4/14/2010. Theoretical purpose of fever? Andrea Marmor, MD, MSEd Assistant Clinical Professor, Pediatrics UCSF April 13, 2010

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Andrea Marmor, MD, MSEd Assistant Clinical Professor, Pediatrics UCSF April 13, 2010 Parental

Axillary and tympanic Vulnerable to environmental and procedural variation Oral:

reliable and accurate method! Bundling does not cause rectal temp! A.

Decrease bacterial growth E. Improve immune system function 0% 0% 0% 0% 0% A. B. C. D. E. :10 Theoretical purpose of fever?

1 Andrea Marmor, MD, MSEd Assistant Clinical Professor, Pediatrics UCSF April 13, 2010 Parental touch? Absence of fever more reliable than presence. Axillary and tympanic Vulnerable to environmental and procedural variation Oral: well-tolerated in older kids Cold drinks/mouth breathing can confound Rectal: still the most reliable and accurate method! Bundling does not cause rectal temp! A. Prevent febrile seizures B. Prevent brain damage C. Make the child feel better D. Decrease bacterial growth E. Improve immune system function 0% 0% 0% 0% 0% A. B. C. D. E. :10 Theoretical purpose of fever? Not shown in humans Dangers of fever? Discomfort, increased metabolism, fluid loss NOT a cause of brain damage or febrile seizures Fever phobia has consequences! 1

2 Primary benefit is comfort Response to treatment not correlated with severity of illness But may make child easier to assess! Acetaminophen and ibuprofen safe, welltolerated and effective Alternating NOT recommended No source after complete H and P for nearly 20% of febrile children A small number of these well-appearing children have a serious bacterial infection (SBI) or occult urinary tract infection (UTI) Guidelines help physicians identify and treat children at high risk for these infections Age groups: neonate, 1-3 mo, 3-24 mo When is viral testing helpful? What if you can t do the workup you planned to do? Bag vs cath? How effective is the pneumococcal vaccine? Do vaccines cause fevers? Daikon is a 29 day-old boy, with a temp of 101 at home He 38.7 R in clinic, well-appearing, without any URI symptoms on exam or history, No immunizations yet Mom says she has the flu and is wondering if he might have the same thing 2

3 What counts as a fever source? Clinical exam is unreliable Infants with viral symptoms may still be at risk for SBI Causes of SBI/UTI: E. Coli, GBS, Listeria, Salmonella Prevalence of SBI in well-appearing infants <28 days with T>38 = 4-12% UTI Prevalence of UTI is HIGH in both boys and girls Associated with a 15-20% risk of bacteremia CBC, blood cultures Cath UA and urine culture LP Antibiotics Ampicillin/gentamicin or amp/cefotaxime IV Ampicillin and cefotaxime can be given IM Consider acyclovir if ill-appearing or pleocytosis on CSF Admission Would viral testing change your management? Recent studies, mostly retrospective, have evaluated risk of SBI in young infants with a positive viral test SBI less likely in infants with + viral test MOST reassuring in low risk patients HOWEVER, in very young infants or those at high risk, consider a small but still appreciable risk of SBI/UTI 3

4 You decide to get a CBC and blood culture, a cath UA and a rapid viral test for RSV and influenza Results: WBC 18, with 67% lymphs Rapid viral test positive for influenza Cath U/A negative What do you want to do? Most conservative option: Perform lumbar puncture, admit for IV antibiotics Less conservative option Admit for observation overnight, no antibiotics, no lumbar puncture NOT an OK option Antibiotics without an LP You decide to do the lumbar puncture, admit and start ceftriaxone. However, you are unable to obtain CSF after 3 tries Now what? 1. Treat without tap: Try again tomorrow for cell count May mean commit to full course for presumed meningitis 2. Don t treat: Admit for obs without tap (plan to tap and treat if illappearing) Rutabaga, a 2.5 mo old boy, presents to the ED with 2 days of fever On exam he is well-appearing, well-hydrated, febrile to 38.9 No source can be found on exam or history He is fully immunized for age, including his 1 st dose of PCV-7 1 week ago He is uncircumcised 4

