Objectives n Define wo is at risk for SBI n Clarify risk stratification n Provide treatment guidelines Neonatal Fever Benjamin B. Constance, MD, FAWM n Bust some myts Based on Case wat do you want to know? n 20 day old male temp 38 C History n Birt istory n Past medical istory n Symptom development n Immunization status n Nutrition source n Sick exposures n Medications used n Maternal HIV / HSV Pysical Exam n Rectal temperature n Full vital signs n Hydration status n Head to toe exam n Complete skin exam n Repeat exams n Observe beavior n Observe feeding Case n 20 day old male temp 38 C n X39 week NSVD n GBS and HSV negative moter n Feeding 3oz q4, wet diapers n Normal pysical exam 1
6/9/14 Case Questions Definitions Wy sould tis baby be admitted? Young infant: < 90 days old Is an LP really necessary? Neonate: 0-28 days old Wat are te odds tis patient as an SBI? Fever: >38 C Wat if te patient ad bronciolitis? SBI: meningitis, bacteremia, UTI, pneumonia, enteritis, cellulitis, abscess, osteo, septic artritis Definitions Perinatally acquired: GBS, E coli, S pneumoniae, S aureus, L monocytogenes, HSV Sepsis Evaluation: CBC, BCx, UA, UCx, CSF cell count, glucose, protein and culture, /- CXR, stool cell count Identifying Sick Patients Somnolent Tacycardia Hypotension Capillary refill >3 seconds Pale, cool skin Diaporesis Respiratory distress Decreased urine output CAUTION!!! SBI can present wit ypotermia (<36 C) Difficulty wit termoregulation Don t miss low core temperature! Consider tis same as fever Wen to consider HSV Mucous membranes, CNS or disseminated Vesicles, conjunctivitis, seizures, CNS Sx, sepsis CSF pleocytosis, elevated LFTs, DIC, acidosis Dx wit HS PCR from vesicles, CSF or blood 2
6/9/14 Neonatal HSV and Status Pediatric Immunity 0-28 days Pediatric Immunity 0-28 days 29-56 days First primary immunizations at 2 monts Regain weigt post birt Protection from maternal breast milk More resilient Still difficulty compartmentalizing infections General Resuscitation Assess airway, breating, circulation IV / IO access IV fluids 20-30 ml/kg Fever control Oxygen Monitor (if available) 29-56 days 57-89 days Little innate immunity Protection from maternal breast milk Unable to compartmentalize infections Present wit vague symptoms Rapidly deteriorate into septic sock Pediatric Immunity 57-89 days 0-28 days 29-56 days 57-89 days First primary immunizations at 2 monts Protection from maternal breast milk More resilient Starting to develop innate immunity Rocester Criteria 8 History and pysical examination istories No antibiotics witin preceding 48 No immunizations witin preceding 48 Band: total neutropil (I:T) ratio < CSF: Gram stain negative Cest x-ray: no infiltrate* on smear* Treatment for ig-risk patients Hospitalize empiric antibiotics Hospitalize empiric antibiotics Hospitalize empiric antibiotics 24- follow-up required, if patient lives witin 30 min of te ospital 24- follow-up required, if caregiver available by telepone Return for 24- follow-up for Performance of low-risk criteria NPV: 98.9% (97.2-99.6) NPV: 100% (99-100) NPV: 94.6% (92.2-96.4) 3
Rocester Criteria Rocester Criteria History and pysical examination istories No antibiotics witin preceding 48 No immunizations witin preceding 48 History and pysical examination istories No antibiotics witin preceding 48 No immunizations witin preceding 48 Band: total neutropil (I:T) ratio < Must be term, no antibiotics, well UA: < 10 WBC/ appearing HPF Normal CBC, UA and stool CSF: Gram Works stain negative 0-60 days Cest x-ray: No no empiric infiltrate* antibiotics on smear* Good NPV Includes CSF and CXR in addition Only 29-56 days Must live close to ospital Best (100%) NPV Band: total neutropil (I:T) ratio < CSF: Gram stain negative Cest x-ray: no infiltrate* on smear* Treatment for ig-risk patients Hospitalize empiric antibiotics Hospitalize empiric antibiotics Hospitalize empiric antibiotics Treatment for ig-risk patients Hospitalize empiric antibiotics Hospitalize empiric antibiotics Hospitalize empiric antibiotics 24- follow-up required, if patient lives witin 30 min of te ospital 24- follow-up required, if caregiver available by telepone Return for 24- follow-up for 24- follow-up required, if patient lives