"Fever in Children" By Dr. Brad Sobolewski - Outstanding Review of Fever

There are many outstanding pediatric podcasts and blog posts on pediatric fever and I have posted links to some of my favorites. I have included these in Additional Resources that follow this post.

Dr. Sobolewski’s slides and lecture are an excellent review of the topic.

Dr. Sobolewski has posted the slides of his outstanding talk on fever. There are 72 slides which you can review or download at Slide Share [and at this link the text of each slide is printed on the slide share page]. And you can also review at his blog site: A presentation on fever – “These are the slides from a presentation I gave on October 28th, 2016 to the residents at Cincinnati Children’s Hospital Medical Center. It reviews some general pearls on fever and febrile illnesses before segueing to fever in neonates, fever in 3-36 months, and fever of unknown origin in older children.”

All that follows is Dr. Sobolewski’s text from the Slide Share Link:

Slides 1 to 17 covers fever in general.

Slides 18 to 41 cover the evaluation in neonates:

18. Febrile Infant
19. The Bottom Line 28 days old and under = full septic workup 29-60 days we can opt to exclude LP if baby is low risk
20. Fever deﬁned as temperature ≥ 38oC / 100.4oF (rectal) Viral URI Sx do NOT count as a fever source
21. H&P are not reliable to rule-out serious bacterial infection (SBI)
22. 12-28% of febrile neonates have SBI • UTIs (12-20%) • Bacteremia (3%) • Meningitis (<1%)
23. Other causes • Bacterial gastroenteritis • Gonococcal keratoconjunctivitis • Omphalitis • Osteomyelitis • Peritonitis • Pneumonia • Septic joint
24. IV access CBC, blood culture Cath UA, urine culture LP + CSF studies ≤28 days Glucose if needed Chest XRay if clinically warranted Consider need for HSV testing Enterovirus CSF PCR in the summer Stool Culture if mucous or gross blood in the stool Respiratory PCR and inﬂuenza
25. LP success rate increases with early stylet removal and use of lidocaine Family presence does not alter success rate Residents get 2 attempts Take a supervisor with you Lumbar puncture
26. CSF Blood Early stylet removal
27. CSF Analysis Tube 1 Culture and Gram stain Tube 2 Glucose, protein Tube 3 Cell count and diﬀerential Tube 4 Viral Studies or to be saved for further studies Lumbar puncture
28. Labs WBC ≤5,000 or ≥15,000 Bands >1,500 Band:Neutrophil <0.2 Bands/Bands + Neutros <10 WBC/hpf Negative gram stain 0-28d – WBC <19/μL 29-60d – WBC <9/μL Normal glucose or protein Gram stain Blood CSFUrine
29. Low Risk for Bacterial Meningitis 29-60 days old Full-term (≥37 weeks gestation) No prolonged NICU stay No chronic medical problems No systemic antibiotics within 72 hours Well-appearing and easily consolable No infections on exam Blood and urine studies reassuring LP
30. Empiric Acyclovir Strongly consider for ALL infants ≤ 21 days and for infants 22 to 40 days with ≥ 1 of the following: • Ill Appearing • Abnormal neurologic status, seizures • Vesicular rash • Hepatitis • Mom known to have primary HSV infection at delivery Labs HSV PCR in CSF and blood HSV PCR of SEM lesions Liver proﬁle, BMP HSV?
31. Antimicrobials 0-21d Ampicillin/Cefotaxime +/- Acyclovir 22-28d Ampicillin/Cefotaxime 29-56d Cefotaxime or Ceftriaxone (>6 weeks and no jaundice)
32. Additional Considerations Add Vancomycin if • Ill Appearing • CSF WBC elevated w/abnormal glucose or protein Gram positive organism on Gram stain
33. What about? Procalcitonin and CRP  do not improve conﬁdence to completely rule out SBI at this time
34. Gomez et al Pediatrics 2016
35. Lab Score
36. Rochester Criteria: Reassuring if all criteria are present Well appearing infant  No skeletal, soft tissue, skin or ear infections  Full term birth  No prior illness •No prior hospitalizations •Not hospitalized longer than mother after delivery •No prior antibiotics •No Hyperbilirubinemia •No chronic or underlying illness  Complete Blood Count normal •White Blood Cell Count normal (5000 to 15,000/mm3) •Band Neutrophils < 1,500/mm3  Other Lab Findings •If Diarrhea is present, Fecal Leukocytes <5 WBC/hpf •Urine White Blood Cells <10 WBC/hpf
37. Population: A prospective study of 2185 infants aged <90 days presenting with a fever without source. Intervention: Risk stratiﬁcation via the “Step by step” approach to identify the level of risk for invasive bacterial infection. Comparison: Rochester criteria and Lab-score for same. Step by Step Approach
38. Step by Step Approach
39. All babies under 28 days are admitted on empiric antibiotics for 36 hours Babies 29-60 days with normal CBC and urine can be discharged home oﬀ antibiotics You can get blood, urine and CSF on a baby 29-60 days and D/C home if normal – but NO antibiotics! Disposition at CCHMC
40. Babies discharged home must have PMD follow up within 24 hours Also, trustworthy caregivers with reliable transportation Always call the PMD If you can’t reach them – baby from out of town consider admission Disposition at CCHMC

