CHLA fever protocol
If < 1 y/o and T>39, get blood and urine cx.
If > 1 y/o and T>39.2?, get blood and urine cx.
Less than 1 month old and T>38: Admit for IV abx
1-2 m/o and T>38: Blood (CBC, Cx), Urine (Analysis, Cx), +/- CSF
Age 2-3 mos: gray zone to tap.
Age 2-12 and 7>39: Needs workup unless have prevnar.
If had
prevnar
X 3, have 80% protection against
bacteremia
2-24 months and T>39: Blood (CBC, Cx)
2-24 months and T>38: Consider urine if 2-6 mos circumcised, 2-12 mos uncirc,
female
If WBC > 20 000, do CXR because 25% have pneumonia.
If < 6 mos and febrile seizure, then tap.
Most blood cultures grow out in 10 hours.
Random notes:
With stomatitis, varicella or another readily identified exanthem, the cause of the fever may be readily apparent on physical examination, and further diagnostic evaluation may not be required.3
A retrospective case series4 found that 32 percent of children two years of age and younger with meningitis had been given oral antibiotics for more than two days before the meningitis was detected. These children tended to be less ill-appearing, more commonly had upper respiratory findings and were less apt to manifest fever. Physicians must always bear in mind the possibility of partially treated meningitis when they are evaluating febrile infants and young children who have recently been prescribed antibiotics.
Day-care center attendance and frequent episodes of otitis media have been identified as risk factors for invasive pneumococcal infection in children younger than two years.5 Hence, infants and children with these risk factors may need to be evaluated more aggressively than those who do not attend day care.
A recent practice parameter on urinary tract infection recommended that urine be collected for culture by catheterization or suprapubic aspiration in all infants and children two months to two years of age with unexplained fever if empiric antibiotic treatment had been prescribed.10 Some authorities11 have suggested that a negative urinalysis on a bagged urine sample may be sufficient to eliminate the need for urine culture obtained by a more invasive technique. Other investigators12 have argued that microscopic urinalysis fails to detect 10 to 20 percent of urinary tract infections in infants and young children, and that culture of urine obtained by bladder catheterization is the only acceptable option.
A recent study13 found that 26 percent of children with fever and leukocytosis (a white blood cell count greater than 20,000 per mm3 [20 3 109 per L]) had pneumonia, even in the absence of respiratory symptoms.
The incidence of bacteremia does not differ significantly in febrile infants and young children with or without otitis media.14,15 Therefore, most authorities advise that otitis media not be considered a cause of fever and recommend that febrile infants and children with otitis media be evaluated for an occult infection.
Approximately 10 percent of well-appearing young infants with a temperature higher than 38°C (100.4°F) harbor a serious bacterial infection or meningitis.20-22 In contrast, fewer than 2 percent of well-appearing older infants and young children with a temperature higher than 39°C (102.2°F) manifest bacteremia.14,23
The authors of a commentary on the 1993 practice guideline argued that young children with fever should be carefully assessed for focal bacterial infection.11 If no focus is found and a child appears well, no tests other than urinalysis are routinely indicated, and antibiotics should not be given.
The following is from e-Medicine: Fever in the Toddler. Last Updated: October 1, 2004. http://www.emedicine.com/ped/topic3009.htm
Clinical and laboratory predictors are often used in trying to identify infants and children at risk for serious bacterial infection. Predictors used more frequently include (1) age of the patient, (2) presenting temperature, (3) absolute neutrophil count (ANC), (4) white blood cell (WBC) count, (5) absolute band count (ABC), and (6) the Yale Observation Scale. The first 3 predictors appear to be the most sensitive.
Stratifying infants into low- and high-risk groups is possible using a number of previously validated criteria. The most commonly used screening criteria are known as the Rochester criteria. To be categorized as low-risk using the Rochester criteria requires that the patient:
Newborns aged 0-28 days
The rate of bacteremia
Because the Rochester criteria are not routinely used to screen febrile
infants for meningitis, the authors advocate performing a sepsis evaluation and
hospitalizing the patient for parenteral antimicrobial therapy pending culture
results. The sepsis workup includes complete blood cell (CBC) count, blood
culture, urine analysis (UA), catheterized or suprapubic urine culture, cerebral
spinal fluid (CSF) cell count, and CSF Gram stain and culture. If diarrhea is
present, patients should have less than 5 WBCs/HPF in a Gram-stained smear of
the stool. The risk of serious infections among the low-risk infants in this age
group is very small. Jaskiewicz et al (1994) found the Rochester criteria to
yield a negative predictive value of 99.3% for the detection of serious
bacterial infection in children.
Similarly, Baraff et al (1992) found the risk of bacteremia to be about 1.1% and
the risk of meningitis about 0.5% in patients classified as low-risk. However,
most physicians perform a full sepsis
workup (ie,
CBC
count, blood culture, UA,
catheterized or suprapubic
urine culture, CSF
examination and culture) in all high- and low-risk infants in this age group,
followed by hospitalization for
parenteral antimicrobial therapy
(eg,
ampicillin/gentamicin
or ampicillin/cefotaxime)
pending culture results. No chest radiograph is necessary in the absence of
respiratory symptoms or signs because the mean probability of finding an
infiltrate on chest radiograph in asymptomatic infants is low.
