This document discusses fever in children and provides definitions for key terms. It reviews the epidemiology of fever in kids and outlines historical perspectives on recognizing potential serious bacterial infections in febrile children. The document examines predictors of occult bacteremia, clinical guidelines for evaluating fever without source, and controversies around the management of febrile children. It also discusses serious bacterial infections like meningitis and the impact of the pneumococcal vaccine.
2. Antipasto
q Ron Dagan q Rochester ,NY
q Paul McCarhty q West Haven,Ct
q Douglas Baker q Philadelphia, Pen
q Baskin q Boston, Mass
q Larry Baraff q Los Angeles,Ca
q Nathan q Davis, Ca
Kuppermann
3. History
q 1920-30; Recognition of potential serious
bacterial infection in well looking febrile
child. Dunham EC:Septicemia in the newborn, Am J Dis Child 1933;45;229-253
q Age 8 weeks or less
q Tº 38ºC rectal
q Long standing controversies
• What risks, who is/who is not, who looks sick/who
doesn’t, who to keep/who to send, who to treat who
not to.
q No consistency
6. Epidemiology of fever
q 10-20% of all ER visits
q 20% of fevers are FWS
q 1.6% of all ED visits, 3-36 Mo
> 39°C, non-toxic
q Most common complaint < 6 Mo
q Most high fever are benign
7. Fever Phobia Revisited: Have
Parental Misconceptions About
Fever Changed in 20 Years?
Pediatrics, Volume 107, Number 6, June 2001, Michael Crocetti 1
MD
Harmful effects of fever
q Type Schmitt (n = 81) Crocetti et al (n =
340 )
q Seizure 15% 32%
q Brain damage 45% 21%
q Death 8% 14%
q Dehydration 4% 4%
q Really sick 1% 2%
q Coma 4% 2%
q Delirium 12% 1%
q Blindness 3% 1%
q No response 6% 9%
q Other - 14%
q Total 100% 100%
8. Clinical Thought
Process
FEVER
S IC K N O T S IC K
W O RK UP F O C A L IN F E C T IO N N O F O C A L IN F E C T IO N
A D M IT hx and PE
IN V E S T IG A T E W H O W IL L G E T S IC K A N D W H A T
TR E AT
A D M IT
9. None of this applies to the sick looking child...
That is assuming we know what a sick kid is?!
10. Relevant Age Groups
and development
q 0………4w
q 0………………..8w
q 0……….……………….12w
q 12w………..3y
q > 3 years old
q Age stratification of risk for SBI
11. LOW AND HIGH-RISK CRITERIA COMMONLY
USED IN STUDIES OF FEVER WITHOUT
SOURCE
q Low-risk Criteria High-risk Criteria
q Term gestation (37 weeks) Recurrent febrile illnesses
q Uncomplicated prenatal course Prematurity
q No recent (7d) antibiotic Congenital immune disease
q No recent surgery Sickle cell disease
q No chronic illness Asplenia
q No perinatal ATB Malignancy/chemotherapy
Recent steroid therapy
q Hospitalized = to mother HIV disease
12. Yale Observation Scale
Score
q Quality of cry q Score 6-10 well
q Alertness q Score 11-15 mod
q Color q Score > 15 toxic
q Hydration
q Response to
parents
q Response to
others
McCarthy PL, Sharpe MR, Spiesel SZ, et al: Observation scales to identify serious illness in
febrile children. Pediatrics 1982; 70:802
13. Yale Observation Scale
Score
q OB
q 6-10 well q 2,5%
q 11-15 mod q 4,7%
q > 15 toxic q 5,7%
14. Patients Patients
with OB without OB
Sens Spec PPV NPV
YOS No. % No. % % % % %
>6 55 28.6 1122 17.5 28.6 82.5 4.7 97.4
>8 32 16.7 522 8.1 16.7 91.9 5.8 97.3
>10 10 5.2 210 3.3 5.2 96.7 4.5 97.1
>12 1 0.5 75 1.2 0.5 98.8 1.3 97.1
Efficacy of an observation scale in detecting bacteremia in febrile children three to thirty-six months of
age, treated as outpatients. Stephen J. Teach Journal of Pediatrics, Volume 126, Number 6, June 1995
15. Predictors of
bacteremia
q History q WBC
q Physical exam q ANC
q Gender q Bands
q Height of fever q Band/Neutrophils
ratio
q PMN%
q ESR-CRP-cytokines
Daniel Isaacman, Predictors of bacteremia in febrile children 3-36 Mo of age, Pediatrics;106;5;Nov 2000
age
Nathan Kupperman, Predictors of occult bacteremia in young febrile children, Ann Emerg Med June 98;31;679-687
children
16. Rochester Criterias for
infants under 3 months
q Term q 15 000 WBC
q Previously q 1500 bands
healthy q 5 WBC/hpf in
q Non-toxic stool
q No focus q 10 WBC/hps in
q No previous ATB spun urine
Ron Dagan, Identification of infants unlikely to have serious bacterial infection although
hospitalized for suspected sepsis, J Pediatr 1985;107;855-860
17. Rochester Criterias for
infants under 3 months
q Risk of 0.5-1.1% for SBI including
meningitis
q NPV 98,5%
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.