Slides 41 to 59 cover the evaluation of fever in those from 3 to 36 months.

41. Fever 3 to 36 months
42. The Bottom Line A child under 3 without an obvious source for their fever has a 5% chance of bacterial infection – mostly UTI Occult bacteremia in post HiB Prevnar is <1-2% Most children have viruses
43. SBI include Bacteremia, UTI, meningitis, periorbital cellulitis, septic arthritis, pneumonia, and focal skin infections
44. Lee Arch Pediatric Adol Med, 1998 Prospective study of 1911 children 3-36 mos with fever >39 C and no source Frequency of bacteremia 1.5% WBC >10K 86% sensitive and 77% speciﬁc CBC
45. Kuppermann, Annals of EM 1998 Multicenter, prospective observational study of 6579 children, 3 to 36 months of age w/ fever without a source ≥39°C frequency of bacteremia 2.5% WBC ≥15 80% sensitive and 69% speciﬁc ANC ≥1076% sensitive and 78% speciﬁc Logistic regression – ANC independent predictor of bacteremia with   adjusted odds ratio (OR) 1.15 (95% CI 1.06-1.25) for each 1000 cells/mm3 increase in the ANC CBC
46. Herz, Pediatric Infectious Dis 2006 Multicenter retrospective observational study of 41,948 children, 3-36 months who had blood cultures Frequency of bacteremia (was 1.6%, contamination 1.8% WBC ≤15 NPV 99.5% CBC
47. WBC >15K and ANC >10K are associated with incr risk of SBI CBC
48. Mean time to positive for pathogen 15 hours – for contaminant 31 hours Blood Culture
49. Urinalysis
50. UTI Disposition Admit UTI <2mos >2 mos DC home if OK Low risk of concurrent meningitis if UTI in healthy Ceftriaxone/cefdinir
51. In FUS patients with tachypnea, respiratory distress or O2 sat <95% consider a chest radiograph WBC >20K without focal ﬁndings also suggests pneumonia Occult pneumonia is more common with fever >5d, cough >10d as well Chest X-Ray
52. Limited sensitivity and speciﬁcity in this population >80 high risk – sens 50% spec 90% <20 low risk – sens 80% and spec 70% CRP
53. PCT Early studies indicate improved sens/spec vs WBC and CRP >2 high risk – sens 50% spec 90% <0.5 low risk – sens 80% and spec 70%
54. Initial approach Ill appearing Blood and urine Cx Empiric antibiotics CSF studies if warranted
55. Initial approach well appearing & incompletely immunized* Risk of occult bacteremia is <5% If well appearing and <24 hours may elect to get no tests Otherwise consider CBC and B/C Urine and U/C for girls <24 months, uncircumcised boys <12 mos & circumcised boys <6 mos CXR if WBC >20K
56. Empiric treatment well appearing & incompletely immunized If WBC >15K give IM or IV Ceftriaxone If allergic Clinda 10mg/kg IV with an oral dose 8 hours later PMD follow up in <24 hours This is AAP rec and based on meta analyses
57. Initial approach well appearing & immunized Risk of occult bacteremia is <1% Labs and empiric antibiotics do not make a difference Get U/A in high risk groups
58. What if the blood culture comes back positive? If persistently febrile get blood, urine and CSF Children that didn’t get antibiotics but are still febrile have a 33-42% chance of bacteremia and a 4% chance of meningitis Well, afebrile kids w/ S. pneumoniae have a 9% risk of persistent bacteremia if no antibiotics given Get another blood culture and continue outpatient PO antibiotics
59. Fever for a month / He’s been sick since January First take a good history. Is the temp >100.5 every day? Multiphasic illnesses are common Kids have 10-12 unique infections a year