InpatientCurriculum20052006

MANAGEMENT OF FEVER IN INFANTS

Introduction
sincetheadventofmodernclinicalthermometrybyWunderlichin1871,theritualoftemperaturetakinghasbeen
surpassedonlybyAlexanderGrahamBellsinventionin1874 asthemajorcurseofpediatrics
DS
SmithfromFeverandthePediatrician
Definition:rectaltemperaturegreaterthan37.9degreesCelsius
Basedon2standarddeviationsfrom37.0(normalinfantbodytemperature)
Rectaltemperatureisthecorebodytemp,andgenerally1degreehigherthanallother
generallyutilizedsites

Incidence:seriousbacterialinfection(SBI)isfoundin610%ofallinfantswithfever
<1motheincidencemaybeashighas13%
<2mo,lessthan1%withseriousbacterialinfectionwillhavefever
Etiology:UTIisthemostcommoncauseofSBIinafebrileinfant
1/3ofallbacterialdiseaseininfants<3mo
conjungatedhyperbilirubinemiaassign
Importance:youngerinfantsoftenshownosignsofclinicalillness
Clinicalscoringsystems(seeYaleAOIS)areunreliablein<2mo
Upto2/3of<2mowithseriousbacterialillness(SBI)areassessedaswellappearingby
physicians
Criteria for Admission
Multipleprotocolshavebeenestablishedtodeterminetheneedforinpatient management.TheBoston,Rochester
andPhiladelphiaCriteriahaveallattemptedtocreatescreeningcriteriathatweresensitive,specificandhadhigh
negativepredictivevalues(NPV).Thoughtheyvaryinprotocolandrecommendations,theyallfocusedonstratifying
febrileinfantsintohighandlowriskcategories.Lowriskinfantscouldbejustifiablysenthomewithclosefollowup.
Thekeydifficultywithallthreecriteriaisthatfollowupmustbeassured,whichisdifficultinachildinanurban ER
whodoesnothaveamedicalhome.
OfNote:

RochesterfocusedonayoungeragegroupanddidnotuseanyInfantObservationScore
RochesterdidnotroutinelyobtainCSF
Bostonwastheonlygrouptorecommendempiricantibiotics,evenasanoutpatient.
Evenwithantibiotics,Bostonwasdeterminedtobemorecosteffectivesincewithalowerriskstratification,
lesschildrenwereadmitted.

RecentdatahasdemonstratedthatPhiladelphiaandBostoncriteriaarenotapplicableto01montholdinfantsand
couldresultin10%ofneonateswithSBIbeingcategorizedaslowrisk.Therefore,
ALLCHILDRENUNDERONEMONTHMUSTBEADMITTED

PhiladelphiaCriteria

Age
Temperature
History

Physicalexamination

Laboratoryparameters
(defineslowerrisk
patients)

Higherriskpatients
Lowerriskpatients

Reportedstatistics

2960d
38.2C
Notspecified

Wellappearing
Unremarkableexamination

RochesterCriteria

60d
38.0C
Terminfant
Noperinatalantibotics
Nounderlyingdisease
Nothospitalizedlongerthan
themother
Wellappearing
Noear,softtissue,orbone
infection
WBC>5000and
<15 000/mm3
Absolutebandcount
<1500/mm3
UA 10WBC/hpf
5WBC/hpfstoolsmearb

BostonCriteria

2889d
38.0C
Noimmunizationswithin
preceding48 h
Noantimicrobialwithin48 h
Notdehydrated
Wellappearing
Noear,softtissue,orbone
infection
CSF<10/mm3
UA<10WBC/hpf
Chestradiograph:noinfiltrate

WBC<15 000/mm3
Bandneutrophilratio<0.2
UA<10WBC/hpf
a
UrineGramstainnegative
3
CSF<8WBC/mm
WBC<20 000/mm3
CSFGramstainnegative
Chestradiograph:noinfiltratea
Stool:noblood,feworno
WBCsonsmearb
Hospitalize + empiricantibiotics Hospitalize + empiricantibiotics Hospitalize + empiricantibiotics
Home
Home
Home
Noantibiotics
Noantibiotics
Empiricantibiotics
Followuprequired
Followuprequired
Followuprequired
Sensitivity98%(92 100)
Sensitivity92%(8397%)
Sensitivity notavailable
Specificity42%(3846%)
Specificity50%(4753%)
Specificity94.6%
Positivepredictivevalue14% Positivepredictivevalue12.3% Positivepredictivevalue
(1117%)
(1016%)
notavailable
NPV99.7%(98100%)
NPV98.9%(97100%)
NPV notavailable

a Ifobtained.

