA/UCx CBC/BCx if T>40 CXR prn resp sx Stool WBC/Cx prn MD Risk Tolerance? Adapted from Ishimine,

Management of 60-90 DAY Old Admit/antibiotics if: -UA positive -CXR positive

2 - All other tests normal -Consider LP if abx to be given** Discharge/no

and admit 30-60 days: Full work-up -->discharge if all normal.

9 Management of DAY Old Admit/antibiotics if: -UA positive -CXR positive Discharge and consider antibiotics: -WBC : >15K <5K - Band/PMN: >0.2 - All other tests normal -Consider LP if abx to be given** Discharge/no antibiotics: -All tests normal -Good follow-up Cheat Sheet < 30 days: Full work-up and admit days: Full work-up -->discharge if all normal. Consider antibiotics days: Urine only or urine/blood; consider viral testing to figure out which way to go. Discharge if nl. 9

Judith Klein, MD 2011 FEVER IN THE FIRST 36 MONTHS OF LIFE

Judith Klein, MD 2011 FEVER IN THE FIRST 36 MONTHS OF LIFE Objectives A short history of the kiddie fever business Vaccinations Rapid viral testing Biomarkers Month-by-month approach to fevers in these