1. Febrile Child

2. Overview
Introduction
Occult bacteremia
Antibiotic prevention of SBI
Febrile seizure
Fever and petechiae
Fever in children with underlying illness
Rare syndromes

3. Introduction
Historical perspective
 Toxic looking child
 Fever, menigeal signs, lethargic, limb, mottled
 Admit, septic work-up, parental antibiotics
 Focal bacterial infection
 Any child with focal bacterial infection (excluding SBI)
such as OM, pharyngitis, sinusitis, etc.
 Oral antibiotics, outpatient care
 Well looking child
 Risk for occult bacteremia and serious bacterial infection
 Previous decision analysis: pre-H. flu immunization
 Current decision analysis

4. Occult Bacteremia
Incidence of occult bacteremia
 Rosen: 3% to 5%
 EMR: 2.8% Fleisher et al Pediatrics 1994
 Alpern et al AAP Sept 2000: 1.9%
 Baraff et at Ann Emerg Med 1993: 4.3%
Organism implicated in OB
 Rosen: 85% strep pneumo; 15% H. flu, N. men., Salmonella
and others
 EMR: strep pneumo and H. flu 99%
 Alpern et al: S. pneumo 82.9%, Salmonella 5.4%, Group A
strep 4.5%, Enterococcus 1.8%, M. cat 1.8%, and no H. flu
 Baraff et al Ann Emerg Med 1993: S. pneumo 85%, H. flu
10%, N. men 5%

5. Occult Bacteremia
Degree of temperature elevation
 Rosen: 39.5 to 39.9 degrees C 3%; 40 to 40.9 4%;
above 41 10% (Harper and Fleisher Pediatrics
Ann 1993)
 EMR: 39.0 to 39.9 1.9%; 40.0 to 40.9 3%; 41+ 9%
 Alpern et al Pediatrics Sept 2000: 40+ 2.9 times
more likely to have OB
Age of the child
 Rosen: children 24 to 36 months are less likely
than those under 24 months
 EMR: most OB between 6 to 18 months
 Alpern et at highest incidence 12-17 months

6. Occult Bacteremia
WBC
 Rosen: cases of H. flu one third of OB have WBC
under 15,000; meningococcemia who appear well
50% will have WBC under 15,000: cases of
pneumococcal bacteremia one quarter will have
WBC under 15,000
 EMR: using 15,000 as cut-off will miss 35% of
bcateremic children
 Isaacman et al Pediatrics Nov 2000 ANC better
predictor of OB
 Kupperman et al Ann Emerg Med 1998 found that
ANC greater than 10,000 better predictor of OB
than WBC 15,000.

7. Occult Bacteremia
Blood cultures
 New blood culture techniques most blood culture
results are positive in less than 24 hrs; Alpern et al
mean time 14.9 hrs
 Most OB spontaneously resolves
Minor infections
 Fleisher et al J Pediatrics 1994: 12.8% OM
 Baraff et al Pediatrics 1993: 3-6% OM
 Children with focal minor infection have lower
serum bacterial concentrations; lower risk men
and SBI (Fleisher et al J Ped 1994; Long J Ped
1994)

8. Occult Bacteremia
Assessment of observational scores:
Bonadio Pediatric Clinics of NA 1998
 Infants younger than 8 weeks
 Retrospective studies
 Prospective studies
 Infants and children older than 8 weeks
 Prospective studies

9. Occult Bacteremia
Guidelines for managing OB
 Guidelines for febrile infants 0-3 months
 Baker et al NEJM 1993: Philadelphia protocol
 Infants under 3 months
 Philadelphia protocol: low risk vs high risk
 100% sensitive; 100% negative predictive value
 Baker et al Pediatrics 1999: validation
 Validation of Philadelphia protocol
 Infants 29-60 days old; low risk vs high risk for SBI
 100% sensitivity; 100% negative predictive value

10. Occult Bacteremia
Guidelines for managing OB
 Guidelines for febrile infants 0-3 months
 Dagan et al J Pediatrics 1985: Rochester
protocol
 Jaskiewicz et al Pediatrics 1994: appraisal
Rochester protocol
 Avner et al Abstract: failure to validate
Rochester protocol