witin 30 min of te ospital 24- follow-up required, if caregiver available by telepone Return for 24- follow-up for Rocester Criteria Rocester Criteria History and pysical examination istories No antibiotics witin preceding 48 No immunizations witin preceding 48 History and pysical examination istories No antibiotics witin preceding 48 No immunizations witin preceding 48 Band: total neutropil (I:T) ratio < UA: < 10 WBC/ No HPF recent abx or immunizations Stool:< 5 wbc Higer /HPF on WBC smear cutoff, UA: includes < 10 WBC/ CSF HPF and CXR Workd 28-89 days CSF: Gram stain negative Empiric ceftriaxone Cest if sent x-ray: ome no infiltrate* Lowest NPV on smear* Band: total neutropil (I:T) ratio < CSF: Gram stain negative Cest x-ray: no infiltrate* on smear* Treatment for ig-risk patients Hospitalize empiric antibiotics Hospitalize empiric antibiotics Hospitalize empiric antibiotics Treatment for ig-risk patients Hospitalize empiric antibiotics Hospitalize empiric antibiotics Hospitalize empiric antibiotics 24- follow-up required, if patient lives witin 30 min of te ospital 24- follow-up required, if caregiver available by telepone Return for 24- follow-up for 24- follow-up required, if patient lives witin 30 min of te ospital 24- follow-up required, if caregiver available by telepone Return for 24- follow-up for n Complete workup, even if known source n Labs n CBC, blood culture n Urinalysis, urine culture n CXR if respiratory symptoms n CSF gram stain and culture n CRP n Consider stool studies n Consider HSV n Empiric terapy wit broad antibiotics n Ampicillin 200 mg/kg/day div q6 IV, AND n Cefotaxime 150 mg/kg/day div q8 IV n Acyclovir 20 mg/kg/dose n Consider Vancomycin 15 mg/kg to cover resistant stap / strep n Consider imipenem for GNR n Hospital admission n Follow cultures n Reassess patient 4
n Complete workup, even if known source n Labs n CBC, blood culture n Urinalysis, urine culture n CXR if respiratory symptoms n CSF gram stain and culture n CRP n Consider HSV No Perform LP if not already All Tests Normal Ceftriaxone 50 mg/kg Yes Consider acyclovir Consider vancomycin Follow-up in 24 ours Admit to ospital Consider ceftriaxone if LP done Admit for poor social situation Only discarge if well appearing n is low risk n Typically 1 dose PCV (ê sepsis risk) n Routine urine testing n Consider blood and CSF (Boston) n Discarge wit 24 follow up if well appearing n Evaluate for source, or occult infection n UTI à UA n Bacteremia à CBC, blood cultures n Pneumonia à cest x-ray n Meningitis à consider CSF if elevated serum WBC n Treat specific sources of infection n If normal workup, reassess in 48 ours n Bronciolitis? à still ceck UA and culture n Ill appearing à admit full sepsis workup ceftriaxone Testing Wat about RSV? n Enterovirus PCR in summer monts (dec osp stay and antibiotic use) n CXR only if aving resp sx <12wks (Crain et al 2 of 148 abnormal cxr) n Sool studies only based on Sx, not routinely elpful n Stud: <56 days 1,248 infants, 269 RSV pos n SBI in RSV 7% vs RSV- 12.5% (still large amount) [Lavine et al] n Given ig risk of SBI in <28 days, full workup sould be done despite flu or RSV 5
Biomarkers Disposition n Procalcitonin may increase risk of SBI but not rule out disease (Gomez et al) n Favorable diagnostic accuracy compared to Rocester (Woelker et al) Patient Admit Abx 0-28 days fever Ill appearing 29-56 days fever 29-56 days fever 57-89 days fever?? 29-56 days, consider discarge if 24 our return and negative workup Consider empiric ceftriaxone if discarged Common Myts Myt = low risk for SBI Normal WBC = low risk for meningi;s Nega;ve workup = low risk criteria in <29d Correc;on 1/5 infants wit a fever will ave a severe infec;on Will be normal in 41% of infants wit meningi;s Low risk criteria performs poorly in febrile neonates Case Conclusion n 20% incidence of SBI in febrile infants n UA neg, WBC 12,000, CSF 2 WBC n Admitted wit amp cefotax acyclovir n Bronciolitis would not cange workup in tis age group Summary < 3 monts are at ig risk for infec;on <56 days sould ave full workup (serum, urine, CSF) <28 days, even well appearing, sould be admiqed wit an;bio;cs (consider HSV) 29-56 days at low risk by criteria can be discarged wit a safe follow up plan 6