Hot Hot Tot:Fever in KIds <36 months

Judith Klein, MD FACEPAssistant Professor of Emergency Medicine

UCSF-SFGH Department of Emergency Medicine

U

The Hot Tot

1 day of fever to 38. 5

Mild cough

PE: T 38. 2, o/w WNL

Do weeks matter?:

2 week old?

7 week old?

6 month old?

GoalsA short history of the kiddie fever business

Vaccinations

Rapid viral testing

Role of biomarkers (CRP/ procalcitonin)

Month by month approach to fevers in little folks including 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-7 2010: PCV-13 (serotype 19a)

Impact: -Hib: Big -PCV-7: *<90 days: herd immunity *>90 days: direct and huge -PCV 13?

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

Role of Biomarkers

CRP (rises slowly over 12 hrs; peak in 48 to 72 hrs) and procalcitonin (rises over 4-6 hr; peak 12-24 hr)

Sensitivity inadequate to r/o SBI if high risk

May be useful in 1-3 month age group to risk stratify

PECARN and RNA transcriptional signatures

Some Fever ground rules

Fever: >38.0 rectal if <3 months >39.0 if >3 months

Fevers at home count!

Fever length (if <5 days) & antipyretic response don’t count

Kids who look sick are sick!

What does Sick Look Like?

Lethargic/irritable

Respiratory distress

Pale or cyanotic/CRT>2 sec

Poor suck/tone

Rash: petechiae, vesicles

Van den Bruel, Lancet 2010.

Fresh out of the Oven

2 week old term female 1 day fever to 38.5

Maternal GBS+ -->got ampicillin peri-partum

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

Approach to <30 day neonate

BCx, UA/UCx (cath or SPA only), LP for all

CXR if: RR, hypoxia (<97%), G/F/R, abnormal lung exam

Viral studies not helpful: RSV+still have high rate of SBI

CRP/PCT? NPV not high enough to rule out 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

3rd generation cephalosporin like cefotaxime or gent AND

Increasing ampicillin resistance; vancomycin if sick or if maternal ampicillin

Add acyclovir if risks for HSV

Now I can Smile....

7 week old term male with 2 days T to 38.9

PE: T 39, RR 70, O2 98% smiles, o/w WNL

What next?

Do a few weeks make a Difference?

<30 days old 30-60 days old

vegetable social smile

Up to 6% of low risk kids have SBI

Lab tests can better predict high risk

OB/mening risk*#: 2.7-4.1%

OB/mening risk*#: 0.7-1.9%

*Pantell, JAMA 2004

#Morely, Pediatr Emerg Care 2012

Approach to 30-60 day old

Clinical exam helpful, but still misses SBI

Rochester/Philadelphia criteria?

Work-up: -UA/UCx? -CBC/BCX? -LP for all? -CXR and stool?

Social: reliable caretaker? transportation? willing parent?

Role of Viral Studies (RVT)

Levine*: SBI in <60d with and without RSV -SBI 12.5 to 7% if RSV+ -Most SBI were UTI

Krief#: 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

*Levine, Pediatrics 2004 #Krief, Pediatrics 2009

Inflammatory Markers

CRP: (>20 mg/L): -general inflammation later

Procalcitonin: (>0.5 ng/ml) -responds to bacterial endotoxin, TNF, IL early-better negative LR

Better than WBC and ANC

Inadequate sensitivity as stand alone tests but may help with risk stratification

Andreola, Pediatr Infect Dis J 2007.

Yo, Ann Emerg Med 2012

Gomez, Pediatrics 2012

Approach to 30-60 DAY old

Full workup if toxic or high risk history*

OPTION #1: UA/UCx

CBC/BCxLP

CXR/stool prn

OPTION #2UA/UCx

CBC/BCx if T>40 CXR/stool prn

RVT-PCT/CRP

RVT+PCT/CRP low

MD Risk tolerance?Social situation?

low/poor high/good

*High risk: preemie, on antibiotics, prolonged hospitalization, immunocompromise

What about 60-90 day Babe?

OB rate even lower! (approaching 0.25%)

Clinical exam even more reliable

If well appearing, option #2! *RSV/flu +CRP/PCT + UA

If bronchiolitis: SBI rate extremely low--> just get UA

Management of 30-90 DAY old

Antibiotics (CTX+/-Vanco) if: -WBC<5K >15K, Band/Neut >0.2 -Elevated CRP/PCT -UA >5 wbc/hpf -CSF >8 wbc -Stool >5 wbc/hpf -CXR with infiltrate

<60 days: strongly consider LP if giving abx: multi-focal infections common

Management of 30-90 DAY Old

Admit: -UA positive and <60d or unable to tolerate po -CXR positive -LP positive -High risk

Discharge/antibiotics:-Abnl CRP/PCT/WBC ->60d: UA+ and looks well

Discharge/no antibiotics: -all tests normal -good follow-up!!

I’ll tell you what’s wrong..

6 month old girl fever of 39.3 for 2 days. Breast feeds well.

2 sets of vaccines

PE: T 39.2. O2 96%. Otherwise normal.

“What are you going to do to me???”

What should I worry about?

Hx and PE work!!