11. Occult Bacteremia
Guidelines for managing OB
 Guidelines for febrile infants 0-3 months
 Baraff et al Ann Emerg Med 1993
 Meta-analysis febrile infants less than 90 days
 Febrile infants less than 28 days; low risk defined by
Rochester protocol; despite 99.3% neg predictive
value they recommend hospitalization, septic work
up, and parenteral antibiotics
 Febrile infants 28-90 days low risk outpatient care
with IM ceftriaxone, septic work up, and 24 hr f/u

12. Occult Bacteremia
Guidelines for managing OB
 Guidelines for febrile infants 3-36 months
 Toxic children: no issue
 Well looking child: current recommendations,
temp greater than 39 and WBC greater than
15,000 get blood culture, IM cetriaxone, and f/u
24hrs; urine culture boys less than 6 months
and girls less than 2 years
 Recent studies challenge these
recommendations; selective approach

13. Occult Bacteremia
Antibiotic use to prevent SBI in children
at risk for OB
 Bulloch et al Acad Emerg Med 1997
 Rothrock et al Pediatrics 1997

14. Febrile seizure
Synopsis of the American Academy of
Pediatric practices parameters on the
evaluation and treatment of children with
febrile seizures (Peditrics 1999)
 LP strongly suggested in the first seizure in infants
less than 12 month because signs and symptoms
of meningitis may be absent in this age group
 12-18 months LP strongly suggested because sign
of meningitis may be subtle in this age group
 18+ months LP only if signs and symptoms of
meningitis

15. Febrile seizure
EEG is not perform in a neurologically healthy
child with simple febrile seizure
The following routine lab should not be
performed in simple febrile seizure: CBC,
lytes, Ca, phos, Mg, or glucose
Neuro-imaging should not be performed
routinely on simple febrile seizure
Anticonvulsant therapy is not recommended
in simple febrile seizure

16. Fever and petechiae
Baker et al Pediatrics Dec 1989
 7% incidence of meningococcal disease
 Petechiae below nipple line associated with
invasive bacterial disease
 Generalized rash more associated with invasive
bacterial disease
 WBC greater than 15,000, ABC greater than 500
cell/ul, CSF abnormality 93% sensitive and 62%
specific for invasive bacterial disease
 Recommend hospitalization, septic work up, and
parenteral antibiotic

17. Fever
Fever in children with underlying illness
 Oncology patients
 At risk of overwhelming sepsis
 When febrile: CBC, CXR, blood culture, urine
culture, and LP when clinically indicated
 Neutropenic patients at risk for Pseudomonas
and other gram negative; combination of
tobramycin and ceftazidime
 Indwelling IV devices add vancomycin to
tobramycin and ceftazidime

18. Fever in children with
underlying illness
Acquired Immunodeficiency Syndrome
 Repeated risk of infection with common bacterial
pathogens, risk of Pneumocytsis carinii,
mycobacterial infections (TB, AI), cryptococcosis,
cytomegalovirus, Ebstein-Barr virus, lymphoma
and other malignancies
 Low CD4 similar approach to neutropenic cancer
patient; septic work up and broad spectrum
antibiotic

19. Fever in child with
underlying illness
Congenital heart disease
 Children with valvular heart disease are at risk for
endocarditis
 Fever without obvious source with a new or
changing murmur; hospitalization, serial blood
cultures, echo, antibiotics against: S.viridans, S
aureus, S. fecalis, S. pneumo, enterococci, H. flu,
and other gram neg rods
 Suggested antibiotics include Vancomycin and
Gentamycin until cultures are positive

20. Fever in child with
underlying illness
Ventriculoperitoneal shunts
 Fever in this group must be evaluated for
shunt infection esp if patient displays
headache, stiff neck, vomiting, or irritability
 Shunt reservoir should be aspirated and
examined for pleocytosis and bacteria
 Most common pathogen is S. epidermidis
 CT head also warranted

21. Febrile child
Other conditions to consider in febrile child
 Collagen vascular disease
 Malignancy
 Drug-induced fever
 Toxic ingestion
 Heat exhaustion and heatstroke
 Kawasaki syndrome
 Thyrotoxicosis