Pediatrics 1994;94:390-396
18. Philadelphia Criterias
q Non-toxic q WBC < 15 000
q No focus q BNR < .2
q No immuno- q U/A
deficiency • < 10 wbc/hpf
spun,
• -ve gram stain
q CSF
• < 8 wbc
• -ve gramstain
• normal gluc, prot
q CXR, if signs
19. “It has been well described
that a well appearing young
infant may have an SBI…
therefore, laboratory
investigation is necessary.”
1-Baraff LJ, Oslund S, Schriger DL, et al. Probability of bacterial infections in infants less
than three months of age: a meta-analysis. Pediatr Infect Dis J. 1992;11:257-265
2-Baker MD, Avner JR, Bell LM. Failure of infant observation scales in detecting serious
illness in febrile 4 to 8 week old infants. Pediatrics. 1990;85:1040-1043
3-Larry J. Baraff Management of fever without source in infants and children
Annals of Emergency Medicine Volume 36 Number 6 December 2000
20. Clinical Thought
Process
FEVER
S IC K N O T S IC K
W O RK UP F O C A L IN F E C T IO N N O F O C A L IN F E C T IO N
A D M IT hx and PE
IN V E S T IG A T E W H O W IL L G E T S IC K A N D W H A T
TR E AT
A D M IT
21. Predictors of
bacteremia
qe w
/ 1+e w
q w = .1673x ANC + .2006x Tº + .
8434x gender - 12.454
Isaacman J., Predictors of bacteremia in febrile children 3 to 36 months of age, Pediatrics Nov
2000;106;5,
22. Common bugs of OB
q S.pneumoniae 1-3%
q Salmonella non-thyphoïd .1-.2%
q N.meningitidis .025%
23. Management
q Mood swings
q ED waiting time
q Gut feeling
q Guidelines
q Clinical policies
q Decision analysis
q Algorithm
q Resolution of conflicts in Freud’s second
stage of development
24. Clinical Guidelines in the Setting
of Incomplete Evidence
DAVID L. SCHRIGER ,Pediatrics, Volume 100 Number 1 July 1997
q “...the infectious disease experts who predominate
the article by Baraff et al emphasize their
experience with the rare child who does poorly;
Kramer and Shapiro emphasize primary care
practitioners' experience with the hundreds of
children who do well…”
q “...while most academic pediatric researchers
have approached the febrile child as if there is only
one opportunity to make the correct diagnosis and
initiate treatment…”
Kramer MS, Management of the febrile infant: a commentary on recent practice guidelines,
Pediatrics;100;1;July 1997
25. Clinical Policy for the Initial Approach to
Children Under the Age of 2 Years Presenting
with Fever
Annals of Emergency Medicine Volume 22 Number 3 March 1993
q “...If the rules regarding admission
appear too stringent at times, we
remind our members that deviation
from the rules requires only that the
physician justify the deviation. In
general, the rules are meant to
protect the child…”
26. A survey about management of febrile
children without source by primary care
physicians.