OB rate very low post PCV7: 0.25-0.5% (false positive rate BCx: 1-3.6%!!): JUST SAY NO TO BCX

Pneumonia and UTI predominate so look for these

the under-immunized Kid

< 2 PCV or Hib: higher risk although herd immunity present

Danger of herd immunity loss

Consider RVT and PCT/CRP in younger (<6-12 months) under-immunized kids-->Bcx/Abx if higher risk

Let’s talk about Pee Pee

2-5% overall risk UTI but some groups 2-3 x higher

UA/UCx indications: -All: <3 months -Uncircumcised boys <6 mos -Girls <24 mos if T> 39 for >2 days and no clear source.

Cath best but can try bag

Abx: CTX then keflex

When do you suspect pneumonia?

CXR only if clinical signs: -tachypnea -hypoxia (< 97%) -respiratory distress (G/F/R)

CXR not good at bacterial vs. viral cause so antibiotics if abnormal

Rx: amoxicillin or azithromycin

Cheat Sheet

< 30 days: Full work-up and admit

30-90 days: UA/UCx; CBC/BCx and/or LP if RVT negative and CRP/PCT up or if poor social -admit for focal infxn or high risk -LP if giving abx <60d

3 mo-36 mo: UTI and pneumonia; bloodwork if high risk or < 2 PCV and CRP/PCT-->discharge if well appearing

Judith R. Klein, MD 2014

Pediatric Fever References: Andreola B, Bressan S, Callegaro S, et al. Procalcitonin and C-reactive protein as diagnostic markers of severe bacterial infections in febrile infants and children in the emergency department. Pediatr Infect Dis J 2007; 26(6): 672. Antonyrajah B, Mukundan D. Fever without apparent source on clinical examination. Curr Opin Pediatr 2008; 20: 96. Bilavsky E, Yarden-Bilavsky H, Ashenkenazi S, et al. C-reactive protein as a marker of serious bacterial infection in hospitalized febrile infants. Acta Pediatr 2009; 98: 1776. Bilavsky E, Yarden-Bilavsky H, Amir J, et al. Should complete blood count be part of the evaluation of febrile infants aged < 2 months? Acta Pediatr 2010; 99(9): 1380. Byington CL, Enriquez FR, Hoff C, et al. Serious bacterial infections in febrile infants 1-90 days old with and without viral infections. Pediatrics 2004; 113(6): 1662. Carstairs KL, Tanen DA, Johnson AS, et al. Pneumococcal bacteremia in febrile infants presenting to the emergency department before and after the introduction of the heptavalent pneumococcal vaccine. Ann Emerg Med 2007; 49: 772. Galetto-Lacour A, Zamora SA, Andreola B, et al. Validation of a laboratory risk index score for the identification of severe bacterial infection in children with fever without source. Arch Dis Child 2010; 95:968. Gomez B, Bressan S, Mintegi S, et al. Diagnostic value of procalcitonin in well appearing young febrile infants. Pediatrics 2012; 130: 81. Herz A , Gree how TL, Alacantara J, et al. Changing epidemiology of outpatient bacteremia in 3 to 36 month old children after the introduction of heptavalent pneumococcal vaccine. Pediatr Infec Dis J 2006; 25: 293. Huppler AR, Eickhoff JC, Wald ER. Performance of low risk criteria in the evaluation of young infants with fever: review of the literature. Pediatrics 2010; 125(2): 228. Ishimine P. The evolving approach to the young child who has fever and no obvious source. Emerg Med Clin N Am 2007; 25: 1087. Jhaveri R, Byington CL, Klein JO, et al. Management of the non-toxic-appearing acutely febrile child: a 21st century approach. J Ped 2011; 159(2): 181. Krief WI, Levine DA, Platt SL, et al. Influenza virus infection and the risk of serious bacterial infections in young febrile infants. Pediatrics 2009; 124:30. Levine DA, Platt SL, Dayan PS, et al. Multi-Center RSV-SBI Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Risk of serious bacterial infection in young febrile infants with respiratory synctial virus infections. Pediatrics 2004. 113(6): 1728. Morely EJ, Lapoint JM, Roy LW, et al. Rates of positive blood, urine and cerebrospinal fluid cultures in children younger than 60 days during the vaccination era. Pediatr Emerg Care 2012; 28(2): 125. Pantell RH, Newman TB, Bernzweig J, et al. Management and outcomes of care of fever in early infancy. JAMA 2004; 291: 1203.

Judith R. Klein, MD 2014

Paquette K, Cheng MP, McGillivray D, et al. Is a lumbar puncture necessary when evaluating febrile infants (30-90 days of age) with an abnormal urinalysis? Pediatr Emerg Care 2011; 27(11): 1057. Purcell K, Fergie J. Concurrent serious bacterial infections in 912 infants and children hospitalized for treatment of respiratory synctial virus lower respiratory tract infection. Pediatr Infect Dis J 2004; 23: 267. Rudinsky SL, Carstairs KL, Reardon JM, et al. Serious bacterial infections in febrile infants in the post-pneumococcal conjugate vaccine era. Acad Emerg Med 2009; 16(7): 585. Schnadower D, Kuppermann N, Macias CG, et al. Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia. Pediatrics 2010; 126: 1074. Wilkinson M, Bulloch B, Smith M. Prevalence of occult bacteremia in children aged 3 to 36 months presenting to the emergency department with fever in the post-pneumoccocal conjugate vaccine era. Acad Emerg Med 2009; 16: 220. Yo CH, Hsieh PS, Lee SH, et al. Comparison of the test characteristics of procalcitonin and c-reactive protein and leukocytosis for the detection of serious bacterial infections in children presenting with fever without a source: a systematic review and meta-analysis. Ann Emerg Med 2012; 60(5): 591.