Your first patient of the day

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Toby Rose
5 years ago
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2 Your first patient of the day 1 month old male with 2 days of fussiness Decreased stool output for 3 days Poor latch during breastfeeding noted at 3AM on day of arrival to the ED Started spitting up later in the morning Was noted to be less alert as well Soft spot was hollow He was also breathing real fast He was making a grunting noise which the parents thought was due to him trying to poop

3 The details Birth and past medical history G1P1 Birth weight 8 pounds 5 ounces C-section for failure to progress at 41 weeks No complications during pregnancy GBS and other labs negative Maternal health Hx negative Unconjugated hyperbilirubinemia required phototherapy on DOL3 Regained birth weight by DOL 7

4 You enter the room The infant s skin is this color You suddenly turn this color

5 First impressions ABCDE s He has an airway He is breathing fast and making a grunting noise He s skin is a lovely shade of grayish purple He appears uncomfortable

6 Your physical exam VS HR205 BP90/65 RR50 T38.8 GEN grunting, gray skin HEENT AF sunken, mmm, + tears CV rate >200, no murmurs, 1+ femoral and brachial pulses, cap refill 5 seconds PULM tachypneic, CTAB ABD firm and distended, tender, no masses, normally positioned anus GU nl male NEURO irritable, nl tone

7 One sick baby What are his problems? What do you think is going on? What do we need to do about it?

8 Goals Discuss fever of uncertain source in infants 0 to 60 days Focus on the Emergency Department setting Clinical assessment Diagnostic evaluation Treatment strategy Discuss use of CCHMC Evidence Based Guidelines

9 Fever of uncertain source FUS is an acute febrile illness with uncertain etiology after thorough H&P No focal infection (eg. otitis media) The prevalence of a serious bacterial infection (SBI) in infants with fever is high Clinical exam alone is unable to reliably predict presence of SBI

10 Etiology SBI include; Meningitis, bone and joint infections, soft tissue infections, pneumonia, UTI, sepsis/bacteremia, enteritis Most common causes of FUS #1 systemic viral infections #2 urinary tract infections #3 upper and lower respiratory tracts #4 middle ear

11 Etiology Prevalence is uncertain in the post Hib, post prevnar era <1 month % according to Bachur, 2001, Kadish, 2001, Baker, months 5 to 8.7% CCHMC data <1 month 9% 1-2 months 8%

12 The villains Bacteria (Baker, 1999) E. coli 39% Klebsiella 11% Group B strep 8% Enterococcus 6% E. cloacae 6% L. monocytogenes 6% Viruses Up to 50% of infants between Aug-Oct w/ FUS have enterovirus HHV-6 in 10% <90 days old HSV incidence is 30/100,000, of these only 7-14% present with FUS

Clinical assessment - Fever Rectal temperature! >38 o C or 100.

13 Clinical assessment - Fever Rectal temperature! >38 o C or o F Magnitude may not predict severity How accurate is parental report of fever felt by touch alone? Answer: pretty darn good! Sens 82-89% Spec 76-86%

14 Clinical assessment - History Low risk for SBI Rochester criteria Term birth >37 weeks No previous hospitalizations No chronic illnesses Not hospitalized longer than mother Not treated for unexplained hyperbili Has not recived antibiotics No intrapartum maternal fever, GBS, antibiotics No focal bacterial infection on exam Purulent otitis, skin/soft tissue infection, bone/joint infection Negative lab screen

15 Clinical assessment - Exam High risk findings include Lethargy Poor or absent eye contact My advice Be thorough! Failure of child to recognize parents, or failure to interact with persons/objects in the environment Poor perfusion of the extremities Acrocyanosis Mottling Cap refill >2 seconds in warm ambient environment Hyper/hypoventilation cyanosis Per Yale Observation scale <24 months of age

16 Clinical assessment - Exam The toxic infant Lethargy Poor perfusion Hypo/Hyperventilation Cyanosis

17 Clinical assessment - Labs CBC Abnormal wbc >15,000 or <5,000 Bands >1,500 Note: wbc values do not predict risk of meningitis (Bonsu, 2003) One Unit, Two Units Ah, Ah, Ahhh Blood Culture

18 Clinical assessment - Labs Urinalysis Abnormal >10wbc/hpf Gram stain for bacteria Sens 94% Spec 92% Urine culture Catheter! (bagged specimens are useless)

Clinical assessment - Labs LP should be performed in all <30 days You can delay/omit 31-60 days IF Low risk via exam AND CBC + U/A Reliable follow