Wittler RR - Pediatr Infect Dis J - 1998 Apr; 17(4): 271-7
q 1600 mailing list
q GP, EP, Paeds
q 3w, 7w, 4 mo, 16 mo, fever without
source
q Strong agreement to admit 3w and
7w
q Outpatient ATB for 4 mo
• GP 28%, Paeds 45%, EP 59%
¢¯ x3À of ceftriaxone since ‘91
27. Pediatricians' Awareness of and
Attitudes About Four Clinical Practice
Guidelines
Pediatrics Volume 101 Number 5 May 1998
q National survey, 300 respondants
• 64% aware
28. How about no treatment
for OB
q Persistent fever
• 76% Vs 24%
q Persistent bacteremia
• 17% Vs 1,6%
q Admitted
• 50% Vs 12%
q Cellulitis
q Pneumonia
q Meningitis
• 2.7%-5.8% Vs 0.4%
29. Serious bacterial
infection
q MENINGITIS
• risk of OB 3% (85% pneumococcal)
• risk of pneumococcal meningitis 3%
• case fatality rate of 7,7%
• 25-30% neurologic sequelae
Arditi M, Mason EO Jr, Bradley JS, et al. Three-year multicenter surveillance of pneumococcal meningitis in
children: clinical characteristics, and outcome related to penicillin susceptibility and dexamethasone use.
Pediatrics. 1998;102:1087-1097.
Pikis A, Kavaliotis J, Tsikoulas J, et al. Long-term sequelae of pneumococcal meningitis in children. Clin Pediatr.
1996;35:72-78.
30. Treatment
q Antibiotics ??? q Route ???
• Benzathine pen • PO
• amoxil • IM
• amoxil/clavulanic • IV
acid
• ceftriaxone
31. Admission
q Is it safe? Reassuring?
q Iatrogenic and financial cost
• nosocomial infections
• iv infiltrates, fluid overload
• drug toxicity
• repeated testing, lost samples, contaminted
samples, mislabeling
• Stolen infant
q There is no such thing as a short admission
q Higher rates of admission if referred
Iatrogenic risks and financial costs of hospitalizing febrile infants, DeAngelis C., AM J Dis
Child;137;1146-1149;Dec 1983
32. Pneumococcal
vaccine
q Capsular polysaccharide, major virulence factor
q Conjugate, improved immunogenicity in young infants
q Pneumococcal proteins
• pneumolysin, pneumococcal surface
protein A and pneumococcal surface
adhesin A
q Decreases colonisation as well as
invasive infection
q Replacement colonisation
Rubin L.G, Pneumococcal vaccine, Pediatric Clinics of North America
Volume 47 Number 2 April 2000
34. Fever in the post-
S.pneumoniae era
q 95% HI-b invasive decrease
1987-1994
q Median age for bacterial
meningitis
• 1986 - 15 months
• 1995 - 25 years
Anne Schuchat, Bacterial meningitis in the US in 1995, N Engl J Med1997;337;970-6
35. Who will you go with?
q Ron Dagan q Rochester ,NY
q Paul McCarhty q New Haven, Ct
q Douglas Baker q Philadelphia, Pen
q Baskin q Boston, Mass
q Larry Baraff q Los Angeles,Ca
q Nathan q Davis, Ca
Kuppermann
36. CONCLUSION
q Adopt one line of conduct
q Primum non-nocere
q Elevate yourself beyond statistical
numbers
q Clinical judgment, medical common sens
and decision making is what we trained for
37. Definitions
q Fever without a source (FWS)
• No apparent etiology from history and
physical examination
q Fever of unknown origin (FUO)
• No apparent etiology from history and
physical examination lasting for at least
14 days
q Serious bacterial infection (SBI)
• Meningitis, bacteremia, pneumonia, uti,
otitis,cellulitis,osteomyelitis
38. Definitions
q Occult bacteremia
• presence of pathogenic bacterial
organism in blood cultures of child
with suspected infection
Notas do Editor
Rectal temperature is long time recognised standard All other methods have prooved to be inconsistent and unreliable in peds Remember the poster with the infant’s blown out eyes because he is getting is rectal temparature taken????? No documented post-traumatic disorders related to rectal temperature taken … or maybe one
Most of the fevers will have an identified source and will be treated accordingly.