5 Causes of SBI/UTI E. Coli (UTI), GBS, S. pneumonia, N. meningitidis, Hib Prevalence of UTI in this age group is highest in uncirc boys (15%) and girls (10%) Only 2% in circumcised boys What is considered a fever source? 1. Bronchiolitis 2. Croup 3. Otitis Media 4. Vomiting 5. Hand Foot Mouth syndrome 73% 18% 2% 5% 3% A. Bronchiolitis B. Croup C. Otitis Media D. Vomiting E. Hand Foot Mouth syndrome What else counts as a fever source? Named viral syndrome Otitis media Non-specific exanthem/uri symptoms??? Urinalysis and urine culture on all infants If UA is positive, begin treatment for pyelonephritis and consider admission If unvaccinated: CBC and blood culture If WBC>15K, antibiotics (ceftriaxone IM/IV) Lumbar puncture If signs of CNS irritability, and strongly consider if giving antibiotics Follow up The next day (2nd dose if antibiotics were given) Admit if unable to follow up 5

6 Urinalysis and urine culture on all infants If UA is positive, begin treatment for pyelonephritis and consider admission If unvaccinated: CBC and blood culture If WBC>15K, antibiotics (ceftriaxone IM/IV) Lumbar puncture If signs of CNS irritability, and strongly consider if giving antibiotics Follow up The next day (2nd dose if antibiotics were given) Admit if unable to follow up When is viral testing helpful? What if you can t do the workup you planned to do? Bag vs cath? How effective is the pneumococcal vaccine? Do vaccines cause fevers? Sensitivity: similar to cath specimen Best NPV in low prior prob patients Specificity: lower than cath specimen Bottom line: If false positive results will negatively impact patient, consider getting a cath instead High risk or ill-appearing infants: Obtain a catheter specimen for UA and culture Negative UA: send for culture to confirm Positive UA: empiric treatment, speciate with culture 6

7 You collect a cath urine on Rutabaga and the dip is negative for LE and nitrites Now what? Toss it? Send it for culture? You collect a cath urine on Rutabaga and the dip is negative for LE and nitrites Now what? Toss it? Send it for culture? There s still no source for Rutabaga s fever, and you are concerned about occult serious bacterial infection (SBI) Urinalysis and urine culture on all infants If UA is positive, begin treatment for pyelonephritis and consider admission If unvaccinated: CBC and blood culture If WBC>15K, give antibiotics (ceftriaxone IM/IV) Lumbar puncture Only if signs of CNS irritability, and strongly consider if giving antibiotics Follow up The next day (2nd dose if antibiotics were given) Admit if unable to follow up 1. Obtain a CBC /blood cx and LP; treat with ceftriaxone 2. Obtain a CBC/blood cx; treat with ceftriaxone if WBC >15 or<5 3. Do not obtain any blood tests; as risk for SBI is very low 29% 4. Obtain a nasal RSV and flu test; obtain a CBC only if this is negative 47% 6% 18%

8 Does partial vaccination protect against invasive pneumococcal disease (IPD)? PCV-7 tested in a large NC Kaiser-based randomized controlled trial of 37,868 children Efficacy against IPD from vaccine serotypes Fully vaccinated children (4 doses): 97.4% Those receiving one or more dose of vaccine: 94%. Efficacy against IPD from any pneumococcal serotype Those receiving one or more doses: 89.1% Data insufficient to quantifyefficacy vaccine after < 3 doses However, immunity against SBI is good in partially immunized infants Herd immunity may be protective Two recent studies have demonstrated good serotype-specific antibody responses after 2 doses of the vaccine (Goldblatt, 2006; Huebner 2002) A. Obtain a CBC/blood cx and LP; treat with ceftriaxone B. Obtain a CBC/blood cx; treat with ceftriaxone if WBC >15 or <5 C. Do not obtain any blood tests, as risk for SBI is very low D. Obtain a nasal RSV and flu test; obtain a CBC only if this is negative 8