19 Clinical assessment - Labs LP should be performed in all <30 days You can delay/omit days IF Low risk via exam AND CBC + U/A Reliable follow up <24 hours Confident in parents ability to recognize changes in condition PCP and family agree with plan Antibiotic therapy will NOT be initiated

20 Clinical assessment - Labs LP Can be performed lying on side or upright Most CCHMC MDs and holders prefer upright Better success after local infiltration of anesthetic, and with early stylet removal Even if you get a bloody tap still initiate antibiotic therapy

21 Clinical assessment - Labs CSF studies Tube 1 protein and glucose Tube 2 culture and gram stain Tube 3 cell count and differential Tube 4 (Wasserman) extra culture, hold Normal values for blood and urine do not rule out meningitis Enteroviral meningitis can have a CSF wbc of >1000! Look for predominance of segs in a high wbc/hpf in bacterial meningitis Normal CSF values vary Boston protocol <10 wbc/hpf Philadelphia protocol <8 wbc/hpf Rochester criteria <5 wbc/hpf

22 Cultures Try to obtain before giving antibiotics Don t withhold if infant is septic/in shock Cultures should be watched for 36 hours at minimum Mean time to true positivity for B/C = 17.5 hours For blood contaminants = 27.9 hours Urine Cx = 16 hours CSF Cx = 18 hours

23 Other adjunctive studies Chest XRay Stool culture if diarrhea Viral studies (+ PCR does NOT rule out SBI) Enterovirus PCR of CSF (summer and fall) Results available in 24 hours PCR is more sensitive than viral culture HHV-6 PCR HSV PCR of CSF (more on HSV later)

24 Treatment Supportive care ABCs O2 if sats <90% Fluid resuscitation w/ NS Generally 20ml/kg, by if you suspect heart failure, 10ml/kg may be appropriate And, oh yeah ANTIBIOTICS!

25 Treatment Antibiotics in ALL infants less than 30 days w/ FUS AMPICILLIN 50mg/kg IV q6h q12h <7days old If you highly suspect Staph you can use NAFCILLIN 20-50mg/kg IV q6h instead of AMPICILLIN + 3 rd generation cephalosporin CEFOTAXIME 50mg/kg IV q8h q8h bacteremia, q6h meningitis OR GENTAMICIN 3mg/kg IV q24h 31-60d - 2.5mg/kg q12h NNT with ampicillin to prevent one case of Listeria or enterococcus is 138

26 Treatment days - 3 rd generation cephalosporin alone 3 rd generation cephalosporin CEFOTAXIME 50mg/kg IV q8h q8h bacteremia, q6h meningitis OR 3 rd generation cephalosporin CEFTRIAXONE 50mg/kg IV q24h for bacteremia 100mg/kg IV q24h for meningitis If infant is severely ill or UTI suspected add AMPICILLIN Listeria, gram + cocci, enterococcus (NNT= 527) Don t give Ceftriaxone if hyperbilirubinemic - since can displace bilirubin from its binding sites concurrent administration with intravenous calcium-containing solutions or products (including TPN) causes potentially fatal precipitation reactions

27 Herpes What about Herpes? Laboratory evaluation and/or treatment should be considered if risk factors are present

28 Herpes Presentation of infants with neonatal HSV 7-14% have FUS 61% have no fever 95-98% present prior to 22 days of age 68% present with a vesicular rash on either the skin or mucous membranes 27% have seizures Overall incidence of HSV infection is 30/100,000 live births

29 Which one is due to HSV? Answer: This is a trick question neither are. They are both examples of candidal diaper dermatitis, which can look like HSV

32 Herpes Highest Risk Primary maternal HSV infection at delivery 2/3 mothers who acquire HSV during pregnancy are symptom free Lower Risk Factors Known exposure to HSV infected persons Caregiver with oral/genital herpes <37 weeks gestational age Fetal scalp electrodes Maternal STD Hx or unexplained fever at delivery CSF pleocytosis with negative gram stain and negative bact Cx Failure of fever to abate within hours after starting ABx Unexplained CNS signs

33 Treatment - HSV Treatment Additional labs/studies recommended Renal + glucose ACYCLOVIR 20mg/kg IV q8h Liver panel Head CT CSF HSV PCR enterococcus PCR (if in season) Viral cultures CSF Skin lesions Conjunctivae NP swab Rectal swab

34 Treatment - HSV The bottom line treat if Mom had HSV at delivery, or infant has been exposed The baby seizes or has worrisome neurologic signs There is clinical evidence to suggest that HSV is present Routine treatment with Acyclovir is NOT recommended