6 items clinical scale to assess risk of SERIOUS ILLNESS 5points scale = normal 1, moderate impairment 3, severe impairment 5 scoring from 6 to 30 list of description found in sick kids interobservers agreement correlation validation by reapplying scale to their study group randomly divided in 2. 4 mo period nov 80-mar81 312 consecutive febrile child, <24mo 165 with complete defined scale points, 16% serious illness INCLUDED CHILD WITH KNOW DISEASE Sensitivity 88% Specificity 77% PPV 56% NPV 95,3%
In studies involving roughly 600 children, it was found that moderate or severe impairment on the YOS (score 10) had sensitivity of 83% to 88% specificity of 64% to 80% PPV of 48% to 56 NPV of roughly 97% . When the history, physical examination, and the YOS did not suggest serious illness, the probability of SBI being found was 1% to 4%. That chance increased to approximately 10% to 28% (seven- to tenfold) when either the history, physical, or YOS suggested serious illness. Other studies have shown that for YOS >10, sensitivity = 5% PPV 5% but included sick child 12% rate of occult bacteremia.
PPV of WBC is 8-15%, despite the fact that WBC>15000 are more common in bacterial infection. Much lower, the less prevalent the disease (meningitis) A HIGH WBC DOES NOT = DISEASE!!!! CBC predictive values may vary with the pathogens involved Hx does not contribute to prediction of occult bacteremia Most occult bacteremias had fever for less than 24h Young boys with high fevers may be at higher risk RISK of occult bacteremia increases with temperature 39-39,4 1.2% 39,5-39,9 2,5% 40-40,4 3,2% >40,5 4,4% WBC <5 0 5-9,9 .3% 10-14,9 1.3% 15-19.9 4% >20 8% ANC >10 12%most sensitive and most accurate from ROC ABC >1.5 5,2% BNR ANC, temp and age are the only sgnificant after adjusment for confounding variable
Clinical and Lab criterias to assess risk of serious bacterial infection Predicts poorly who will be sick Fairly good to triage who will not be sick criterias based on previous reports all hospitalized infants < 3mo; 39% <30d; 41% 31-60d; 15 >60d temp 38 233 144 low risk; 1 SBI; 89 high risk; 22 SBI; NPV for SBI 99,3% NPV for sepsis 100% 90% admission for benign disease
It makes no clinical sens to order a CBC and Blood cultures. The latter obviates the need of the former.
Knowing that since 1933, We had to start looking for the unknown
Prevention of either death or serious morbidity is extremely rare. No testing other than U/A in certain situations. FOLLOW-UP
The majority of kids do not have persistent bacteremia and so on. The data on meningitis comes from meta-analysis on the topic
Conclusions are drawn over a very small number of outcomes, even if a large number of kids with fever enter the study. Analyzed over the wrong denominator, ie bacteremic as opposed to febrile. ANALYSE WHAT YOU RANDOMIZE
41/100 000 to 1,6/100 000, most cases in incomplete vaccination
Kupperman: no test if Temp <39.5 in 2-3 y or <39 3-36mo, F/U 24h,risk<1% CBC if Temp >39.5 or 39 Approximately 76% of cases of occult pneumococcal bacteremia would be correctly identified by this strategy. For every 1000 febrile pediatric outpatients screened with an ANC, approximately 240 would have ANCs of 10 × 10 9 cells/L or more and therefore have blood cultures obtained and receive empiric antibiotics. Of these 240 patients, approximately 20 would have pneumococcal bacteremia, of whom approximately 1 would develop meningitis if not treated with empiric antibiotics. Shapiro: No test besides U/A,No ATB Baker: Temp>38 + IOS<10 + -ve full septic W/U, WBC AND BNR with easy follow-up, NPV 100%, with or without ATB Baskin: Like Baker, WBC 20 000 Baraff: 0-3MONTHS :Temp<38-ve clinical criteria + WBC + ABC + BNR, urine culture, blood cultures, ± Ceftriaxone if LP 3-36 MONTHS and no Prevnar : Temp <39.5, U/A +cultures if risks, WBC + ANC then blood cultures If +ve, Ceftriaxone anyways, CXR prn Dagan: Temp>38, <2Mo, home low risk with ± ATB pending cultures McCarthy: Nosuggestions for management
The management of febrile pediatric patient will remain a clinical situation that calls for an educated guess of a patient’s risk for bacteremia based on the available data at hand Avoid double standards of treatment