9 Chayote is 7 month old girl who presents to the ED after having a 5 minute, generalized, tonic-clonic seizure at home The seizure resolved before EMS arrived, and the patient was post-ictal but responsive, with T= 39.1 rectal. Rectal tylenol was given. VS otherwise unremarkable Parents report that she has not been ill, and they were not aware that she had a fever until the paramedics told them She just received her 3rd dose of PCV-7 2 days ago (along with Hib, DTap and IPV) There is no source for fever on exam or history. The child is sleepy, but the exam is otherwise unremarkable. Causes of SBI: S. pneumonia>>>n. meningitidis, Hib Causes of UTI: E. Coli>>>Klebsiella, Proteus, Strep spp Risk highest in girls <2 and in uncirc boys up to 6 mo Risk for SBI VERY LOW if 2 doses of PCV-7 or PCV-13 Is the child effectively immunized? At least two doses (3 is better!) 2 weeks from 2nd dose Screen for UTI as for the unvaccinated child Well-appearing, vaccinated children are low risk, so blood tests not likely to change management! 9

10 Infants 3-24 months with FWS (T>39): All girls Uncircumcised boys < 12 mo of age Circumcised boys < 6 mo of age Other factors to consider: length/height of fever, viral symptoms Are the vaccines the source for her fever? Does the fact that she had a febrile seizure change your management? Fever within 24 hours of receiving vaccines (esp multiple vaccines) is common However vaccines are NOT likely to cause fever >39 or prolonged fever (> 24 hours) Conservative approach most important in younger/higher risk infants 1. Bacteremia 2. Meningitis 3. UTI 4. Another febrile seizure 5. Developmental delay 94% 0% 3% 3% 0%

11 Literature reviews (1996, 2003) found rates of SBI/meningitis in SFS similar to age-matched febrile children No cases of meningitis presenting with SFS alone Labs/imaging: No benefit shown EEG: Not useful in predicting recurrence or epilepsy, even in complex febrile seizures Anticonvulsants/antipyretics : do not alter course Identify and treat source for fever If no source, age-appropriate FWS evaluation Perform further evaluation if failure to return to neurologic baseline and consider for Child < 6 mo Complex or focal seizure Educate family Anticonvulsants NOT recommended A. Bacteremia B. Meningitis C. UTI D. Another febrile seizure E. Developmental delay Is the child effectively immunized? At least two doses (3 is better!) 2 weeks from 2nd dose Screen for UTI as for the unvaccinated child Well-appearing, vaccinated children are low risk, so blood tests not likely to change management! How do you obtain urine? 11

High risk or ill-appearing infants: Obtain a catheter specimen for UA and culture Negative UA: consider sending for culture, if high

unlikely, toss the specimen Positive UA: consider empiric treatment, but confirm with a culture If you send the bag for culture consider

How effective is the pneumococcal vaccine? Do vaccines cause fevers? Chayote 1 Is this child toxic? 2 Is there a source for the fever?

12 High risk or ill-appearing infants: Obtain a catheter specimen for UA and culture Negative UA: consider sending for culture, if high prior prob Positive UA: empiric treatment, speciate with culture Lower risk patients: Bag if desired Negative UA (cath or bag): UTI is unlikely, toss the specimen Positive UA: consider empiric treatment, but confirm with a culture If you send the bag for culture consider implications of a false positive! When is viral testing helpful? What if you can t do the workup you planned to do? Bag vs cath? How effective is the pneumococcal vaccine? Do vaccines cause fevers? Chayote 1 Is this child toxic? 2 Is there a source for the fever? 3 Has this child been vaccinated against pneumococcus? 4 If it s a boy, is he circumcised? 5 Will this child come back if he/she gets sick? Daikon Rutabaga 12

Evidence-based Management of Fever in Infants and Young Children

Evidence-based Management of Fever in Infants and Young Children Shabnam Jain, MD, MPH Associate Professor of Pediatrics Emory University Medical Director for Clinical Effectiveness Objectives Understand