35 Disposition <30 days definitely buys you an admission Approximately 3% of infants that are low risk STILL have SBI days can be managed at home or inpatient Low-risk infants days can be D/C home IF Baby meets all history and exam findings for LOW RISK Negative labs (LP not necessarily needed) They have excellent follow up <24 hours CALL THE PMD! Parents are comfortable You can admit without antibiotics if labs are negative but parents are uncomfortable or follow up is lacking Some MDs may wish to give IM/IV CEFTRIAXONE and D/C home If you give antibiotics you SHOULD do an LP too Consider PICU or RCNIC if Shock Bacterial meningitis suspected

36 When you are at CCHMC In EmSTAT click on the orders tab

37 Choose the Fever/Sepsis set from the list of Standard Order Panels It will take you to a screen where you can order all of the requisite labs

38 Choosing these orders is most appropriate for a 0-30 day old with FUS Then click to order the appropriate antibiotics

39 Evidence based guidelines You can always access the guidelines You ll find the guidelines on the Pediatric Residents tab on CenterLink while working at CCHMC

40 Evidence based guidelines Choose Guidelines to be taken to the list

41 Evidence based guidelines You can download the pdfs When away from CCHMC you can still access the guidelines health-policy/ev-based/default.htm You can also search for Evidence Based Care Guidelines after directing your browser of choice to cincinnatichildrens.org

42 Case #1 3 week old former 39 week infant with temp of 38.4, feeding well, no respiratory distress, excellent perfusion Labs? Antibiotics? Disposition?

5 week old former 35 week old infant Fever to 100.

43 5 week old former 35 week old infant Fever to o F rectally at home Looks well in the ED Can we apply the CCHMC guidelines to this infant? Case #2

44 You are seeing a 7 week old girl at Clinton Memorial Former 39 week infant Fever to 102 at home for 2 days Feeding well Crying but consolable Defervesces with Tylenol Visiting family in Ohio they live in Chicago What are you going to do? Case #3

45 Back to our first patient He was clearly quite sick We obtained CBC, B/C U/A, U/C CSF labs Serum glucose We also elected to get XRays I-STAT

46 S 72 Bd 9 L 6 M 3 U/A wbc + Leuk Est no bacteria 7.1 / 69 / -9 CSF Prot, gluc nl 12 rbc 2 wbc No organisms on gram stain

47 Back to our first patient He was started on Ampicillin and Cefotaxime He was intubated for worsening respiratory distress Resuscitated w/ 60ml/kg NS though MAPs still in 50 s started on Dopamine for perfusion Admitted to the RCNIC Cultures grew E. coli in blood and urine Dx E. coli urosepsis Developed a protracted septic ileus D/C after 27 days in the ICU returned to breast feeding and doing well

48 Take home point #1 FUS is an acute febrile illness with uncertain etiology after thorough H&P Rectal temperature! >38 o C or o F Clinical exam alone cannot reliably predict presence or absence of SBI The toxic infant Lethargy Poor perfusion Hypo/Hyperventilation Cyanosis

49 Take home point #2 30 days or less and FUS Blood, Urine, and CSF studies Ampiciliin + Cefotaxime OR Gentamicin Admission Remember, bagged specimens are USELESS!

50 Take home point #3 31 to 60 days and well appearing CBC, B/C, U/A, U/C Positive labs LP and CSF studies 1. Reliable f/u in hours 2. Parental education 3. Plan OK w/ PMD and family 1. IV Antibiotics 2. Admit D/C home 1. f/u in hours at PMD 2. If meets low risk criteria consider D/C w/o antibiotics unless there are PCP concerns 3. If you do give antibiotics empirically you SHOULD do an LP

51 Take home point #4 HSV Mom had HSV at delivery, or infant has been exposed The baby seizes or has worrisome neurologic signs There is clinical evidence to suggest that HSV is present Treat with Acyclovir Don t forget adjunctive labs

52 Take home point #5 The CCHMC Evidence based Guidelines are a Great Resource Familiarize yourself with them before your rotation pdfs are always available on the web health-policy/ev-based/default.htm

Beyond the Reflex Arc: An Evidence-Based Discussion of the Management of Febrile Infants

Beyond the Reflex Arc: An Evidence-Based Discussion of the Management of Febrile Infants Cole Condra, MD MSc Division of Emergency Medical Services Children s Mercy Hospital October 1, 2011 Disclosure