High-risk newborns aged 4-8 weeks (29-56 d)
This includes both
As in the category of newborns aged 0-28 days, these infants deserve a full
sepsis workup, followed by hospitalization for parental antimicrobials
while waiting for culture results.
Low-risk newborns aged 4-8 weeks (29-56 d)
Febrile children aged 3-36 months
Summary of the Yale Observation Scale
|
|||||||||||||||||||||||||||||
Children with a total
WBC
count greater than 20,000/mL
or an ANC of 12,000/mL
or more carry a risk of occult
bacteremia close to 20%. The
bacteria most often isolated from the blood of children with
bacteremia
are Streptococcus pneumoniae
(85-90%), Neisseria
meningitidis,
Streptococcus pyogenes,
and Salmonella species.
The overall risk for children with bacteremia without antimicrobial therapy was
quoted to be 21% for persistent bacteremia and 9% for meningitis. With the
virtual elimination of Haemophilus influenzae because of routine immunization
against this organism, current numbers are likely to be much lower than
previously cited. In general, children
in this age group with a temperature lower than 39°C should be assessed
clinically. Laboratory tests or antibiotics are unnecessary if the child appears
well.
Controversy exists about the management
of the well-appearing child with temperatures higher than 39°C and no focus (or
a minor upper respiratory focus) of infection. A meta-analysis conducted
by Bulloch et al (1997) involving the use of empiric antibiotics in older
infants and children with fever concluded that no significant outcome advantage
exists for antibiotic therapy. The extravagant use of antibiotics may accelerate
drug resistance, increase healthcare cost, and lead to development of partially
treated meningitis.
A well-circulated practice guideline(1) for the management of this problem has
recommended a CBC
count, blood culture (see red highlight below on value of blood work),
UA,
and urine culture in girls younger than 2 years and boys younger than 6 months.
According to those recommendations, children with WBC counts equal to or higher
than 15,000/mL or an ANC higher than 10,000/mL should have blood cultures sent
and receive ceftriaxone IM at a dose of 50 mg/kg as empiric therapy for possible
occult bacteremia. Much of the
controversy relating to the practice guideline involves the selection of
this cutoff value. One set of investigators14
has advocated 18,000 white blood cells per mm3
(18 3 109 per L) as the cutoff value, arguing
that use of this higher count is justified by the post-vaccination disappearance
of H. influenzae infection and a lower overall prevalence of bacteremia
than previously reported.
Reevaluate these patients in 18-24 hours
and administer a second dose of
ceftriaxone to provide antibiotic
coverage until blood culture results have been negative for 48 hours.
While most would concur that children
should be screened for UTI,
some maintain that the incidence of
bacteremia
and its complications has declined dramatically over the past decade;
therefore, no blood work is necessary and only
close outpatient follow-up is needed for these patients. With the introduction
of the new heptavalent conjugate vaccine active against the most virulent
pneumococcal
serotypes, the incidence of
bacteremia may decline further,
providing additional support to this approach.
Factors most often associated with a failure to follow up include parental age
younger than 21 years, lack of ownership of a car and parental perception of a
lesser degree of illness in their child.19
| Definitions of Terms in the
1993 Practice Guideline on the Management of Fever in Infants and Young
Children |
|
| Term |
Definition
|
| Fever | Rectal temperature of 38°C (100.4°F)* |
| Fever without source | Acute febrile illness in which the etiology of the fever is not apparent after a careful history and physical examination |
| Serious bacterial infection | Meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia, enteritis |
| Toxic appearance | Clinical presentation characterized by lethargy, evidence of poor perfusion, cyanosis, hypoventilation or hyperventilation |
| Lethargy | Poor or absent eye contact; failure of child to recognize parents or to interact with persons or objects in the environment |
Hoberman A, Wald ER, Reynolds EA, et al: Pyuria and
bacteriuria in urine specimens obtained by catheter from young children with
fever. J Pediatr 1994 Apr; 124(4): 513-9
Jaskiewicz JA, McCarthy CA, Richardson AC, et al: Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics 1994 Sep; 94(3): 390-6
Baraff LJ, Oslund SA, Schriger DL, Stephen ML: Probability of bacterial infections in febrile infants less than three months of age: a meta-analysis. Pediatr Infect Dis J 1992 Apr; 11(4): 257-64
Bulloch B, Craig WR, Klassen TP: The use of antibiotics to prevent serious sequelae in children at risk for occult bacteremia: a meta-analysis. Acad Emerg Med 1997 Jul; 4(7): 679-83
Baraff LJ, Bass JW, Fleisher GR, Klein JO, McCracken GH, Powell KR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Pediatrics 1993; 92:1-12.
*Greenes DS, Harper MB. Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatr Infect Dis J 1999;18:258-61.
**Rothrock SG, Green SM, Wren J, Letai D, Daniel-Underwood L, Pillar E. Pediatric bacterial meningitis: is prior antibiotic therapy associated with an altered clinical presentation? Ann Emerg Med 1992;21:146-52.
***Takala AK, Jero J, Kela E, Ronnberg PR, Koskenniemi E, Eskola J. Risk factors for primary invasive pneumococcal disease among children in Finland. JAMA 1995;273:859-64.