Interpreting Labs
Uponadmission,bytheabovecriteria,allpatientswillhaveCBC,Bloodculture,UA,Urineculture,CSFcounts,
chemistriesandcultures.
Chestxrays
Notrequiredinmostprotocolsunlesspresenceofrespiratorysymptoms
IndatafromthePhildelphiastudy,5/36patientswithpositivechestxraysdidnothave
respiratorysymptoms.However,theywerenotnecessarilybacterialinorigin.
HSVPCR
Controversial:routineinsomehospitals,notinothers
Notrecommendedroutinelyinthewellappearingfebrileinfant

 ConsiderwhensymptomsofHSVpresent(seeantibioticdiscussionbelow)
LumbarPuncture
Bloodytaps(traumaticvs.pathologic)willobscurepicture(1520%occurrence)
WBCsintraumatictapscanrepresentbloodcontaminantinsteadof infection
BloodytapthatdoesnotclearinsubsequenttubesishighlysuggestiveofHSV
Traumatictaps:controversialdataoncorrecting.Ratiosinclude
WBC:RBCratio
ObservedtoPredictedRation(O:P)
RatiosareintendedfordischargefromtheER
Urineculture
Suprapubictap:anygrowthindicatesaUTI
Catheterized:>10,000organisms
CleanCatch:>100,000organismsofonebacteria
CultureGrowth
Datainchildren2890daysandolder
Inonestudy,100%ofCSFpositiveat24h,93%ofbloodat28h,100%urineat30h
Antibiotics
Empiricantibioticcoverageisbestdeterminedbytheageofthepatient.
Birthto28d:

Ampicillin plus Gentamicinor3rd generationCephalosporin

(plusorminusAcyclovir)
CoveringforListeria(Ampicillin),E.coli,GBS,othergramnegatives
Ceftriaxoneisnotrecommendedbefore24weeksduetotheincidenceofbiliarysludging
Gentamicinusenecessitatesfollowinglevelssecondarytonephro/ototoxicity
Acyclivir:currentlynotrecommendedasstandardempirictherapy
IndicatedwithelevatedsuspicionforHSV(i.e.presentswithseizures,
abnormalEEG,cutaneouslesions,acutelyill)
AlsoindicatedifpatientnotresponsivetostandardAbxat4872h

2990days:

3rd GenerationCephalosporin
CongenitalHSVnolongerin differential
Listeriacanpresentlate(upto3months),butwouldonlyaddAmpicillinifpatientpresented
withCSFpleocytosis
OtherwisecoveringforS.pneumo,E.coli

Viralsource: Thereisvaryingliteratureontheworkupoffeverinaninfantwithdocumented
viralinfection.
Retrospectivestudyin056do:2/174RSV(+)hadSBI(2 UTI)
Prospectivestudyin060do: 17/244RSV(+)hadSBI(14UTI,3bacteremic)
Prospectivestudyin090do:Rochesterriskstratifiedhighriskvs.lowrisk
LR/+:3/167withSBI

 LR/:9/289withSBI
HR/+:18/323withSBI(15UTI,3bacteremic)
HR/:100/599withSBI
(61UTI,18bactermic,6meningitis)
AdverseEffects:
Ceftriaxoneincreasestheriskofbiliarysludging/pseudolithiasis
Casestendtospontaneouslyresolveaftercessationofthedrug
Miscellaneous
Defervescence
ThereisnocorrelationbetweendefervescencewithantipyreticsandincidenceofSBI
Antipyretics
AlternationofTylenolandMotrin hasnotbeenproventoprovidefasterdefervescenceor
hasgreaterefficacy
Parentalconfusionandsubsequentoverdosecanleadtotoxicity
Temperaturetaking
Counselfamilytoappropriatetemperaturetakingtechnique
Provideguidelinesforconcerningtemperatures

References
Avner JR,BakerMD.Managementoffeverininfantsandchildren. EmergencyMedicineClinicsofNorthAmerica. 200220:49
67.
BachurRG,HarperMB.Predictivemodelforseriousbacterialinfectionamonginfantsyoungerthan3monthsofage. Pediatrics.
2001108:311316.

BakerMD,BellLM,AvnerJR.Theefficacyofroutineoutpatientmanagementwithoutantibioticsoffeverinselectedinfants. N
EnglJMed. 1993329:14371441.
BaskinMN,ORourkeEJ,FleisherGR.Outpatienttreatmentoffebrileinfants2889daysofagewithintramuscular
administrationofceftriaxone. JPediatr. 1992:120:2227.
ByingtonCL,EnriquezFR,HoffC,etal.Seriousbacterialinfectionsinfebrileinfants1to90daysoldwithandwithoutviral
infections. Pediatrics. 2004113:16621666.
DaganR,PowellKR,HallCB,MenegusMA.Identificationofinfantsunlikelytohaveseriousbacterialinfectionalthough
hospitalizedforsuspectedsepsis. JPediatr. 1985107:855860.
JaskiewiczJA,McCarthyCA,RichardsonAC,etal.Febrileinfants atlowriskforseriousbacterialinfection anappraisalofthe
RochesterCriteriaandimplicationsformanagement. Pediatrics. 199494:390396.
KaplanRL,HarperMB,BaskinMN,etal.Timetodetectionofpositiveculturesin28 to90dayoldfebrile infants. Pediatrics.
2000106:34.
LevineDA,PlattSL,DayanPS,etal.Riskofseriousbacterialinfectioninyoungfebrileinfantswithrespiratorysyncytialvirus
infections. Pediatrics. 2004113:17281734.
SmithermanHF,CavinessAC,MaciasCG.Retrospectivereviewofseriousbacterialinfectionsininfantswhoare0to36months
ofageandhaveinfluenzeAinfection. Pediatrics. 2005115:710718.