Pediatric fever of uncertain source

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Background

  • Medicine is an art as well as science, practice clinical judgment when using guidelines
  • Preemies: Count age by estimated postconception date (not by actual delivery date) for 1st-90d
Age 0-14 days 14-28 days 28-60 days (pre vaccine) 28-60 days (post vaccine) 60-90 days > 90 days
Meningitis/SBI Prevalence 1/10 1/20 1/100 1/1000 1/1000-10,000 > 1/10,000

Facts and Figures

From ACEP's Clinical Policy on Pediatric Fevers[1]

  • 7% of patients < 2 years old with fever have pneumonia, however the etiology (viral/bacterial) or even the presence of pneumonia has low inter-observer reliability even among pediatric radiologists
  • 4% Prevalence of UTI with common other sources of fever (OM, viral URI, et cetera)
  • 1.5-2% background prevalence of asymptomatic bacteruria in healthy afebrile controls
  • 0.3% Rate of occult bactremia with healthy, well-appearing child who has a fever 2-24 months
  • 0.3% of previously well children aged 3-36 months who have a fever without a source will develop significant sequelae, 0.03% will develop sepsis or meningitis

Concomitant RSV or Infulenza Infection

  • In RSV+ (by PCR) neonates aged 0-28 days, 6.1% had UTIs and 3.7% were bactremic; there was no difference in rates of SBI between RSV+ and RSV- neonates in a large prospective multicenter study entailing 1,248 children[2]
  • RSV+ infants aged 29-60 days, the SBI rate was 5.5%, all of which were UTIs
  • Influenza+, low risk of bacterial illness

Differential Diagnosis

Pediatric fever

Evaluation & Management

Algorithm for the evaluation of pediatric fever

0-28dy

Child Appearance Work Up Treatment Disposition & Follow-up Comments
Temperature ≥38°

Toxic or Well

  • CBC
  • Blood cultures
  • Urinalysis, Urine culture
  • LP-CSF
  • CXR
  • +/- Stool studies (if diarrhea)
 Admit SBI incidence
  • Ill appearing: 13%–21%
  • Not ill appearing: <5%

^Acyclovir if:

  • HSV infection in baby or mother
  • CSF pleocytoisis
  • Concerning skin lesions
  • Seizures
  • Abnormal LFTs

28dy-90dy[3]

Appearance Work Up Treatment Disposition & Follow-Up
Temp≥38° + Toxic
  • CBC
  • Blood cultures
  • Urinalysis, Urine culture
  • LP-CSF
  • +/- CXR
  • +/- Stool studies (if diarrhea)
 Admit

Temp≥°38 + Well

  • CBC
  • Blood cultures
  • Urinalysis, urine culture
  • +/- LP-CSF (must do before giving antibiotics)
  • +/- CXR
 Workup(+): Antibiotics and admit

Workup(-): ?antibiotics; home with 24 follow-up

^^Can use ceftriaxone 50-100mg/kg, but concern for bilirubin displacement

  • CXR for (use clinical judgment):
    • Resp symptoms
    • Fever >48 hrs
    • Tachypnea
    • Decreased SaO2

^Acyclovir if:

  • HSV infection in baby or mother
  • CSF pleocytoisis
  • Concerning skin lesions
  • Seizures
  • Abnormal LFTs

90dy-36mo[4]

Appearance Work Up Treatment Disposition & Follow-Up
T≥38° + Toxic Admit
T≥39°C + Well + Non-complete Prevnar

(No Prevnar or <4 wks post 1st Prevnar dose)

If WBC(+): Outpatient (24 hour follow-up)
T≥39°C + Well + Prevnar

(2 Prevnar or ≥4 wks post 1st Prevnar dose)

  • Urine workup (UA, urine culture) for:
    • Circumcised males <6 months
    • Uncircumcised males <12 months
    • All females
  • +/- CXR
 Treat cystitis or pneumonia if postitive Outpatient (48hour follow up)
T≥38-38.9°C + Well Consider UA, CXR based on symptoms, etc Treat cystitis or pneumonia if positive Outpatient (48-72 hour follow-up)[5]
  • CXR for (use clinical judgment):
    • Resp symptoms
    • Fever >48 hrs
    • Tachypnea
    • Decreased SaO2

Low Risk Lab Criteria

If low-risk criteria below not met, then perform the LP (if not done) and admit for inpatient antibiotics[6][7]

CBC

  • WBC 5-15 /mm3
  • Absolute Band count <1500 /mm3

Urinalysis

  • Clear
  • Neg Nitrate and Leukocyte esterase
  • WBC <10/high powered field

CSF

0-28 days

  • WBC: 0-22/mm3
  • Protein: <100mg/dL

>29 days

  • WBC 0-7/mm3
  • Protein: 15-25mg/dL

Low Risk by Step-By-Step Approach[8]

Study validated against Rocheter criteria and Lab-score for identifying low risk for invasive bacterial infections (IBI), with NPV ~98%

  • Well appearing
  • Age > 21 days
  • No leukocyturia
  • Procalcitonin < 0.5 ng/mL
  • ANC < 10,000/mm3
  • CRP < 20 mg/L

Low Risk Management[9]

  • Offer no LP, no antibiotics, 24 hrs observation
  • Plan for prompt follow-up

Symptomatic Managment

Acetaminophen Pediatric Dosing Chart

Weight (kg) Weight (lbs) Age Dosage (mg)
3-4 6-11 0-3 mo 40
5-7 12-17 4-11 mo 80
8-10 18-23 1-2 y 120
11-15 24-35 2-3 y 160
16-21 36-47 4-5 y 240
22-26 48-59 6-8 y 320
27-32 60-71 9-10 y 400
33-43 72-95 11 y 480
Dosage can be given q6hours

See Also

External Links

References

  1. ↑ Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545
  2. ↑ Greenes, D.S.M., & Harper, M. B.M. (1999). Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatric Infectious Disease Journal, 18(3), 258-261.
  3. ↑ Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Powell, K. R., et al. (1994). Febrile infants at low risk for serious bacterial infection-an appraisal of the Rochester criteria and implications for management. Pediatrics 94(3), 390-396.
  4. ↑ Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Powell, K. R., et al. (1994). Febrile infants at low risk for serious bacterial infection-an appraisal of the Rochester criteria and implications for management. Pediatrics 94(3), 390-396.
  5. ↑ Baker, M.D., Bello, L.M., & Avner, J.R. (1993). Outpatient management without antibiotics of fever in selected infants. New England Jouranl of Medicine, 329(20), 1437-1441.
  6. ↑ Smitherman, H.F. & Macias, C.G. (2014). Evaluation and management of fever in the neonate and young infant (less than three months of age) [Electronic Version]. UpToDate,Teach, S.J., Kaplan, SL, Wiley, JF.
  7. ↑ Dagan, R. Sofer, S., Phillip, M., & Shachak, E. (1988). Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serous bacterial infections. Journal of Pediatrics, 112(3), 355-360.
  8. ↑ Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics. 2016;138(2):e20154381
  9. ↑ Mintegi S, Gomez B, Martinez-Virumbrales L, et al. Outpatient management of selected young febrile infants without antibiotics. Arch Dis Child. 2016 Jul 28. pii: archdischild-2016-310600. doi: 10.1136/archdischild-2016-310600.
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